대한안과학회지 2018 년제 59 권제 4 호 J Korean Ophthalmol Soc 2018;59(4):307-313 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2018.59.4.307 Original Article 코경유눈물주머니코안연결술시트리암시놀론을적신코충전물의임상적효과 The Clinical Effects of Triamcinolone-soaked Nasal Packing on Endonasal Dacryocystorhinostomy 송석현 1,2 이가현 1,2 Seok Hyeon Song, MD 1,2, Ka Hyun Lee, MD 1,2 건양대학교의과대학안과학교실 1, 건양대학교명곡의과학연구소 2 Department of Ophthalmology, Konyang University College of Medicine 1, Daejeon, Korea Myunggok Medical Research Institute, Konyang University 2, Daejeon, Korea Purpose: To evaluate the clinical effects of triamcinolone-soaked nasal packing on endonasal dacryocystorhinostomy (DCR). Methods: The study included 91 patients (156 eyes) with primary acquired nasolacrimal duct obstruction who underwent endonasal DCR from March 2015 to February 2017. A total of 50 eyes were packed with triamcinolone-soaked Nasopore and 106 eyes were packed with Nasopore without triamcinolone (control group). The anatomical and functional success percentage, revision percentage, and postoperative complications such as granulation, synechiae, and membrane formation were compared between the groups at 1 week, 1 month, 2 months, and 4 months postoperatively. Results: At postoperative 2 months, there was a statistically significant difference in the anatomical success percentage in the triamcinolone-soaked group (100%) compared to the control group (86.8%; p = 0.007). There were no statistically significant differences between the two groups in anatomical success percentage at postoperative 4 months (p > 0.05). However, there was a statistically significant difference in the functional success percentage in the triamcinolone-soaked group (92.0%) compared to the control group (78.3%; p = 0.035). When comparing postoperative complications, the triamcinolone-soaked group (4.0%) had a lower incidence of granulation than the control group (16.0%) (p = 0.032), but there were no differences in synechiae and membrane formation (p > 0.05). There was a statistically significant difference in the revision percentage in the triamcinolone-soaked group (4.0%) compared to the control group (16.0%) (p = 0.032). Conclusions: Triamcinolone-soaked nasal packing for endonasal DCR is an effective method for increasing the success percentage and lowering the incidence of granuloma and revision percentages. J Korean Ophthalmol Soc 2018;59(4):307-313 Keywords: Endonasal dacryocystorhinostomy, Nasopore, Triamcinolone Received: 2017. 11. 23. Revised: 2017. 12. 28. Accepted: 2018. 4. 1. Address reprint requests to Ka Hyun Lee, MD Department of Ophthalmology, Konyang University Hospital, #158 Gwanjeodong-ro, Seo-gu, Daejeon 35365, Korea Tel: 82-42-600-9258, Fax: 82-42-600-9251 E-mail: chullan@kyuh.ac.kr * This work was supported (in part) by Konyang University Myunggok Research Fund of 2016. * Conflicts of Interest: The authors have no conflicts to disclose. 코경유눈물주머니코안연결술은원발코눈물관막힘환자에서가장널리시행되고있는수술방법으로, 1989년 McDonogh and Meiring에의해코안내시경을이용한눈물주머니코안연결술이처음소개된이후수술기구와술기방법의지속적인발전으로현재는수술성공률이 80-95% 로보고되고있다. 1,2 코경유눈물주머니코안연결술의수술초기실패의흔한요인으로창상치유기간동안발생하는육아종, 염증, 반흔조직의과다형성등으로인 c2018 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution 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. 307
- 대한안과학회지 2018 년제 59 권제 4 호 - 한협착및유착이제시되고있다. 3-8 창상치유과정은크게염증기, 증식기, 성숙기로나누어지는데, 스테로이드는창상치유과정초기에염증반응을억제하여수술후반흔형성과부종발생을억제하고수술부위재상피화를촉진하는효과가있다고알려져있다. 9.10 Côté and Wright 11 는내시경을이용한부비동수술에서트리암시놀론을적신코충전물의수술초기상처회복촉진효과를보고하였으며, Cheng et al 12 은코경유눈물주머니코안연결술과비중격성형술을동시에시행할때트리암시놀론을적신코충전물을수술부위에채워넣은결과 96.4% 의높은수술성공률을보고한바있다. 아직안과영역에서코경유눈물주머니코안연결술시스테로이드사용의효과에대한보고는많지않으며, 국내에서코경유눈물주머니코안연결술에서트리암시놀론을적신코충전물의임상효과를보고한문헌은없다. 이에저자들은본연구에서코경유눈물주머니코안연결술중트리암시놀론을적신코충전물을사용하여얻을수있는임상적효과를해부학적및기능적수술성공률, 합병증발생률, 재수술률을통해알아보고자하였다. 대상과방법 2015년 3월부터 2017년 2월까지본원에서원발코눈물관막힘으로진단받고코경유눈물주머니코안연결술을시행받은환자 91명, 156안을대상으로후향적연구를시행하였다. 본연구는헬싱키선언을준수하였고본원윤리위원회의승인을받아 (2017-11-016) 진행하였다. 이전에실리콘관삽입술, 눈물주머니코안연결술을시행한환자, 공동눈물소관막힘, 눈물소관폐쇄가있는환자, 외상이나종양등이차적인원인에의한코눈물관막힘이있는환자, 비내시경검사상비중격만곡, 중비갑개비후등의비강내이상이심한환자들은대상에서제외하였다. 대상 156안중코충전물로트리암시놀론을적신 Nasopore 를넣은 50안을실험군, 트리암시놀론을적시지않은 Nasopore 를넣은 106안을대조군으로나누었으며, 트리암시놀론사용여부는무작위로결정하였다. 각군별로환자의나이, 성별, 수술받은눈의방향, 이전에눈물주머니염과거력, 실리콘관유지기간, 총경과관찰기간, 당뇨, 고혈압유무, 항응고제또는항혈소판제복용여부를조사하였고, 환자가항응고제또는항혈소판제를복용하는경우는수술전, 후 1주일간중단하도록하였다. 수술은숙련된한명의술자에의해동일한술식으로전신마취하에서시행되었다. 수술과정은 Epinephrine 1 mg/ml (Bosmin solution, Jeil Pharm., Seoul, Korea) 에적신거즈를 Bayonet forceps를이용하여비강내중비도에충분히채워넣어비점막을수축시키고, 20 gauge light probe (Endoillumination probe, 0.9 mm in diameter, DORC, International BV, Zuidland, Netherlands) 를상누점으로삽입하여중비도의눈물주머니부위를확인하였다. 광원이투영되는눈물주머니부위의코점막을겸상도 (sickle knife) 로절개하고, 노출된골조직은 Microdrill (Aesculap, 3 mm, B.Braun, Melsungen, Germany) 을이용하여약 10 mm 크기의골공을만들었다. 눈물주머니는사골겸자 (Ethmoid forceps) 를이용하여제거하였으며, 눈물소관탐침및관류검사로눈물주머니코안연결을확인하였다. 모든환자에서실리콘관을삽입하였고, 실험군은 Triamcinolone 40 mg/ml (Rheudenolone, Kukje Pharm., Seongnam, Koera) 1 ml를적신합성스펀지 (Nasopore, Corp., Stryker, Groningen, Netherlands) 를, 대조군은트리암시놀론을적시지않은합성스펀지 (Nasopore, Corp., Stryker) 를비강내수술부위에채워넣었다 (Fig. 1). 실험군과대조군수술부위에모두항생제및다른약물주사는시행하지않았다. 수술부위출혈방지를위해거즈를비강에채워넣고술후 1일째아침까지유지하였다. 합성스펀지 (Nasopore, Corp., Stryker) 는술후 1주일까지흡수되지않은경우에는비내시경검사를통해제거하였고, 술후직후부터 1개월동안 Levofloxacin 점안액 (Cravit Ophthalmic solution, Santen, Osaka, Japan) 과 0.1% Fluorometholone 점안액 (Fluorometholone Ophthalmic solution, Taejoon, Seoul, Korea) 을하루 4회점안하게하였다. 또한술후 1일째아침비강에채워넣은거즈를제거한뒤 Ciclesonide (Omnaris, Takeda, Osaka, Japan) 를비강에하루 2번분무하게하였고, 술후 5일동안 Prednisolone 20 mg을복용하도록하였다. 수술후 1주, 1, 2, 4개월에눈물소관관류검사, 눈물흘림증상의정도, 비내시경검사결과를평가하여해부학적및기능적수술성공률, 합병증발생여부, 재수술여부를비교분석하였다. 눈물소관관류검사를시행하여통과가원활한경우 (good pass), 통과는되지만약간역류가있는경우 (fair pass), 많은역류가있는경우 (poor pass), 전혀통과가되지않는경우 (not pass) 로분류하였으며, good pass만해부학적성공으로정의하였다. 수술후환자의주관적인눈물흘림증상을 score 0, 1, 2로나누어평상시눈물흘림증상이없는경우를 score 0, 하루에 10회이하로눈물을닦아내는눈물흘림증상을 score 1, 평상시에눈물흘림이있으면 score 2로분류한뒤 score 0만을기능적수술성공으로정의하였다. 또한비내시경검사를시행하여수술후육아종형성, 비강내유착, 막형성이발생한환자의비율을조사하였고, 재수술여부를분석하였다. 재 308
- 송석현ㆍ이가현 : 트리암시놀론의임상적효과 - 수술은환자가 1개월이상주관적인눈물흘림증상을호소하고, 눈물소관관류검사에서역류가있으며, 비내시경검사에서육아종, 비강내유착, 막형성의소견이있는경우에시행하였다. 통계학적분석은 SPSS 18.0 (IBM Corp., Armonk, NY, USA) 을이용하였으며, 통계분석은카이제곱검정과독립표본 t-검정을사용하였다. p-value가 0.05 미만인경우를통계학적으로유의한것으로정의하였다. 결과 본연구는총 91명, 156안을대상으로하였으며, 트리암시놀론을적신 Nasopore (Corp., Stryker) 를넣은군이 32 명, 50안, 트리암시놀론을적시지않은 Nasopore (Corp., Stryker) 를넣은군이 59명, 106안이었다. 대상환자 156 안중남자 27안, 여자 129안으로두군모두여자가많았으나, 두군간에통계학적으로유의한차이는없었다 (p=0.229). 평균연령은트리암시놀론사용군이 59.96 ± 13.47세, 대조군이 59.74 ± 10.61세로두군간에통계학적으로유의한차이가없었고 (p=0.165), 내과적과거력, 눈물주머니염과거력, 술후실리콘관유지기간, 총경과관찰기간에서도두군간의유의한차이는없었다 (p>0.05) (Table 1). 눈물소관관류검사로알아본해부학적수술성공률은수술후 2개월에트리암시놀론사용군이 100% 로대조군 86.8% 에비해통계학적으로유의하게높은결과를보였다 (p=0.007). 술후 4개월에는트리암시놀론사용군이 96.0%, 대조군이 87.7% 로트리암시놀론사용군에서더높은성 A B Figure 1. Endoscopic view of one patient. Endoscopic appearance of the middle meatus (A) before endonasal dacryocystorhinostomy, (B) after endonasal dacryocystorhinostomy with triamcinolone-soaked Nasopore packing. Table 1. Patient demographics and characteristics at baseline No triamcinolone (n = 106) Triamcinolone (n = 50) p-value Age (years) 59.74 ± 10.61 59.96 ± 13.47 0.165 * Sex (n, %) Male 21 (19.8) 6 (12.0) 0.229 Female 85 (80.2) 44 (88.0) Side (n, %) Right 47 (44.3) 28 (56.0) 0.174 Left 59 (55.7) 22 (44.0) DM (n, %) 9 (84.9) 1 (2.0) 0.122 HTN (n, %) 28 (26.4) 12 (24.0) 0.747 Antiplatelet (n, %) 13 (12.3) 3 (6.0) 0.229 Previous dacryocystitis history (n, %) 3 (2.8) 0 (0) 0.230 Mean time to tube removal (weeks) 8.76 ± 2.24 8.80 ± 1.21 0.916 * Total follow up period (months) 5.98 ± 1.79 6.08 ± 1.05 0.718 * Values are presented as mean ± SD or number (%) unless otherwise indicated. SD = standard deviation; DM = diabetes mellitus; HTN = hypertension. * Independent t-test; Chi-square test. 309
- 대한안과학회지 2018 년제 59 권제 4 호 - 공률을보였으나통계학적으로유의한차이는없었다 (p=0.102) (Table 2) (Fig. 2). 주관적인눈물흘림증상으로알아본기능적수술성공률은수술후 4개월에트리암시놀론사용군이 92.0% 로대조군 78.3% 에비해통계학적으로유의하게높았고 (p=0.035), 술후 1, 2개월에는유의한차이를보이지않았다 (p>0.05) (Table 3) (Fig. 3). 수술후육아종은트리암시놀론사용군 2안 (4.0%), 대조 군 17안 (16.0%) 에서발생하여트리암시놀론사용군에서통계학적으로유의하게더적은결과를보였다 (p=0.032). 술후발생한육아종은트리암시놀론사용군에서는 2안모두술후 1개월에, 대조군에서는 8안은술후 1개월, 9 안은술후 2개월에비내시경검사로확인되었다. 그외비강내유착, 막형성에서는유의한차이를보이지않았다 (p>0.05). 재수술이필요한경우는트리암시놀론사용군 2안 (4.0%), 대조군 17안 (16.0%) 으로트리암시놀론사용군에서통계학적으로유의하게더적은결과를보였다 (p= 0.032) Figure 2. Comparison of the anatomical success percentage between the two groups over time. At postoperative 2 months, there was a statistically significant difference in the anatomical success percentage in the triamcinolone-soaked group compared to the control group (p = 0.007). There were no statistically significant differences between the two groups in anatomical success percentage at postoperative 4 months (p > 0.05). Figure 3. Comparison of the functional success percentage between the two groups over time. At postoperative 4 months, there was a statistically significant difference in the functional success percentage between the two groups (p = 0.035). Table 2. Comparison of the anatomical success percentage No triamcinolone (n = 106) Triamcinolone (n = 50) p-value * Postoperative 1 week (n, %) 102 (96.2) 50 (100) 0.164 Postoperative 1 month (n, %) 102 (96.2) 50 (100) 0.164 Postoperative 2 month (n, %) 92 (86.8) 50 (100) 0.007 Postoperative 4 month (n, %) 93 (87.7) 48 (96.0) 0.102 Values are presented as n (%) unless otherwise indicated. * Chi-square test. Table 3. Comparison of the functional success percentage No triamcinolone (n = 106) Triamcinolone (n = 50) p-value * Postoperative 1 week (n, %) 81 (76.4) 49 (98.0) 0.001 Postoperative 1 month (n, %) 84 (79.2) 44 (88.0) 0.184 Postoperative 2 month (n, %) 83 (78.3) 43 (86.0) 0.255 Postoperative 4 month (n, %) 83 (78.3) 46 (92.0) 0.035 Values are presented as n (%) unless otherwise indicated. Chi-square test. Table 4. Comparison of postoperative complications No triamcinolone (n = 106) Triamcinolone (n = 50) p-value * Revision (n, %) 17 (16.0) 2 (4.0) 0.032 Granuloma formation (n, %) 17 (16.0) 2 (4.0) 0.032 Synechiae (n, %) 2 (1.8) 1 (2.0) 0.962 Membrane formation (n, %) 5 (4.7) 0 (0) 0.119 Values are presented as n (%) unless otherwise indicated. Chi-square test. 310
- 송석현ㆍ이가현 : 트리암시놀론의임상적효과 - (Table 4). 재수술을시행한트리암시놀론사용군 2안중육아종이발생한경우는 1안, 비강내유착이발생한경우는 1안이었고, 술후 1주내에육아종이발생한 1안은이비인후과진료시비내시경을이용하여제거한후호전되어재수술을시행할필요가없었다. 재수술을시행한대조군 17안중육아종, 비강내유착, 막형성이발생한경우는각각 13 안, 2안, 2안이었으며, 술후 2주내에육아종이발생한 4 안, 막형성이발생한 3안역시이비인후과에서비내시경을이용하여제거한후재발없이호전되는결과를보였다. 고찰 코경유눈물주머니코안연결술의주된실패원인으로골공부위의막성폐쇄나육아종생성, 골공부위와비중격, 혹은중비갑개간의유착등이보고되고있으며, 특히수술초기실패의흔한요인으로창상치유기간동안발생하는육아종, 염증, 반흔조직의과다형성등으로인한협착및유착이제시되고있다. 3-8 그동안코경유눈물주머니코안연결술의성공률을높이기위한다양한관점의연구가시행되었고, 수술시히알루론산나트륨과카르복시메틸셀룰로오스나트륨혼합액, 마이토마이신, 스테로이드, 다양한흡수성코충전물사용의효과가보고된바있다. 창상치유과정은크게염증기, 증식기, 성숙기의 3단계로진행되는데, 그과정을자세히살펴보면수술로손상받은점막하층에서혈관활성인자가방출되면서염증세포가축적되고세포간질형성이촉진되면서섬유소가풍부한혈병을생성하게된다. 이후섬유아세포, 대식세포, 거대세포등이침윤하여혈관육아조직으로대체되면서교원질이생성되고결체조직이구조화되어유착이조직화하는것으로알려져있다. 2,13 증식기에재상피화가빨리일어나면과도한염증반응, 육아종과반흔조직의형성, 수술부위유착을막고창상치유기간을단축하여수술성공률을높일수있는데, 마이토마이신이증식기에관여하여수술부위회복을돕고코눈물관막힘재발방지에효과가있다고알려져있다. 9,14-16 스테로이드는창상치유과정초기에염증반응을억제하여수술후반흔형성과부종발생을억제하고수술부위재상피화를촉진하는효과가있다고알려져있다. 9,10 Sabarinath et al 10 은부비동내시경수술시스테로이드를적신코충전물사용이술후염증세포의침윤을줄이고, 비강점막의과민반응과혈관투과성을감소시킴으로써점막부종, 반흔과딱지형성을줄이고점막의창상회복을빠르게한다고하였다. 스테로이드중트리암시놀론은 12-36시간의생물학적반감기를가지며베타메타손 (betamethasone) 에비해서는식욕증가와혈당상승과같은합병증이적어코경유눈물주머니코안연결술외에도갑상선안병증, 안와모세혈관종, 특발안와염등의다양한안와질환의국소치료제로사용되고있다. 17,18 최근코경유눈물주머니코안연결술과부비동내시경수술시스테로이드를적신코충전물의사용효과에대한다양한관점의연구가진행되고있으며, 그효과가입증되고있다. Zeldovich and Ghabrial 19 은코경유눈물주머니코안연결술재개통시베타메타손 1 mg을눈물주머니와골공의반흔조직에주사하였을때 89% 의높은수술성공률을보고하였고, Cheng et al 12 은코경유눈물주머니코안연결술과비중격성형술을동시에시행할때트리암시놀론을적신코충전물을수술부위에채워넣은결과 96.4% 의높은수술성공률을보고한바있다. Côté and Wright 11 는부비동내시경수술시트리암시놀론을적신코충전물을사용하면술후 6개월까지비강의창상회복과재발방지에도움이된다는것을증명하였고, Xu et al 20 은창상회복뿐만아니라후각기능향상에도효과적이라고하였다. Li et al 9 은코경유눈물주머니코안연결술시골공부위에마이토마이신과스테로이드를함께사용한결과창상부위의반흔형성방지에대한두약물의상승효과를보고하였다. Hong et al 21 은부비동내시경수술중트리암시놀론을적신코충전물사용시혈청코티솔 (cortisol), 12시간소변코티솔, 혈청부신피질자극호르몬 (adrenocorticotropic hormone), 혈청오스테오칼신 (osteocalcin) 농도를측정하여전신에미치는영향과안정성을평가하였고, 분석결과술후 2일까지혈청코티솔과오스테오칼신농도가통계학적으로유의하게낮았으며특별한치료없이술후 10일경정상수치로회복되는것을확인하였다. 또한트리암시놀론을적신코충전물을사용하면코충전물이녹는기간인약 2주동안점막에직접적인효과가전달되어코스프레이, 점안액보다더효과적이며, 경구약복용시발생가능한전신부작용의발생가능성이낮다고하였다. 9,21 Kang et al 22 은부비동내시경수술시고용량스테로이드를적신거즈를 2달동안 1주에한번씩비강에채워넣은경우가코스프레이를사용하는것보다더효과적이라고하였고, More et al 23 은부비동내시경수술시트리암시놀론을적신코충전물의사용의효과를경구스테로이드복용과비교한결과술후초기비강내폴립형성방지에비슷한효과를보인다고보고하였다. 이는코경유눈물주머니코안연결술이나부비동내시경수술시창상회복촉진과재발방지를위해스테로이드성분의코스프레이, 점안액, 311
- 대한안과학회지 2018 년제 59 권제 4 호 - 경구약을사용하고있지만, 코스프레이와안약은직접점막에도달하기어렵고, 경구약은전신적부작용가능성때문에사용이제한적이라는점에서스테로이드를적신코충전물의사용의장점이부각되는부분이다. Jung and Lee 24 는실패한눈물주머니코안연결술환자에서트리암시놀론을적신코충전물로내시경적재개통술을시행하여술후 9개월이상재발없이효과적으로치료했던사례를보고한바있다. 본연구에서는원발코눈물관막힘으로진단받고코경유눈물주머니코안연결술을시행한환자를무작위로트리암시놀론을적신 Nasopore (Corp., Stryker) 를골공부위에넣은군과대조군으로트리암시놀론을적시지않은 Nasopore (Corp., Stryker) 를넣은군으로나누어수술후 1주, 1, 2, 4개월에눈물소관관류검사, 눈물흘림증상의정도, 비내시경검사결과를평가하여해부학적및기능적수술성공률, 합병증발생률, 재수술률을후향적으로비교분석하였다. 눈물소관관류검사로알아본해부학적수술성공률은수술후 2개월에트리암시놀론사용군이대조군에비해통계학적으로유의하게높았고, 주관적인눈물흘림증상으로알아본기능적수술성공률은수술후 4개월에트리암시놀론사용군이대조군에비해통계학적으로유의하게높았다. 수술부위육아종발생률과재수술률은트리암시놀론사용군이대조군에비해통계학적으로유의하게낮은결과를보였다. 이전의연구에서보고된스테로이드를적신코충전물사용의부작용으로는안압상승, 피부탈색, 점막융해, 지방위축등이있으나, 본연구의대상환자에서발생한경우는없었다. 9 본연구는후향적으로연구를진행하였고, 연구대상수가적고, 추적기간이짧아장기적인수술성공률에대한비교가어려웠다는제한점이있어추후많은환자를대상으로장기적인전향적연구가필요할것으로생각된다. Nasopore (Corp., Stryker) 는 5-14일이내자연분해및배출되는흡수성물질로증식기에빠른재상피화를촉진하며과도한염증반응이나조직학적변화를줄여반흔을억제하고, 강한형태복원력이있어충전후이틀까지상처부위를압박하여지혈하고상처건조를방지하는습윤드레싱의효과를가지는것으로알려져있다. 24 본연구에서트리암시놀론을단독으로사용하지않고 Nasopore (Corp., Stryker) 에적셔서사용하였던이유는트리암시놀론을단독으로사용한경우보다 Nasopore (Corp., Stryker) 에적셔수술부위에채워넣은경우에 Nasopore (Corp., Stryker) 가유지되는기간만큼수술부위에트리암시놀론이더오래접해있어효과가오래지속될수있다고판단하였기때문이다. 본연구에서 Nasopore (Corp., Stryker) 자체 의재상피화촉진및반흔억제효과를배제하지못한점은연구의한계점으로생각되며, 추후 Nasopore (Corp., Stryker) 없이트리암시놀론을단독사용한환자에대한연구가필요할것으로생각된다. 하지만본연구는트리암시놀론을적신코충전물의효과를해부학적및기능적수술성공률, 합병증발생률, 재수술률을통해알아보았고, 수술중트리암시놀론을적신코충전물의사용이통계학적으로유의하게수술부위육아종형성과재수술시행을감소시킨다는것을증명하였다는점에서의의가있다. 결론적으로원발코눈물관막힘환자에서코경유눈물주머니코안연결술시트리암시놀론을적신코충전물의사용은수술성공률을높이고육아종과재수술률을감소시켜효과적인치료방법이될것으로생각된다. REFERENCES 1) McDonogh M, Meiring JH. Endoscopic transnasal dacryocystorhinostomy. J Laryngol Otol 1989;103:585-7. 2) Park JW, Park HY, Yoon KC. Clinical effect of the mixed solution of sodium hyaluronate and sodium carboxymethylcellulose after endonasal dacryocystorhinostomy. J Korean Ophthalmol Soc 2010;51:795-801. 3) Choi YJ, Hwang SJ, Lee TS. Short-term clinical results of amniotic membrane application to endonasal dacryocystorhinostomy. J Korean Ophthalmol Soc 2008;49:384-9. 4) Kim JH, Shin JC. Clinical evaluation of endoscopic transnasal dacryocyocystorhinostomy. J Korean Ophthalmol Soc 1997;38: 1706-11. 5) Metson R. Endoscopic surgery for lacrimal obstruction. Otolaryngol Head Neck Surg 1991;104:473-9. 6) Goldberg RA. Endonasal dacryocystorhinostomy: is it really less successful? Arch Ophthalmol 2004;122:108-10. 7) Mannor GE, Millman AL. The prognostic value of preoperative dacryocystography in endoscopic intranasal dacryocystorhinostomy. Am J Ophthalmol 1992;113:134-7. 8) Ali MJ, Wormald PJ, Psaltis AJ. The dacryocystorhinostomy ostium granulomas: classification, indications for treatment, management modalities and outcomes. Orbit 2015;34:146-51. 9) Li EY, Cheng AC, Wong AC, et al. Safety and efficacy of adjunctive intranasal mitomycin C and triamcinolone in endonasal endoscopic dacryocystorhinostomy. Int Ophthalmol 2016;36: 105-10. 10) Sabarinath V, Harish MR, Divakaran S. Triamcinolone impregnated nasal pack in endoscopic sinus surgery: our experience. Indian J Otolaryngol Head Neck Surg 2017;69:88-92. 11) Côté DW, Wright ED. Triamcinolone-impregnated nasal dressing following endoscopic sinus surgery: a randomized, double-blind, placebo-controlled study. Laryngoscope 2010;120:1269-73. 12) Cheng AC, Wong AC, Sze AM, Yuen HK. Limited nasal septoplasty by ophthalmologists during endonasal dacryocystorhinostomy: is it safe? Ophthalmic Plast Reconstr Surg 2009;25:293-5. 13) Hellebrekers BW, Trimbos-Kemper TC, Trimbos JB, et al. Use of fibrinolytic agents in the prevention of postoperative adhesion 312
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