대한안과학회지 2008 년제 49 권제 9 호 J Korean Ophthalmol Soc 2008;49(9):1443-1452 DOI : 10.3341/jkos.2008.49.9.1443 전안부빛간섭단층촬영을이용한백내장수술후앞방깊이와앞방각의변화측정 장동호 1 이승찬 2 진경현 1 경희대학교의과대학안과학교실 1, 강원대학교의과대학안과학교실 2 목적 : 전안부빛간섭단층촬영을이용하여백내장수술후의앞방내계측치의변화를알아보고, 백내장의정도에따라앞방내계측치의변화가다른지를알아보고자하였다. 대상과방법 : 백내장수술을시행받은환자 14 명, 19 안에서전안부빛간섭단층촬영의방법중세극등현미경장착빛간섭단층촬영을이용하여수술전과수술후 1 주, 1 개월의최대앞방깊이, 앞방각간거리 (AOD250, AOD500), 앞방각을측정하고, 백내장의정도 (N, C) 에따른앞방내계측치의변화를분석하였다. 결과 : 최대앞방깊이, 앞방각간거리, 앞방각은수술후 1 주와 1 개월에의미있게증가하였다. 수술전의최대앞방깊이, 앞방각간거리, 앞방각은수술후 1 주와수술전의계측치의차이, 수술후 1 개월과수술전의계측치의차이와음의상관관계가있었다. 수술전의백내장의정도에따라수술후 1 주, 1 개월의최대앞방깊이, 앞방각간거리, 앞방각은차이는없었다. 결론 : 백내장수술후최대앞방깊이, 앞방각간거리, 앞방각은의미있게증가하였으며, 수술전최대앞방깊이가얕을수록, 앞방각간거리가작을수록, 앞방각이작을수록수술후의최대앞방깊이, 앞방각간거리, 앞방각의변화가컸다. < 대한안과학회지 2008;49(9):1443-1452> 백내장수술후수술받은눈에서앞방이깊어지고, 앞방각이넓어진다는사실은여러연구를통해밝혀져왔다. 1-5 또한수정체의두께가두꺼워질수록앞방각의밀집현상 (angle crowding) 으로상대적인동공차단 (pupillary block) 을일으키므로, 원발폐쇄각녹내장에서백내장적출술후앞방각이넓어진다고알려져있다. 6,7 한편 Shibata et al 8 은 Scheimpflug came ra 를이용하여수정체의혼탁정도가수정체핵과겉질의두께에영향을미칠수있다고하였다. 많은연구자들이이러한앞방내의변화를생체계측하고자다양한시도를해왔다. 고전적인세극등현미경을이용한앞방각보개검사는검사자의주관적인측정에따르므로, 객관성이떨어지며정량적인측정이가능하 < 접수일 : 2007 년 7 월 11 일, 심사통과일 : 2008 년 6 월 11 일 > 통신저자 : 진경현서울시동대문구회기동 1 경희대학교병원안과 Tel: 02-958-8451, Fax: 02-966-7340 E-mail: khjinmd@khmc.or.kr * 본논문의요지는 2006 년대한안과학회제 96 회추계학술대회에서구연으로발표되었음. 지않고, 오차가발생할소지가많고반복측정시재현성이떨어지는문제점이많고검사자의숙련도가필요한검사라는문제점이있다. Scheimpflug camera 를이용하는방법은세극촬영을한후컴퓨터를이용하여화상계측을함으로써객관적인평가가가능하며, 정확성및재현성이좋다는장점이있는반면에, 9 검사방법이복잡하고해상도가떨어지며약간확대되어나오는단점이있어임상적으로활용도가높지못하다. 9,10 또한초음파생체현미경은좋은해상도로실시간으로정량적인측정이가능한장점이있지만, 검사시간이많이걸리고침습적방법이며안구움직임에따른인공상이생기는단점이있다. 11 다른앞방내계측치측정방법으로빛간섭단층촬영을이용하는방법이제시되었는데, 2005 년에 Wirbelau er et al 12 은앞방내계측치를측정하는방법으로빛간섭단층촬영과초음파생체현미경을비교하였는데빛간섭단층촬영이해상도와재현성에서초음파생체현미경보다우수한방법이라고보고하였다. Radh akrishnan et al 13 은전안부빛간섭단층촬영과초음파생체현미경이동일한재현성과비슷한앞방각계측치의평균치를보인다고하였다. 또한섬모체의시각화에는전안부빛간섭단층촬영이초음파생체현미경에서보 1443
장동호외 : 백내장수술과앞방내계측치의변화 다불리하지만공막극의시각화에는유리하다고하였다. 이에저자들은백내장수술을시행한후이에저자들은백내장수술을시행한후전안부빛간섭단층촬영을이용하여앞방내계측치의변화를알아보고백내장의정도와의상관관계를알아보고자하였다. 대상과방법 2006 년 6 월부터 9 월까지본원안과에서소절개백내장적출술및뒤방인공수정체삽입술을시행한환자중무작위로선택된 14 명, 19 안을대상으로하였다. 남자가 6 명 (8 안 ), 여자가 8 명 (11 안 ) 이었으며, 연령층은 52 세에서 86 세로평균연령은 71.05±10.4 세였다. 수술전검사에서폐쇄각의소견이나주변홍채앞유착이있는경우, 녹내장이나안구내수술을받은경우, 기타안질환치료를받고있는경우를제외하였다. 백내장수술은모두동일술자에의해시행되었고, 이측투명각막절개 (3 mm) 를시행하였고, 대개는무봉합방법을사용하였으나필요한경우에는 #10-0 Nylon 을이용하여한바늘의봉합을하고수술후 1 주에서 1 달사이에봉합사제거를시행하였다. 수술후모든환자에서 0.5% levofloxacin (Cravit, San ten, Japan) 과 0.1% fluorometholone (Ocume tholone, Sam-il, Korea) 을하루 4 회 3 주간점안하게하였다. 전안부빛간섭단층촬영 (anterior segment optical coherence tomography) 을이용한앞방내계측치의변화는세극등현미경장착빛간섭단층촬영 (slit- lamp adapted OCT; Heidelberg engineering, Heidelberg, Germany. 1,300 nm SLD light sou rce) 을이용하였다. 피검자는세극등현미경장착빛간섭단층촬영기를장착한세극등현미경 (BD 900, Haag-Streit, Bern, Switzerland) 에턱을붙이고전방을똑바로주시하게한후스캔너비는앞방중심과앞방주변부전체가스캔가능한 15 mm 로, 스캔깊이는각막에서수정체혹은인공수정체전체가스캔가능한 7 mm 로시행하였으며 200 Hz 의스캔속도로영상을촬영하고저장한후 caliper 기능을이용하여계측치를측정하였다. 12 시에서 6 시방향으로스캔을시행했을경우눈꺼풀에의해앞방주변부전체의스캔이불가능했기때문에스캔방향은모든환자에서 3 시에서 9 시방향으로시행했다. 앞방내계측치는 Pavlin et al 11 의정의에따른최대앞방깊이 (anterior chamber depth; ACD), 앞 Figure 1. The definition of anterior chamber parameters. The anterior chamber depth (ACD) can be measured between the endothelium and the lens surface. The angle-opening distance was measured on a line perpendicular to the trabecular meshwork at points 250 µm (AOD250) and 500 µm (AOD500) from the scleral spur. The trabecular-iris angle was measured with the apex in the iris recess and the arms of the angle passing through a point on the trabecular meshwork 500 µm from the scleral spur and the point on the iris perpendicularly opposite. Figure 2. The anterior segment OCT (optical coherence tomography) image by slit-lamp-adapted OCT and anterior chamber parameters of the anterior chamber in phakic eye (A) and pseudophakic eye (B). ACD1, which is measured between the inner corneal surface and the intraocular lens surface, extends into the posterior chamber (Pavlin s original definition). ACD2, which is measured between the inner corneal surface and the plane of the posterior aspect of the iris at pupillary margin, represents the real anterior chamber depth in eyes with pseudophakia. As ACD1 extends into the posterior chamber, it is not the real ACD in pseudophakia. AOD250, which is the angle-opening distance at 250 µm from the scleral spur. AOD500, which is the angle-opening distance at 500 µm from the scleral spur. TIA, which is the trabecular-iris angle. 1444
대한안과학회지 2008 년제 49 권제 9 호 방각간거리 (angle-opening distance at 250 µm from scleral spur; AOD250), angle-opening distance at 500 µm from scleral spur; AOD 500), 앞방각 (trabecular-iris angle; TIA) 을측정하였다. 최대앞방깊이 (ACD) 는각막내측표면으로부터수정체의앞쪽표면까지의거리로정의되는데, 인공수정체삽입술후 Pavlin et al 11 의정의에따른최대앞방깊이 (ACD) 는후방까지일부측정값에포함되는단점이있으므로각막내측표면부터동공경계부위의홍채의뒤쪽면까지를최대앞방깊이 (ACD) 로정의하여측정하였다 (Fig. 1, 2). AOD500 은공막극에서 500 µm 떨어진각막내피면에서수직으로홍채를향해이은가상의직선의길이로정의하였다. TIA 는공막극에서 500 µm 떨어진각막내피면에그은가상선과그선에서수직으로홍채를향해이은점이홍채와만나는점을공막극과이은가상선사이의각으로정의하였다 (Fig. 1). 11 공막극은앞방내계측치의객관적인측정을위한기준점으로쓰이는중요한해부학적구조로서고리모양의아교질섬유로구성되어각막윤부와평행하게주행하므로전안부빛간섭단층촬영에서광학조직신호밀도에의한공막과비슷한정도의반사율을보이는고반사율의구조로서, 앞방으로약간튀어나와있는부분과섬유주의후방경계사이로정의된다. 14 LOCS III 분류에따르면백내장의정도를 Nuclear opalescence (NO), color (NC), cortical (C), posterior subcapsular opacity (P) 로분류하였는데, 본연구에서는 NO 와 NC 는 N 으로분류하고, N2, N3 를 1 군, N4, N5 를 2 군으로, C2, C3 을 1 군, C4, C5 를 2 군으로분류하였고, posterior subcapsular opacity 는연구대상에포함시키지않았다. 이것은본연구에서의연구대상숫자가적었기때문이며, N1, C1 군은본연구에서 1 안도수술대상에포함되지않았기때문이다. 또한 posterior subcapsular opacity 는대상숫자가적었고앞방내계측치의변화에영향이없을것으로생각되어연구대상에포함시키지않았다. 계측은한명의검사자에의해동일한환자의자세 로, 동일한조명하에시행되었으며, 산동에따른계측치의변화를배제하기위해산동되지않은조건에서시행하였다. SPSS 13.0 통계프로그램을사용하여측정한최대앞방깊이 (ACD), 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 의수술전과수술후의계측치의차이는 Wilcoxon signed rank test 로유의성을검정하고 Spearman`s rho correlation 을이용하여상관관계분석하였다. 수술전요소로백내장의정도에따른수정체의두께의차이가앞방내계측치의변화와연관되었는지를알기위해, 백내장의정도는 LOCS III 분류에따른 Nuclear, cortical opacity 정도에따라수술전과수술후의앞방내계측치의차이가있는지를 Kolmo gorov-smirnov Z-test 로유의성을검정하였다. 결 과 수술전의최대앞방깊이 (ACD), 앞방각간거리 (AOD 250, AOD500), 앞방각 (TIA) 의평균치는 2670.32 ±653.66 µm, 342.58±127.27 µm, 532.53±226.22 µm, 34.92±13.36 이었고, 수술후 1 주째의최대앞방깊이 (ACD), 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 의평균치는 3591.21±456.91 µm, 470.11 ±123.78 µm, 725.05±235.07 µm, 43.26±8.66 이었으며, 수술후 1 개월째의최대앞방깊이 (ACD), 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 의평균치는 3735.63±605.34 µm, 470.16±113.10 µm, 768.32±150.31 µm, 48.37±7.92 이었다 (Table 1). 수술전과수술후 1 주, 1 개월의실제촬영영상 (Fig. 3) 을보면홍채가후방전위된것을관찰할수있었다. 최대앞방깊이 (ACD) 는수술후 1 주에 1.34 배, 1 개월에 1.4 배, 앞방각간거리 (AOD250) 는수술후 1 주와 1 개월에 1.37 배, 앞방각간거리 (AOD500) 는수술후 1 주에 1.36 배, 1 개월에 1.44 배, 앞방각 (TIA) 는수술후 1 주에 1.24 배, 1 개월에 1.39 배증가하였다 (Table 1). 최대앞방깊이 (ACD), 앞방각간거리 (AOD250, AOD Table 1. The anterior chamber parameters of before and after small-incisional cataract surgery 1week and 1month Variable Preoperative 1 week 1 month 1 week difference 1 month difference ACD (µm)* AOD250 (µm) AOD500 (µm) TIA (degrees) 2670.32±653.66 342.58±127.27 532.53±226.22 34.92±13.36 3591.21±456.91 470.11±123.78 725.05±235.07 43.26±8.66 3735.63±605.34 470.16±113.10 768.32±150.31 48.37±7.92 920.89±698.45 127.53±149.33 192.53±244.09 8.34±13.19 1065.32±779.79 127.58±154.30 235.79±244.74 13.45±13.01 * ACD=anterior chamber depth; AOD250=angle-opening distance at 250 µm from the scleral spur; AOD500=angle-opening distance at 500 µm from the scleral spur; TIA=trabecular-iris angle. 1445
장동호외 : 백내장수술과앞방내계측치의변화 Figure 3. Anteior segment optical coherence tomography (OCT) image before cataract surgery (A), postoperative 1 week (B), postoperative 1 month (C). Note deepening of the anterior chamber depth (ACD), flattening of the convex iris configuration, and widening of the angle after cataract surgery. 500), 앞방각 (TIA) 은수술후 1 주 (P=0.000, 0.002, 0.005, 0.022) 와 1 개월 (P=0.000, 0.004, 0.001, 0.002) 에의미있게증가하였다 (Fig. 4, 5). 수술전의최대앞방깊이 (ACD), 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 은수술후 1 주와수술전의계측치의차이 (γ=-0.834, -0.591, -0.421, -0.826), 수술후 1 개월과수술전의계측치의차이 (γ=-0.659, -0.700, -0.770, -0.821) 와음의상관관계가있었고, 수술후 1 주와수술전의계측치의비 (γ=-0.875, -0.810, -0.638, -0.855), 수술후 1 개월과수술전의계측치의비 (γ=-0.789, -0.792, -0.817, -0.894) 와음의상관관계가있었다 (Fig. 6, Table 2). 수술전의백내장과앞방내계측치의변화를분석한결과, Nuclear opacity 의경우수술후 1 주째의최대앞방깊이, 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 의차는 1 군 (N2, N3. 10 안 ) 의평균치가 873.60±711.48 µm, 131.76±126.13 µm, 157.00 ±273.45 µm, 9.00±12.97 이었고, 2 군 (N4, N5. 9 안 ) 의평균치는 973.44±722.66 µm, 122.89±179.53 µm, 232.00±215.87 µm, 7.61±14.18 로의미있는차이는없었다 (P=0.959, 0.916, 0.824, 1.000)(Table 3). 수술후 1 개월째의최대앞방깊이, 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 의차는 1 군 (N2, N3. 10 안 ) 의평균치가 1129.30±965.33 µm, 121.60±120.22 µm, 230.10±195.42 µm, 14.80±11.70 이었고, 2 군 (N4, N5. 9 안 ) 의평균치는 994.22±555.88 µm, 132.22±192.92 µm, Table 2. The correlation efficients* of differences of anterior chamber parameters before and after small-incisional cataract surgery 1 week and 1 month Variable 1 week s difference 1 month s difference 1 week s ratio 1 month s ratio ACD (µm) AOD250 (µm) AOD500 (µm) TIA (degress) -0.834-0.591-0.421-0.826-0.659-0.700-0.770-0.821-0.875-0.810-0.638-0.855-0.789-0.792-0.817-0.894 * by Spearman's rho correlation; ACD=anterior chamber depth; AOD250=angle-opening distance at 250 µm from the scleral spur; AOD500=angle-opening distance at 500 µm from the scleral spur; TIA=trabecular-iris angle. Table 3. The change of the anterior segment parameters and P value at postoperative 1 week according to the nuclear opacity by LOCS Ⅲ Variable Group 1 (N2, N3) Group 2 (N4, N5) P value* ACD (µm) AOD250 (µm) AOD500 (µm) TIA (degress) 873.60±711.48 131.76±126.13 157.00±273.45 9.00±12.97 973.44±722.66 122.89±179.53 232.00±215.87 7.61±14.18 0.959 0.916 0.824 1.000 * by Kolmogorov-Smirnov Z test; ACD=anterior chamber depth; AOD250=angle-opening distance at 250 µm from the scleral spur; AOD500=angle-opening distance at 500 µm from the scleral spur; TIA=trabecular-iris angle. 1446
대한안과학회지 2008 년제 49 권제 9 호 Figure 4. The changes of anterior chamber parameters before and after surgery. (A) ACD change. (B) TIA change. (ACD, anterior chamber depth; TIA, trabecular-iris angle; P, p-value by Wilcoxon sign rank test) Figure 5. The changes of anterior chamber parameters before and after surgery. (A) AOD250 change. (B) AOD500 change. (AOD250, angle-opening distance at 250 µm from scleral spur; AOD500, angle-opening distance at 500 µm from scleral spur; P, p-value by Wilcoxon sign rank test) Table 4. The change of the anterior segment parameters and P value at postoperative 1 month according to the nuclear opacity by LOCS Ⅲ Variable Group 1 (N2, N3) Group 2 (N4, N5) P value* ACD (µm) AOD250 (µm) AOD500 (µm) TIA (degress) 1129.30±965.33 121.60±120.22 230.10±195.42 14.80±11.70 994.22±555.88 134.22±192.92 242.11±302.86 11.94±14.89 0.858 0.973 0.959 0.959 * by Kolmogorov-Smirnov Z test; ACD=anterior chamber depth; AOD250=angle-opening distance at 250 µm from the scleral spur; AOD500=angle-opening distance at 500 µm from the scleral spur; TIA=trabecular-iris angle. 242.11±302.86 µm, 11.94±14.89 로의미있는차이는없었다 (P=0.858, 0.973, 0.959, 0.959)(Table 4). cortical opacity 의경우수술후 1 주째의최대앞방깊이, 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 의차는 1 군 (C2, C3. 13 안 ) 의평균치가 916.15± 625.20 µm, 123.54±176.17 µm, 179.46 ±286.75 µm, 7.58±15.66 이었고, 2 군 (C4, C5. 6 안 ) 의평균치는 931.17±904.39 µm, 136.17±75.21 µm, 220.83± 125.44 µm, 9.98±5.76 로의미있는차이는없었다 (P=0.454, 0.665, 0.578, 0.578)(Table 5). 수술후 1 개월째의최대앞방깊이, 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 의차는 1 군 (C2, C3. 13 안 ) 1447
장동호외 : 백내장수술과앞방내계측치의변화 Table 5. The change of the anterior segment parameters and P value at postoperative 1 week according to the cortical opacity by LOCS Ⅲ Variable Group 1 (C2, C3) Group 2 (C4, C5) P value* ACD (µm) AOD250 (µm) AOD500 (µm) TIA (degress) 916.15±625.20 123.54±176.17 179.46±286.75 7.58±15.66 931.17±904.39 136.17±75.21 220.83±125.44 9.98±5.76 0.454 0.665 0.578 0.578 * by Kolmogorov-Smirnov Z test; ACD=anterior chamber depth; AOD250=angle-opening distance at 250 µm from the scleral spur; AOD500=angle-opening distance at 500 µm from the scleral spur; TIA=trabecular-iris angle. Table 6. The change of the anterior segment parameters and P value at postoperative 1 month according to the cortical opacity by LOCS Ⅲ Variable Group 1 (C2, C3) Group 2 (C4, C5) P value* ACD (µm) * AOD250 (µm) AOD500 (µm) TIA (degress) 1062.15±859.99 89.38±132.69 213.69±234.53 12.39±13.48 1072.17±643.39 210.33±177.34 283.67±282.15 15.73±12.80 0.999 0.207 0.950 0.981 * by Kolmogorov-Smirnov Z test; ACD=anterior chamber depth; AOD250=angle-opening distance at 250 µm from the scleral spur; AOD500=angle-opening distance at 500 µm from the scleral spur; TIA=trabecular-iris angle. 의평균치가 1062.15±859.99 µm, 89.38±132.69 µm, 213.69± 234.53 µm, 12.39±13.48 이었고, 2 군 (C4, C5. 6 안 ) 의평균치는 1072.17±643.39 µm, 210.33±177.34 µm, 283.67±282.15 µm, 15.73±12.80 로의미있는차이는없었다 (P=0.999, 0.207, 0.950, 0.981) (Table 6). 고 찰 본연구에서세극등현미경장착빛간섭단층촬영을이용하여앞방내계측치를측정한결과백내장적출술및뒤방인공수정체삽입술후 1 주째의앞방의깊이는평균 921 µm, 1.34 배증가하였고, 앞방각은평균 8.34, 1.24 배증가하였고, 1 개월째의앞방의깊이는평균 1065 µm, 1.40 배증가하였고, 앞방각은평균 13.45, 1.39 배증가하여수술전보다유의한증가를한것으로나타났다 (P<0.01, 단수술후 1 주째의앞방각의변화는 P=0.022). 1986 년에 Murphy 15 는 100 안에서백내장낭외적출술과후방인공수정체삽입술을시행한후평균 2.4 년후앞방각보개검사를시행한결과, 44 안에서주변홍채앞유착이관찰되었고, 이중 12 안은수술절개창에서주변부홍채앞유착이발생하였지만이로인한폐쇄각녹내장은유발되지않았다고보고하였다. Steuhl et al 1 은 1992 년에 Laser tomographic scanner 를사용하여앞방각의크기를측정한바에따르면백내장낭외적 출술과뒷방인공수정체삽입시앞방각의크기가술전 28.0 에서술후 37.4 로 9.4 가넓어졌으며증가비는 1.3 이었고연령이증가할수록수술에의한앞방각의증가가현저하다고하였다. 또한 Koo et al 2 이 1996 년에보고한바에따르면정상안압의백내장에서백내장낭외적출술및후방인공수정체삽입술시행한후 1 주째에 Scheimpflug camera 로측정하여앞방의깊이는 0.22 mm 증가하고, 앞방각의크기는 2.51 증가한다고하였다. 1997 년 Kurimoto et al 3 은초음파생체현미경을이용하여백내장수술전과 3 개월후의 cornea center 에서의최대앞방깊이 (ACD), 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 을측정한결과앞방은의미있게깊어졌으며앞방각도의미있게넓어졌다고하였다. 또한수술전의앞방이얉을수록수술후의앞방의변화가크고, 수술전의앞방각이좁을수록수술후의앞방각의변화가크다고하였다. Lee et al 4 은 1998 년에수정체유화술과계획적백내장낭외적출술을시행하고뒤방인공수정체를삽입한후 Scheimpflug camera 를이용하여수술전및후의앞방각변화를비교한결과, 두군모두술전보다유의한증가를보였으나, 수정체유화술과백내장낭외적출술에따른앞방각의차이는없었으며, 앞방각증가는수정체의제거와인공수정체의종류등이수술후앞방각변화에영향을미친것으로생각하였다. 또한 2003 년 Pereira and Cronemberger 5 는초음파생체현미경을이용하여백내장수술전, 수술후 1 개월과 3 개월의 1448
대한안과학회지 2008 년제 49 권제 9 호 Figure 6. The preoperative anterior chamber parameters and ratio of postoperative 1 week parameters. X-axis: preoperative value, Y-axis: postoperative 1 week value/preoperative value (A) ACD (B) AOD250 (C) AOD500 (D) TIA. (ACD, anterior chamber depth; AOD250, angle-opening distance at 250 µm from scleral spur; AOD500, angle-opening distance at 500µm from scleral spur, TIA, trabecular-iris angle) 앞방내계측치의변화를측정한바에따르면앞방의깊이는 30 퍼센트증가하였고, 앞방각은 10 도증가한다고하였다. 전안부빛간섭단층촬영은기존의앞방각을평가하는다른방법에비해여러가지장점을갖는생체계측방법으로알려져있다. 16 전안부빛간섭단층촬영은초음파생체현미경에비해해상도가더높고비접촉으로검사가가능하므로환자에게편안하며비침습적이며영상의왜곡이없고, 비교적숙련되지않아도가능한검사이다. 17 그러나기존에전안부빛간섭단층촬영을이용하여백내장수술후백내장의정도에따른앞방내계측치의변화를측정하는연구는시행된바가없으므로본연구를계획하게되었다. 본연구에서는백내장수술후의앞방내의변화를알아보기위해앞방내계측치로최대앞방깊이 (anterior chamber depth; ACD), 앞방각간거리 (angleopening distance at 250 µm from scleral spur; AOD250), angle-opening distance at 500 µm from scleral spur; AOD500), 앞방각 (trabecu lar-iris angle; TIA) 를이용하였다. 최대앞방깊이 (ACD) 는각막내측표면 ( 각막내피 ) 로부터수정체의앞쪽표면까지의거리로정의하고, 백내장수술후는각막내피로부터동공경계부위의홍채의뒤쪽표면까지의거리로정의하여측정하였다. Palvin et al 11 에의하면평균치는 3128±372 µm 이다. 또한 AOD250 은공막극에서 500 µm 떨어진각막내피면에서수직으로홍 1449
장동호외 : 백내장수술과앞방내계측치의변화 채를향해이은가상의직선의길이로정의되며, 이것은섬유주에해당된다. 평균치는 347±181 µm 이다. 4 AOD500 은공막극에서 500 µm 떨어진각막내피면에서수직으로홍채를향해이은가상의직선의길이로정의되며, 섬유주의앞쪽에해당하고평균치는 208 ±109 µm 이다. 11 앞방각 (TIA) 은공막극에서 500 µm 떨어진각막내피면에그은가상선과그선에서수직으로홍채를향해이은점이홍채와만나는점을공막극과이은가상선사이의각으로정의되고평균치는 30±11 이다. 11 최대앞방깊이 (ACD) 는앞방의깊이를정량적으로측정하기위해앞방깊이중최대거리를측정하여앞방깊이의변화를정량적으로측정하는계측치로이용하며, 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 은앞방각의변화를정량적으로측정하는계측치로이용된다. 앞방각의크기는수정체의두께, 홍채의안구내상대적위치, 각막의두께, 각막의직경, 각막의곡률반경, 홍채의산동정도, 홍채의기시부위치, 홍채의굴곡정도에따라결정되며, 또한성별, 굴절이상, 연령에따라변화한다. Lee et al 18 은 Scheimpflug came ra 를이용하여정상성인 64 명에서측정한앞방각의크기는 32.190±4.58 이었으며, 연령이젋을수록컸으며, 남자가여자보다크다고하였다. 본논문에서측정된수술전앞방각은 34.92±13.36 였으나, 연령, 굴절이상, 성별에따른변화는연구대상이적어검토하지못했다. 또한 Müller et al 14 에의하면전안부빛간섭촬영 (anterior segment optical coherence tomo graphy) 을이용한앞방각의변화측정시한환자에서의좌안과우안의연관관계가없다고하였기때문에동일한환자에서의좌안혹은우안, 혹은양안에서의측정을시행하였고, 한검사자에의한측정이나두사람이상의검사자에의한측정이나앞방각계측치의재현성이높았기때문에 14 동일한측정자에의한측정으로도계측치의재현성은보장되리라생각되어한검사자에의한측정을시행했다. 또한전안부빛간섭촬영을이용한앞방각의변화측정시한환자에서의 3 시에서나 9 시에서의연관관계가없기때문에 14 앞방각의측정은동일한환자에서 3 시에서혹은 9 시에서의구별없이무작위로위치를정하여측정을시행하였다. 본연구에서는백내장수술전의최대앞방깊이 (ACD), 앞방각간거리 (AOD250, AOD500), 앞방각 (TIA) 은수술후 1 주와수술전의계측치의차이와음의상관관계가있었고, 또한수술후 1 개월과수술전의계측치의차이와도음의상관관계가있었다. 결론적으로백내장수술후최대앞방깊이, 앞방각간거리, 앞방각은의 미있게증가하였으며, 수술전최대앞방깊이가얕을수록, 앞방각간거리가작을수록, 앞방각이작을수록수술후의최대앞방깊이, 앞방각간거리, 앞방각의변화가크다고할수있다. 소절개백내장적출술및뒤방인공수정체삽입술후앞방이깊어지고, 앞방각이넓어지는기전으로알려진것은백내장을제거한후뒤방인공수정체를삽입하면뒤방인공수정체가수정체보다두께가얇아서각막후면으로부터의거리가멀어지며, 인공수정체가앞방으로굴곡된지지부에의하여후방전위되어뒤로밀리는효과가발생하여백내장수술후앞방깊이가증가된다고알려져있다. 19,20 이에저자들은백내장의정도에따라수정체두께가차이가날수있고, 그에따른앞방각의밀집현상 (crowding) 으로앞방깊이나앞방각의변화에영향을미치므로, 백내장수술후수정체의제거가앞방깊이나앞방각의변화에도영향을미칠수있는지에대한가설을세우고, 환자의수술전요소로 LOCS Ⅲ 분류에따른백내장의정도를고려하였다. 본연구에서수술전의백내장의정도에따라수술후 1 주, 1 개월의최대앞방깊이, 앞방각간거리 (AOD 250, AOD500), 앞방각의차는다르지않았다. 따라서수술전의백내장의정도는백내장수술후앞방내계측치의변화에영향을미치지않는다고생각된다. 본논문은전안부빛간섭단층촬영이라는새로운기계를이용하여백내장의정도에따른앞방내계측치를구체적인수치로제시한데의의가있지만계측치의표준변차가커서분석의통계적인검정의한계는있다고사료된다. 참고문헌 1) Steuhl KP, Marahrens P, Frohn C, Frohn A. Intraocular pressure and anterior chamber depth before and after extracapsular cataract extraction with posterior chamber lens implantation. Ophthalmic Surg 1992:23;233-7. 2) Koo BS, Chung J, Baek NH. The effect of extracapsular cataract extraction in patients with chronic angle-closure glaucoma combined with cataract. J Korean Ophthalmol Soc 1996:37;1045-53. 3)Kurimoto Y, Park M, Sakaue H, Kondo T. Changes in the anterior chamber configuration after small-incision cataract surgery with posterior chamber intraocular lens implantation. Am J Ophthalmol 1997;124:775-80. 4) Lee HJ, Chung SK, Baek NH. Changes of preoperative and postoperative anterior chamber angle in phacoemulsification and planned extracapsular cataract extraction. J Korean Ophthalmol Soc 1998;39:1170-5. 5) Pereira FA, Cronemberger S. Ultrasound biomicroscopic study 1450
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장동호외 : 백내장수술과앞방내계측치의변화 =ABSTRACT= Changes of Anterior Chamber Depth and Angle After Cataract Surgery Measured by Anterior Segment OCT Dong Ho Chang, M.D. 1, Seung Chan Lee, M.D. 2, Kyung Hyun Jin, M.D. 1 Department of Ophthalmology, KyungHee University College of Medicine 1, Seoul, Korea Department of Ophthalmology, Kangwon University College of Medicine 2, Gangwon, Korea Purpose: To report the change of anterior chamber parameters according to cataract severity after cataract surgery and to determine its relationship to the severity of cataract by using anterior segment optical coherence tomography. Methods: We measured the anterior chamber parameters in 19 eyes of 14 patients before, 1 week after, and 1 month after cataract surgery by slit lamp-adapted optical coherence tomography (SL-OCT). The measured parameters were as follows : the anterior chamber depth (ACD), the angle-opening distance 250 μm from the scleral spur (AOD250), the angle-opening distance 500 μm from the scleral spur (AOD500), and the trabecular-iris angle (TIA). We analyzed the relationship between the severity of cataract and the change of the anterior chamber parameters. Results: The ACD, AOD250, AOD500, and TIA increased significantly at postoperative 1 week (P=0.000, 0.002, 0.005, 0.022) and 1 month (P=0.000, 0.004, 0.001, 0.002). The preoperative parameters were negatively correlated with the differences between the postoperative 1 week and preoperative parameters (γ = -0.834, -0.591, -0.421, -0.826) and between postoperative 1 month and preoperative parameters (γ = -0.659, -0.700, -0.770, -0.821). The change of parameters at postoperative 1 week (by N P=0.959, 0.916, 0.824, 1.000, by C P=0.454, 0.665, 0.578, 0.578) and 1 month (by N P=0.858, 0.973, 0.959, 0.959, by C P=0.999, 0.207, 0.950, 0.981) were not significantly different according to the severity of cataract (N, C). Conclusions: Our results showed that cataract surgery significantly deepened the anterior chamber and widened its angle. The shallower and narrower the preoperative anterior chamber depth and angle were, respectively, the greater the postoperative changes of anterior chamber depth and angle were. J Korean Ophthalmol Soc 2008;49(9):1443-1452 Key Words: Anterior chamber depth (ACD), Angle-opening distance 250 (AOD250), Angle-opening distance 500 (AOD500), Slit-lamp adapted optical coherence tomography (SL-OCT), Trabecular-iris angle (TIA) Address reprint requests to Kyung Hyun Jin, M.D. Department of Ophthalmology, KyungHee University College of Medicine #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea Tel: 82-2-958-8451, Fax: 82-2-966-7340, E-mail: khjinmd@khmc.or.kr 1452