대한안과학회지 2014 년제 55 권제 6 호 J Korean Ophthalmol Soc 2014;55(6):847-853 pissn: 0378-6471 eissn: 2092-9374 http://dx.doi.org/10.3341/jkos.2014.55.6.847 Original Article 특발성망막전막에서내경계막제거시인도시아닌그린염색의용매에따른수술결과비교 Effect of Solvent in Indocyanine Green-Assisted Internal Limiting Membrane Peeling During Idiopathic Epiretinal Membrane Surgery 김미래 박주홍 사공민 장우혁 Mi Rae Kim, MD, Ju Hong Park, MD, Min Sagong, MD, PhD, Woo Hyok Chang, MD, PhD 영남대학교의과대학안과학교실 Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea Purpose: This study was designed to compare the outcomes in idiopathic epiretinal membrane (ERM) surgery according to solvents of indocyanine green (ICG) for internal limiting membrane (ILM) peeling. Methods: The medical records of 27 patients (27 eyes) with idiopathic ERM who had undergone pars plana vitrectomy with ICG staining for ILM peeling were retrospectively reviewed. The patients were divided into two groups according to solvents of 0.25% ICG solutions. Solvents used were balanced salt solution (BSS) in group I (15 eyes) and 5% glucose in group II (12 eyes). The severity of ERM, the duration of symptoms, the preoperative and postoperative best corrected visual acuity (BCVA) values, the visibility of the stained ILM (Good, Fair, Poor), and the postoperative complications were compared in the two groups. Results: There was no statistically significant difference in the severity of ERM, the duration of symptoms and the preoperative BCVA in the two groups. The postoperative BCVA was significantly improved in both groups, and the difference was not statistically significant (p = 0.675). There was a significantly smaller number of eyes with poor ILM staining in group II than in group I (p = 0.014). No complications such as recurrence of ERM, atrophy of the retinal pigment epithelium (RPE) or retinal detachment were observed in the two groups. Conclusions: The higher specific gravity of 5% glucose compared with that of BSS as ICG solvents allows for improved ILM visualization. Therefore using the 5% glucose-icg solution for staining ILM improved the visibility of ILM compared BSS-ICG solution and led to comparable visual recovery. J Korean Ophthalmol Soc 2014;55(6):847-853 Key Words: Epiretinal membrane, Glucose solution, Indocyanine green, Internal limiting membrane, Solvent Received: 2013. 10. 4. Revised: 2014. 5. 1. Accepted: 2014. 5. 15. Address reprint requests to Woo Hyok Chang, MD, PhD Department of Ophthalmology, Yeungnam University Medical Center, #170 Hyeonchung-ro, Nam-gu, Daegu 705-703, Korea Tel: 82-53-620-3445, Fax: 82-53-626-5936 E-mail: changwh@ynu.ac.kr * This study was presented as an e-poster at the 109th Annual Meeting of the Korean Ophthalmological Society 2013. 1978년 Machemer에의해유리체절제술을통한망막전막의성공적인제거가처음보고된이래로 1 여러연구에서망막전막제거수술의성공적인결과와함께술후 70% 이상의시력호전을보고하였다. 2-8 따라서증상이있는망막전막의경우유리체절제술을통한망막전막의제거술이선호되고있다. 내경계막은망막과유리체사이의구조적경계를이루는구조로근섬유세포증식의발판역할을함으로써망막전막, 유리체- 황반견인, 황반원공과같은황반질환의발생에관 c2014 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. 847
- 대한안과학회지 2014 년제 55 권제 6 호 - 여한다. 9-14 특히, 망막전막의수술에서내경계막을함께제거해줌으로써망막전막의재발을줄이고황반주름을호전시키며시력향상을가져온다는여러보고가있다. 15-20 그러나얇고투명한조직인내경계막은육안적관찰이용이하지않아실제수술적제거의어려움이있었으며이를극복하기위하여 2000년도에내경계막만선택적으로착색시키는인도시아닌그린 (ICG, Indocyanine green) 의사용이소개되었고 14 이후많은연구에서 ICG 용액을사용함으로써내경계막의시인성과수술의용이성을향상시키고망막손상의위험성을줄일수있음을보여주었다. 14,18,21-23 최근내경계막제거시 ICG는가장흔히사용되고있는염료이나, 현재까지도 ICG 용액을희석하는방법은표준화되지않아다양한농도로사용되고있다. 22-26 Kwok et al 27 은내경계막을효율적으로염색할수있는최소농도를구하기위해 ICG의농도를달리하여수술의용이성과임상적결과및 ICG 독성을비교하였는데 ICG 농도가높을수록시인성은향상되나안전성에대한연구가더필요하다고보고하였으며다른여러연구에서도높은 ICG 농도가망막독성을증가시킬수있다고하였다. 26,28-30 이에저자들은 ICG 용액의농도는일정하게한상태에서, 평형염액 (BSS) 보다비중이큰 5% 포도당액을용매로사용하여내경계막제거를시행하고, 이를 BSS를용매로사용한경우와수술의용이성및수술결과를비교해보고자한다. 대상과방법 본원에서특발성망막전막으로진단받고유리체절제술시행시 ICG 용액을이용하여내경계막염색을시행하였던환자중 6개월이상경과관찰가능하였던연속된환자 27 명 27안을대상으로의무기록을통하여후향적으로조사하였다. 수술전다른황반부질환이함께동반되어있었던경우와속발성망막전막을일으킬수있는안내병증의기왕력이있는경우, 망막전막외에시력을저하시킬만한안질환이있는경우는대상에서제외하였다. 내경계막제거시사용한 ICG 용액의용매의종류에따라 BSS를이용한군 15안 (I군) 과 5% 포도당액을사용한 12안 (II군) 으로나누어분석하였다. 내경계막제거시사용한염색용액의혼합은 ICG (Diagnogreen Injection: Daiichi Pharmaceutical, Tokyo, Japan) 25 mg을증류수 1 ml로완전히용해시킨후이중 0.1 ml를 I군에서는 0.9 ml BSS와혼합하고, II군에서는 0.9 ml 5% 포도당액과혼합하여최종적으로 2.5 mg/ml (0.25%) 농도가되도록하였다. 수술전증상기간을조사하고최대교정시력측정, 전안부및수정체검사, 안저검사를시행하였으며스펙트럼영역빛간섭단층촬영 (SD-OCT, Spectral domain optical coherence tomography, Spectralis, Heidelberg Engineering GmbH, Heidelberg, Germany) 분석을통한망막전막의심한정도를비교하였다. 수술은숙련된단일술자에의해 23게이지경결막무봉합유리체절제술 (Accurus, Alcon, USA) 을시행하였다. 먼저후유리체박리를일으킨후, 후유리체및망막전막을제거하였다. 내경계막을염색하기위하여관류액의주입을멈추고 I군에서는 BSS와혼합된 0.25% ICG 용액을, II군에서는 5% 포도당용액과혼합된 ICG 용액을황반부에 0.1 ml 주입하고 10초후재관류하여 ICG 용액을제거하였다. 염색된내경계막은안내겸자를이용하여중심와로부터약 3-4배유두직경크기의원형으로제거하였으며그후주변망막의유리체절제술을추가로시행하였다. 백내장수술이 A B C Figure 1. Surgeon s view. Visual quality of the stained internal limiting membrane (ILM). (A) Good stain. (B) Fair stain. (C) Poor stain. 848
- 김미래외 : 망막전막수술시 ICG 용매의비교 - 필요한경우에는유리체절제술전 12시방향의투명각막절개를통하여초음파유화술을먼저시행하고유리체절제술이모두끝난다음마지막에접형인공수정체를삽입하였다. 망막전막의심한정도는 OCT를통하여분석하였으며 1 단계는내측망막의불규칙한주름을일으킬수있으나망막전막의가장자리는보이지않는미세한전막의경우, 2단계는망막전층의변형을일으키며망막전막의가장자리가보이고망막전막의절반미만의부분에서아래의망막과혈관구조가불분명하게관찰될정도의상당한전막의경우, 그리고 3단계는망막전막의절반이상의부분에서아래의망막과혈관구조가불분명하게관찰될정도의두껍고뚜렷한혼탁이있는전막의경우로나누었다. 27 내경계막의시인성은녹화된영상파일을분석하여 Good, Fair, Poor 3단계로나누었으며, Good은밝은녹색으로염색된경우, Fair는내경계막이연한녹색으로염색된경우, Poor은내경계막이뚜렷이구분이되지않는염색의경우로나누었다 (Fig. 1). 27 수술후경과는술후 6개월째빛간섭단층촬영을통한망막전막의성공적인제거여부와황반주름의호전여부및 중심와윤곽의회복여부를파악하여해부학적성공여부를비교하였고, 기능적성공여부는수술전과비교하여술후 6개월째한천석시력표상두줄이상의시력호전을보이는경우로정의하였으며, 술후 6개월과술전의시력을비교하기위해 Log 스케일 (LogMAR) 로환산하였다. 그외망막전막의재발여부, 술후합병증으로망막색소상피의위축, 망막박리등을확인하였다. 각용액의삼투압은 Advanced 2020 multi-sample osmometer 를이용하여측정하였으며, ph는 Blood gas and electrolytes analyzer ABL800 BASIC 을이용하여측정하였다. 비중은 OHAUS PRECISION Advanced 410을이용하여각용액의단위부피당질량을측정한후밀도를구하고, 표준물질인물의밀도를 1 g/ml로보고각용액의밀도와물의밀도의비를구하였다. 통계학적분석은 PASW statistics v. 18.0을사용하여두군간의비교는 Mann-Whitney U-test, Fisher s exact test, Chi-squre test를, 수술전후시력호전은 Wilcoxon signed rank test를이용하였으며수술의해부학적결과와시력과의상관관계는 Pearson 상관계수를이용하였다. p값이 0.05 Table 1. Comparison of patients demographics between two groups Group I * Group II Total p-value No. of eyes 15 12 27 Age (years) 63.7 ± 6.0 66.0 ± 6.8 64.7 ± 6.3 0.464 Sex (M:F) 9:6 4:8 13:14 0.168 Periods of Sx (months) 16.4 ± 23.7 11.2 ± 14.0 13.9 ± 19.4 0.496 Baseline BCVA (log MAR) 0.55 ± 0.26 0.40 ± 0.22 0.49 ± 0.25 0.172 Lens state (phakic:pseudophakic) 15:0 10:2 25:2 0.188 Phacovitrectomy:Vitrectomy 14:1 10:2 24:3 0.569 ERM stage (%) 1.000 Stage 1 7 (46.7) 5 (41.7) 12 (44.4) Stage 2 7 (46.7) 6 (50.0) 13 (48.1) Stage 3 1 (6.7) 1 (8.3) 2 (7.4) Values are presented as mean ± SD. BCVA = best corrected visual acuity; ERM = epiretinal membrane; Sx: symptom. * Using balanced salt solution (BSS) as solvent of indocyanine green; Using 5% glucose solution as solvent of indocyanine green; Mann- Whitney U-test; Fisher s exact test. Table 2. Visualization of internal limiting membrane and number of indocyanine green (ICG) injection with different solvents No. of eyes (%) Group I * Group II Total p-value Visualization of ILM (%) 0.014 Poor 7 (46.7) 1 (8.3) 8 (29.6) Fair 6 (40.0) 3 (25.0) 9 (33.3) Good 2 (6.7) 8 (66.7) 10 (37.0) No. of ICG injections 1.2 ± 0.4 1.1 ± 0.3 1.2 ± 0.4 0.405 Values are presented as mean ± SD. ILM = internal limiting membrane. * Using balanced salt solution (BSS) as solvent of indocyanine green; Using 5% glucose solution as solvent of indocyanine green; Fisher s exact test; Mann-Whitney U-test. 849
- 대한안과학회지 2014 년제 55 권제 6 호 - 미만인경우에통계적으로유의하다고판단하였다. 결과 전체 27명의대상안중 I군이 15안, II군이 12안이였으며, 남자와여자의비율은 I군이 9:6, II군이 4:8로통계적으로유의한차이는없었다. 평균연령은 I군이 63.7세, 2군이 66.0세로유의한차이는없었으며증상기간은 I군이평균 16.4개월, II군이 11.2개월로 I군이더길었으나통계적으로유의하지않았다. 초진시시력은 I군이 0.55 logmar, II군이 0.40 logmar로 II군이더좋았으나통계적의의는없었다. 3단계로분류한망막전막의심한정도에서도두군간의유의한차이는없었다 (Table 1). ICG 용액염색후내경계막의시인성은 BSS를용매로이용한 I군에서는 Poor가가장많았고 (46.7%), 5% 포도당액을용매로이용한 II군에서는 Good이가장많았으며 (66.7%), II 군이통계적으로유의하게시인성이좋았다 (Fisher s exact test, p=0.014, Table 2). ICG 용액을주입한횟수는 I군이평균 1.2회로 II군의평균 1.1회보다많았으나통계적으로의의는없었다. 두군모두에서해부학적으로망막전막및내경계막은완전히제거되었으며, 술후 6개월째 OCT에서망막주름이남아있는경우는 I군이 10안 (66.7%), II군이 4안 (33.3%) 으로통계적으로유의하지는않았으나 I군이더많았고, 중심와윤곽이회복된경우는 I군이 5안 (33.3%), II군이 9안 (75.0%) 으로통계적으로유의하게 II군이더많았다 (Chi-square test, p=0.031, Table 3). 기능적성공은술후한천석시력표상두줄이상의시력호전을보이는경우로하였는데 I군에서는 10안 (66.7%), II 군에서는 8안 (66.7%) 에서두줄이상의시력호전을보였으며두군간의유의한차이는없었다. 술전과수술 6개월후시력의변화는 I군에서는 0.55에서 0.26 logmar로, II군에서는 0.40에서 0.20 logmar 로두군모두통계적으로유의하게호전되었으며 (Wilcoxon signed rank test, p=0.004, 0.029), 술후 6개월째최대교정시력은 I군이 0.26 logmar, II군이 0.20 logmar로두군간에통계적으로유의한차이는없었다 (Table 4, Fig. 2). 술후 I군에서는 1안 (6.7%), II군에서는 2안 (16.7%) 이술전에비해시력감소가있었다. 망막전막의재발은두군모두에서관찰되지않았으며, 망막색소상피의위축, 망막박리등의술후합병증도두군모두에서관찰되지않았다. 두군에서이용한 ICG 용액의성질을비교해보면, BSS-ICG 용액의삼투압은 272 mosm/kg, 5% 포도당액-ICG용액의경우는 256 mosm/kg로 5% 포도당액을용매로이용한경우더낮은삼투압이측정되었으며, ph는 BBS-ICG 용액의경우 7.643으로약한알칼리성을, 5% 포도당액-ICG는 6.999로거의중성을나타냈다. 두용액의비중을비교해보면, BSS-ICG 용액은 1.094, 5% 포도당액-ICG 용액은 1.140으로 5% 포도당액을용매로이용한경우좀더잘가라앉는성질을보였다 (Table 5). Table 3. Comparison of the anatomical and functional success after surgery between two groups Group I * No. of eyes (%) Group II p-value Anatomical success Complete ILM removal 15 (100.0) 12 (100.0) 1.000 Remained retinal wrinkling 10 (66.7) 4 (33.3) 0.085 Foveal contour 5 (33.3) 9 (75.0) 0.031 Functional success 10 (66.7) 8 (66.7) 1.000 ILM = internal limiting membrane. * Using balanced salt solution (BSS) as solvent of indocyanine green; Using 5% glucose solution as solvent of indocyanine green; Chi-square test; Improvement visual acuity more than 2 lines. Table 4. Comparison of the BCVA (log MAR) changes after surgery between two groups BCVA (log MAR) Group I * Group II p-value Baseline 0.55 ± 0.26 0.40 ± 0.22 0.172 Postoperative 6 months 0.26 ± 0.26 0.20 ± 0.17 0.675 Changes 0.29 ± 0.28 0.20 ± 0.25 0.478 p-value 0.004 0.029 Values are presented as mean ± SD. BCVA = best corrected visual acuity. * Using balanced salt solution (BSS) as solvent of indocyanine green; Using 5% glucose solution as solvent of indocyanine green; Mann- Whitney U-test; Wilcoxon signed rank test. 850
- 김미래외 : 망막전막수술시 ICG 용매의비교 - Table 5. Measurement in osmolality, ph and specific gravity of two solutions ICG solution mosm/kg ph Specific gravity BSS-ICG 272 7.643 1.094 5% glucose-icg 256 6.999 1.140 ICG = indocyanine green; BSS = balanced salt solution. BCVA (log MAR) 0.1 0.2 0.3 0.4 0.40 Group I Group II 0.20 0.26 0.5 0.55 0.6 Baseline Postop Postop 6 months 6 Figure 2. Changes in best corrected visual acuity (BCVA) between preoperation (Preop) and postoperation (Postop). 고 망막전막수술에서내경계막을함께제거하는것은망막전막의재발률을줄일수있어여러술자에의해시행되고있으며, 내경계막의시인성을높이기위해 ICG 용액이흔히사용되고있다. 그러나몇몇연구에서는 ICG 용액이망막에대한독성을가지고있어수술후기능적결과를저하시킨다는문제점을제기해왔는데 20,29,31-35 Gandorfer et al 29 과 Hillenkamp et al 30 은망막손상을일으키는기전으로 ICG 용액의농도와삼투압, 조직과의접촉시간, 제거시가해진힘에의한견인등을제시하였고, Stalmans et al 36 은 ICG 용액의용매종류에따라다른삼투압이망막색소상피세포의손상과관계된다고보고하였으며 Konstantinidis et al 18 은용매의종류와삼투압, 용매내나트륨의여부도망막독성과연관된다고보았다. 따라서내경계막의시인성은극대화하면서 ICG의독성을최소화시키기위해 ICG 용액의적절한농도와적절한용매의사용은매우중요함에도불구하고표준화되지않아매우다양한방법으로사용되고있다. ICG 염색의가장효율적인최소농도를구하기위해 Kwok et al 27 은다른농도의 ICG 용액을사용하여수술의용이성과결과를비교하였다. 그러나 ICG 희석에사용하는용매에따른수술의용이성과결과를임상적으로연구한논문은없어, 이에저자들은주로사용하는두가지용매인 BSS와 5% 포도당액을사용한망막전막수술을임상적으로비교분석하였다. 찰 수술중내경계막의시인성은 5% 포도당액을사용한 II 군에서통계적으로유의하게좋았으며 (Fisher s exact test, p=0.014) 따라서수술의편의성도향상되었는데이는두용매의비중의차이로인한것으로생각한다. 5% 포도당액 -ICG 용액의비중이 1.140으로 BSS-ICG 용액의비중 1.094보다높았는데유리체절제술중 BSS로채워진안구내로 ICG 용액을주입하는경우 BSS보다비중이높은 ICG 가좀더잘가라앉아착색이잘되는것으로보인다. 술후해부학적결과를비교해보면, 두군에서모두망막전막및내경계막은완전히제거되었으며잔존망막주름은유의하진않으나 BSS를사용한 I군에서더많았고, 중심와윤곽의호전은통계적으로유의하게 5% 포도당액을사용한 II군에서더좋았다 (Chi-square test, p=0.031). 두줄이상시력호전을나타내는기능적성공률은 66.7% 로두군에서동일하며두군모두에서술후통계적으로유의하게시력호전을보였다. 더잘가라앉는 5% 포도당액군을용매로이용한경우내경계막의시인성을높여수술을용이하게하고따라서망막주름및중심와윤곽의회복을향상시켜해부학적성공률을높일수있었으나기능적결과에는뚜렷한차이가없었다. Kim and Kim 20 의연구에서제시하였듯이특발성망막전막이시력감소를일으키는기전은황반부를왜곡시키는것외에도망막전막이황반부위를덮거나, 견인성망막박리, 망막내부종을동반한혈관유출, 그리고축삭이동의차단등여러인자가작용하므로망막전막이제거된후잔존하는망막주름만으로시력저하를야기한다고보기는어려우며망막주름의호전및중심와윤곽의회복과기능적인시력의향상과의직접적인연관성을판단하기는어렵다. 본연구에서도잔존하는망막주름및윤곽선회복여부와시력변화사이에는통계학적으로상관관계가없었다 (Pearson상관계수 r=0.012, 0.169). BSS-ICG 용액의삼투압은 272 mosm/kg, 5% 포도당액 -ICG 용액의삼투압은 256 mosm/kg로 5% 포도당액을용매를사용한경우가더낮았다. Stalmans et al 36 과 Sippy et al 31 은 ICG의망막색소상피에대한독성은용매의저삼투압과관련된다고하였다. 또한 Stalmans and Himpens 37 의연구에서저삼투압용액에노출되면망막색소상피세포내로 Ca 2+ 의유입이증가하여세포독성을일으킨다고보고하였다. 본연구에서 5% 포도당액을용매로사용한군에서시력감소를보인경우가더많이관찰되었는데 (I군 =6.7%, 851
- 대한안과학회지 2014 년제 55 권제 6 호 - II군 =16.7%), 이는낮은삼투압으로인한독성과관계된것이아닌가생각한다. 그러나 Haritoglou et al 38 은다양한농도로서로다른종류의용매를사용한 ICG용액의흡수스펙트럼을측정하여 ICG용액의농도가높을수록광민감성이증가함으로써망막색소상피의광독성이증가한다고하였으며 BSS보다 5% 포도당액을사용하는것이광독성을줄일수있다고하였고 Ho et al 39 은 Sodium이없는용매를사용하면 ICG로인한광독성을줄일수있다고보고하였다. 이두연구의결과로볼때 5% 포도당액을용매로사용하는것은광독성으로인한망막손상을줄이는데는도움이된다. 본연구에서두용매를사용하였을때기능적결과측면에서차이가없었던것은망막독성을일으키는여러기전에따른영향이상반되어결론적으로두용매가큰차이가없었던것으로보이며따라서 ICG의독성과용매와의관계에대하여여러측면에서좀더체계적인연구가필요할것으로생각한다. 결론적으로내경계막제거시 ICG 용액의용매로 5% 포도당액을사용하는것은 BSS를사용하는것과비교하여볼때기능적측면에서비슷한정도의시력회복을기대할수있을뿐만아니라내경계막의시인성을향상시켜수술의용이성을높이고해부학적성공률을높일수있었다. 따라서내경계막제거시 5% 포도당을 ICG 용매로사용하면낮은 ICG 농도로도내경계막의시인성을향상시킬수있으므로이를긍적적으로고려해볼필요가있다고생각한다. 그러나이연구는적은환자를대상으로하여정확한통계적비교가어려우며추적관찰기간이 6개월로비교적짧아장기적인예후를알기힘들어더많은환자를대상으로더장기적인추적관찰을할필요가있다. 또한 ICG 용액의독성기전을좀더체계적으로분석하여 ICG의독성을최소화하면서수술의용이성을높일수있도록 ICG 용액을만드는방법을표준화할필요가있다. REFERENCES 1) Machemer R. The surgical removal of epiretinal macular membranes (macular puckers). Klin Monbl Augenheilkd 1978;173: 36-42. 2) Michels RG. Vitrectomy for macular pucker. Ophthalmology 1984;91:1384-8. 3) Margherio RR, Cox MS Jr, Trese MT, et al. Removal of epimacular membranes. Ophthalmology 1985;92:1075-83. 4) McDonald HR, Verre WP, Aaberg TM. Surgical management of idiopathic epiretinal membranes. Ophthalmology 1986;93:978-83. 5) Pesin SR, Olk RJ, Grand MG, et al. Vitrectomy for premacular fibroplasia. Prognostic factors, long-term follow-up, and time course of visual improvement. Ophthalmology 1991;98:1109-14. 6) Donati G, Kapetanios AD, Pournaras CJ. Complications of surgery for epiretinal membranes. Graefes Arch Clin Exp Ophthalmol 1998;236:739-46. 7) Benhamou N, Massin P, Spolaore R, et al. Surgical management of epiretinal membrane in young patients. Am J Ophthalmol 2002; 133:358-64. 8) Massin P, Paques M, Masri H, et al. Visual outcome of surgery for epiretinal membranes with macular pseudoholes. Ophthalmology 1999;106:580-5. 9) Zarbin MA, Michels RG, Green WR. Epiretinal membrane contracture associated with macular prolapse. Am J Ophthalmol 1990; 110:610-8. 10) Clarkson JG, Green WR, Massof D. A histopathologic review of 168 cases of preretinal membrane. Am J Ophthalmol 1977;84:1-17. 11) Michels RG. A clinical and histopathologic study of epiretinal membranes affecting the macula and removed by vitreous surgery. Trans Am Ophthalmol Soc 1982;80:580-656. 12) Smiddy WE, Green WR, Michels RG, de la Cruz Z. Ultrastructural studies of vitreomacular traction syndrome. Am J Ophthalmol 1989;107:177-85. 13) Fine BS. Limiting membranes of the sensory retina and pigment epithelium. An electron microscopic study. Arch Ophthalmol 1961;66:847-60. 14) Burk SE, Da Mata AP, Snyder ME, et al. Indocyanine green-assisted peeling of the retinal internal limiting membrane. Ophthalmology 2000;107:2010-4. 15) Park DW, Dugel PU, Garda J, et al. Macular pucker removal with and without internal limiting membrane peeling: pilot study. Ophthalmology 2003;110:62-4. 16) Kwok AK, Lai TY, Yuen KS. Epiretinal membrane surgery with or without internal limiting membrane peeling. Clinical and Experimental Ophthalmology 2005;33:379-85. 17) Bovey EH, Uffer S, Achache F. Surgery for epimacular membrane: impact of retinal internal limiting membrane removal on functional outcome. Retina 2004;24:728-35. 18) Konstantinidis L, Uffer S, Bovey EH. Ultrastructural changes of the internal limiting membrane removed during indocyanine green assisted peeling versus conventional surgery for idiopathic macular epiretinal membrane. Retina 2009;29:380-6. 19) Kim TW, Song SJ, Chung H, Yu HG. Internal limiting membrane peeling in surgical treatment of macular epiretinal membrane. J Korean Ophthalmol Soc 2005;46:989-94. 20) Kim YC, Kim KS. The effect of internal limiting membrane peeling in treatment of idiopathic epiretinal membrane. J Korean Ophthalmol Soc 2007;48:1067-72. 21) Gandorfer A, Messmer EM, Ulbig MW, Kampik A. Indocyanine green selectively stains the internal limiting membrane. Am J Ophthalmol 2001;131:387-8. 22) Da Mata AP, Burk SE, Riemann CD, et al. Indocyanine green-assisted peeling of the retinal internal limiting membrane during vitrectomy surgery for macular hole repair. Ophthalmology 2001; 108:1187-92. 23) Kwok AK, Lai TY, Li WW, et al. Indocyanine green-assisted internal limiting membrane removal in epiretinal membrane surgery: a clinical and histologic study. Am J Ophthalmol 2004;138:194-9. 24) von Jagow B, Hoing A, Gandorfer A, et al. Functional outcome of indocyanine green-assisted macular surgery: 7-year follow-up. Retina 2009;29:1249-56. 25) Lanzetta P, Polito A, Del Borrello M, et al. Idiopathic macular hole surgery with low-concentration infracyanine green-assisted peel- 852
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