대한안과학회지 2015 년제 56 권제 2 호 J Korean Ophthalmol Soc 2015;56(2):304-308 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) http://dx.doi.org/10.3341/jkos.2015.56.2.304 Case Report 가림치료중단후에도회복되지않은우세안의가림원인약시 1 예 Case of Reverse mblyopia of the Dominant Eye that was Refractory to Treatment 김민석 김원제 김명미 Min Seok Kim, MD, Won Jae Kim, MD, Myung Mi Kim, MD, PhD 영남대학교의과대학안과학교실 Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea Purpose: The treatment for reverse amblyopia is to discontinue occlusion therapy with most cases showing improvement of visual acuity in the dominant eye. Herein, we report a case of reverse amblyopia after monocular cataract surgery which was refractory to treatment and showed strabismus. Case summary: 3-month-old female was diagnosed with congenital cataract in her left eye and underwent aspiration of lenses, posterior capsulectomy, and anterior vitrectomy. fter the surgery, her mother performed strict 6:1 occlusion therapy on her right eye as prescribed. The best corrected visual acuity measured for the first time at the age of 32 months was 1.70 in the right eye and 0.52 in the left eye and the patient was referred to the Pediatric Ophthalmology clinic. t that time, eccentric fixation with slight exotropia was observed. With the diagnosis of reverse amblyopia in the right eye, the occlusion therapy was postponed for several months, however, visual acuity in the right eye did not recover after 4 months. fter the age of 3 years, she was treated with left eye occlusion therapy, but the vision was still low and eccentric fixation was observed. t the age of 5 years she was continuously treated with left eye occlusion and the eccentric fixation improved, and at 6 years of age, a secondary intraocular lens implantation was performed. t 9 years of age, the patient underwent lateral rectus recession and medial rectus resection in the right eye for the treatment of exotropia. Conclusions: In the case of monocular congenital cataract, occlusion therapy should be prescribed after surgical treatment. However, because reverse amblyopia which is refractory to treatment can occur, the fixation pattern should be monitored carefully and the occlusion duration controlled appropriately. J Korean Ophthalmol Soc 2015;56(2):304-308 Key Words: Congenital cataract, Eccentric fixation, Exotropia, Occlusion therapy, Reverse amblyopia 약시는안과검사에서안구의구조적, 기질적이상이없으나, 임상적으로시력저하가있으면서안경교정으로정상시력이나오지않는상태를말한다. 1,2 약시는일정한시기 Received: 2014. 2. 7. Revised: 2014. 10. 23. ccepted: 2015. 1. 7. ddress reprint requests to Myung Mi Kim, MD, PhD Department of Ophthalmology, Yeungnam University Medical Center, #170 Hyeonchung-ro, Nam-gu, Daegu 705-802, Korea Tel: 82-53-620-3441, Fax: 82-53-626-5936 E-mail: mmk@med.yu.ac.kr 가지나면치료할수없는비가역적인상태가되기에조기검진을통해가역적인약시민감기에찾아내어적극적인치료를시행해야한다. 3 약시치료의일차적인목표는약시안의시력회복이나개선으로, 약시안을강제로쓰게하는방법으로치료하게된다. 굴절이상교정과우세안에대한가림치료, 처벌치료, 혹은약물치료등을시행하는데가림치료가비용효과측면에서가장선호되고있는치료방법이다. 1,2,4 가림치료는우세안을가려약시안을강제로쓰게하는효과적인약시치료방법이지만드물게가린우세안의가림원인약시가발생할수있다는점에서정기적인경과관 c2015 The Korean Ophthalmological Society This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 304
- 김민석외 : 회복되지않은가림원인약시 1 예 - 찰이필수적이다. 4 가림치료도중에우세안에발생한가림원인약시는대부분의환자들에서우세안의가림치료를중단하면쉽게회복이된다고알려졌다. 5-8 그러나저자들은선천백내장으로수술후가림치료시행중에우세안의가림원인약시가발생하여다시약시안의가림을시행하였으나시력이완전히회복되지않고사시가발생한 1예를경험하였기에이를보고하고자한다. 증례보고 생후 2개월된여아가좌안백색동공을주소로내원하였다. 초진때세극등현미경검사에서좌안의수정체중심부위에핵혼탁소견이있었고이때문에안저는보기힘들었으나초음파검사에서망막박리소견은없었다. 조절마비굴절검사에서우안의굴절이상은 +2.50 D sph +2.00 D cyl 90 axis이었고, 좌안은망막반사를볼수없었다. 환아는출생체중이 3,000 gm으로제태기간은 40주이었고질식분만으로출생하였으며성장및발육의지연은보이지않았다. 산모의산과력에서특이사항은없었으며, 부모의가족력에서전신질환, 유전질환이나안질환은없었다. 좌안의선천백내장으로진단하고자궁내선천감염검사를위해시행한 TORCH 검사 (Toxoplasma, Rubella, Cytomegalovirus, and Herpes) 에서혈청거대세포바이러스 IgM 항체가양성이었고혈액검사에서 aspartate aminotransferase (ST) / alanine aminotransferase (LT) 가 80/53 IU/L로높게나타나선천거대세포바이러스감염에의한급성간염으로진단되었다. 진단즉시선천거대세포바이러스감염치료를위해소아청소년과에입원하였고 ganciclovir (Cymevene R, Roche pharma Ltd., asel, Switzerland) 150 mg를하루에 3회정맥주사로치료를시작하였으며치료를시작한지 13일째에수정체유화술과후낭절제술, 앞유리체절제술을시행받았다. 수술후 2일째에시행한안저검사에서망막에특이소견은없었으며싸이클로질에의한조절마비굴절검사에서우안은 +2.50 D sph +0.50 D cyl 90 axis, 좌안은 +21.50 D sph +1.00 D cyl 90 axis의굴절이상이있었다. 안경을처방하였으며시력은측정할수없었지만좌안의약시가있을것이라고설명후우안에 6:1 종일가림치료를처방하고외래경과관찰을시행하였다. 보호자는가림치료를매우잘준수하였다. 생후 32개월때에처음으로시력을측정할수있었으며당시측정한최대교정시력 (best corrected visual acuity, CV) 은우안이안전수지 1.70 m (x-2.50 D sph +2.00 D cyl 90 axis), 좌안은 0.52 (x+17.50 D sph +0.50 D cyl 90 axis) 으로가림원인약시를의심하고우안의가림치료를중단한후소아안과외래에의뢰되었다. 생후 35개월에처음의뢰되었을당시 CV는우안이안전수지 1.70 m, 좌안은 0.05이었으며우안에는중심외주시가관찰되었고안구운동검사에서약간의외사시가있었다. 생후 36개월에측정한 CV는우안이안전수지 1.70 m, 좌안은 0.22이었고, 안구운동검사에서우안의 30 프리즘디옵터 (prism diopters, PD) 의외편위가있었다. 우안의가림치료를중단한이후 4개월의기다림에도가림원인약시가호전되지않아이때 ( 만 3세 ) 부터깨어있는시간의 80% 를목표로좌안의가림치료를시작하였고, 이후지속적인좌안가림치료를시행하였으나우안의시력이쉽게회복되지않았으며지속적으로중심외주시양상이관찰되었다 (Fig. 1). 가림치료를계속하였으나만 5세경 CV는우안이 1.00 (x plano +1.50 D cyl 90 axis), 좌안은 0.30 (x+16.50 D sph) 이었으며중심외주시는없어졌지만안구운동검사에서우안에 12 PD의외편위와 25 PD의해리수직편위가있었다. 만 6세경좌안의이차인공수정체삽입술후 1개월째의 CV는우안이 0.40 (x-0.50 D sph +1.00 D cyl 90 axis), 좌안은 0.15 (x-2.50 D sph +0.50 D cyl 90 axis) 이었고, 안구운동검사에서우안의 18 PD의외편위와 18 PD의해리수직편위가있었다. 꾸준히좌안가림치료를시행하였으나만 9세경 CV 는우안이 0.40 (x-1.25 D sph +0.75 D cyl 90 axis), 좌안은 0.15 (x-2.00 D sph) 로우안의약시가지속되었으며안구 Figure 1. The eccentric fixation on the right eye (), and left eye fixation without correction (). 305
- 대한안과학회지 2015 년제 56 권제 2 호 - Figure 2. The preoperative ocular alignment (). Postoperative 1 month after the lateral rectus recession and medial rectus resection on the right eye (). C D Figure 3. t the age of 11 years, the color fundus photographs (, C) and the spectral-domain optical coherence tomography (, D) were normal in the both eyes. 운동검사에서우안에 32 PD의외편위와 8 PD의해리수직편위가관찰되었고 (Fig. 2), 눈에띄는사시를교정하기위하여이때외사시에대해우안에외직근후전및내직근절제술을시행하였다. 수술후 1개월째 CV는우안이 0.30 (x-1.25 D sph +0.75 D cyl 90 axis), 좌안은 0.05 (x-2.50 D sph) 이었고안구운동검사에서우안에 2 PD의해리수직편위가관찰되었다 (Fig. 2). 이후 1년이상의가림치료에도불구하고더이상시력회복을보이지않아가림을중단하였다. 만 10세경 CV는우안이 0.15 (x-2.00 D sph +0.75 D cyl 90 axis), 좌안은 0.05 (x-2.50 D sph) 이었으며안구운동검사에서외사시는없이 10 PD의우안해리 수직편위만보였다. 최근경과관찰에서 CV는우안이 0.15 (x-1.25 D sph +0.75 D cyl 90 axis), 좌안은 0.00 (x-3.50 D sph) 이었고안구운동검사에서우안에 16 PD의외편위와 10 PD의해리수직편위가관찰되었으며안저사진및빛간섭단층촬영상좌안과우안모두에서구조적이상을시사하는소견은관찰되지않았다 (Fig. 3). 고찰 약시의치료는우세안의자극을감소시켜약시안을강제로쓰도록하는것으로의사에따라선호도차이가있지만 306
- 김민석외 : 회복되지않은가림원인약시 1 예 - 일반적으로가림치료가가장효과가좋다고알려졌다. 4 가림치료는우세안을안대로가리는치료로종일가림치료와부분가림치료로구분된다. 3 가림치료의부작용으로는안대로인한피부문제와미용상문제, 가림원인약시가있으며 9-11 이중임상적으로가장심각한가림원인약시는가림치료중에오히려우세안의시력이감소하는것으로 Scott et al 8 은이전의약시안으로주시하거나기존의우세안시력이약시안의시력보다적어도한줄이상떨어진경우를가림원인약시로정의하였다. 이전의연구에서가림원인약시의빈도는 4-25% 로다양하게보고되고있으며, 대부분의환자에서우세안의가림치료를중단하면쉽게회복이된다고알려졌다. 6,8,12 Pediatric Eye Disease Investigator Group 6 의연구에서가림치료를받은 200명중 14명 (7%) 에서 6개월후한줄이상의우세안시력저하를보였는데, 이들은모두특별한치료없이시력을회복하였다. 국내의보고에서 Park and Chang 13 은가림치료를시행한 500명중 28명 (5.6%) 에서우세안의시력이약시안보다한줄이상의시력저하를관찰했으며 28명중 21명 (75%) 에서가림시간의감소혹은가림중단으로, 나머지 7 명 (25%) 에서는반대안가림혹은추가적인안경교정으로시력회복을보여모든환자에서우세안의시력이회복되었다고보고하였다. 그러나본증례의경우와같이우세안의가림치료를중단하여도회복되지않는가림원인약시도있다. Patil et al 14 은가림치료가아닌아트로핀처벌치료중우세안의시력이약시안보다낮아진 1예를보고하였다. 아트로핀처벌치료를시작한후 3개월째에발생한우세안의가림원인약시는즉각적인처벌치료중단이후에도회복되지않았으며약시안의적극적인아트로핀처벌치료와약시이었던눈의가림치료를 1년이상시행후에도결국회복되지않았다. 본증례의경우선천백내장으로수술을시행한후가림치료를시작하였으며치료후 32개월째에가림원인약시가발견되었다. 이후우세안의가림치료를중단하고약시안에준수도가높은가림치료를열심히하였지만시력이회복되지않았고사시에대해서는사시수술을시행하였다. 이전의가림원인약시에대한보고와는달리발생후 6년이상의적극적인약시치료에도불구하고원래우세안이었던눈이오히려약시안으로남았다. 가림치료때문에생기는우세안의가림원인약시는심각한부작용으로, 일반적으로가림치료를중단하면쉽게회 복되는것으로알려졌으나늦게발견되면본증례처럼회복되지않는경우도있다. 그러므로가림치료의처방후, 정기적인경과관찰에서는비우세안의시력뿐만아니라우세안의시력도특별히주의깊게측정하도록노력해야하며, 만일환자가어려서시력측정이안된다면주시형태의면밀한관찰을통해시력저하를파악하는것이필요하다. 만일우세안의시력저하가발견되면가림시간을조절하여우세안에도충분한양의시자극을제공함으로써가림원인약시를예방해야하겠다. REFERENCES 1) Simons K. mblyopia characterization, treatment, and prophylaxis. Surv Ophthalmol 2005;50:123-66. 2) von Noorden GK. inocular vision and ocular motility, 6th ed. St. Louis: Mosby, 2002;246-97. 3) Korean ssociation for Pediatric Ophthalmology and Strabismus. Current concepts in strabismus, 2nd ed. Naewae Haksool, 2008;403-7. 4) Scott WE, Stratton V, Fabre J. Full-time occlusion therapy for amblyopia. m Orthopt J 1980;30:125-30. 5) Foley-Nolan, McCann, O'Keefe M. tropine penalisation versus occlusion as the primary treatment for amblyopia. r J Ophthalmol 1997;81:54-7. 6) Pediatric Eye Disease Investigator Group. randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. rch Ophthalmol 2002;120:268-78. 7) Simons K, Stein L, Sener EC, et al. Full-time atropine, intermittent atropine, and optical penalization and binocular outcome in treatment of strabismic amblyopia. Ophthalmology 1997;104:2143-55. 8) Scott WE, Kutschke PJ, Keech RV, et al. mblyopia treatment outcomes. J POS 2005;9:107-11. 9) Simons K. Preschool vision screening: rationale, methodology and outcome. Surv Ophthalmol 1996;41:3-30. 10) Oliver M, Gotesman N, Shimshoni M. Compliance and results of treatment for amblyopia in children more than 8 years old. CHILDREN 1986;197:75. 11) Searle, Norman P, Harrad R, Vedhara K. Psychosocial and clinical determinants of compliance with occlusion therapy for amblyopic children. Eye (Lond) 2002;16:150-5. 12) Kim YH, Choi MY. The prospective comparison of the efficacy of intermittent atropine penalization and part-time occlusion therapy. J Korean Ophthalmol Soc 2008;49:958-66. 13) Park SH, Chang HR. Decreased visual acuity of dominant eye compared to amblyopic eye during occlusion therapy. J Korean Ophthalmol Soc 2010;51:1374-9. 14) Patil P, Meenakshi S, Surendran TS. Refractory reverse amblyopia with atropine penalization. Oman J Ophthalmol 2010;3: 148-9. 307
- 대한안과학회지 2015 년제 56 권제 2 호 - = 국문초록 = 가림치료중단후에도회복되지않은우세안의가림원인약시 1 예 목적 : 가림치료중우세안에발생한가림원인약시의경우대부분가림을중지하면시력이회복된다고알려졌으나, 반대눈의가림치료에도시력이완전히회복되지않고이후사시가발생하였던예를경험하여이를보고하고자한다. 증례요약 : 좌안의선천백내장으로생후 3 개월째에수술한여자환자에서수술후약시치료로우안에 6:1 가림치료를하면서경과관찰중생후 32 개월때에처음측정한최대교정시력이우안은안전수지 1.70 m, 좌안이 0.52 로가림원인약시를의심하고우안의가림치료를중단한후소아안과외래에의뢰되었다. 이때우안은중심외주시가있었고안구운동검사에서약간의외사시소견을보였다. 우안의가림치료를중단한채기다려보기로하였지만약시안의시력은호전되지않았다. 만 3 세때부터는좌안의가림치료를시행하였으나우안의시력은쉽게회복되지않고지속적으로중심외주시양상을보였다. 가림치료를계속하는도중만 5 세경에중심외주시는좋아졌고만 6 세경좌안의이차인공수정체삽입술을시행하였다. 경과관찰중만 9 세경 32 프리즘디옵터 (prism diopters, PD) 의외편위와 8 PD 의해리수직편위에대해우안외직근후전및내직근절제술을시행하였다. 결론 : 단안선천백내장은수술후매우적극적으로가림치료를시행해야한다. 그러나그결과로가림원인약시가생겨서치료해도회복되지않는경우가있으므로, 시력측정이안되는어린나이에서는주시형태변화등으로우세안의시력저하를주의깊게관찰하여우세안가림의시간을조절함으로써가림원인약시의예방이필요하다고생각한다. < 대한안과학회지 2015;56(2):304-308> 308