대한안과학회지 2014 년제 55 권제 12 호 J Korean Ophthalmol Soc 2014;55(12):1883-1889 pissn: 0378-6471 eissn: 2092-9374 http://dx.doi.org/10.3341/jkos.2014.55.12.1883 Original Article 상사시를동반한간헐외사시에서상사시교정에대한임상적고찰 Correction of Hypertropia Coexisting with Intermittent Exotropia 조관혁 이주연 Kwan Hyuk Cho, MD, Joo Yeon Lee, MD 한림대학교의과대학한림대학교성심병원안과학교실 Department of Ophthalmology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea Purpose: To investigate the clinical features associated with hypertropia and report the surgical outcomes of hypertropia coexisting with exotropia. Methods: We reviewed the medical records of 148 patients with intermittent exotropia coexisting with hypertropia over 4 PD who received exotropia surgery. The cases accompanied by apparent paralytic strabismus such as superior oblique palsy were excluded. Patients were divided into groupⅠ(clinically diagnosed hypertropia) and group Ⅱ (non-specific hypertropia) and the clinical features of coexisting hypertropia and surgical outcomes were analyzed. Results: Among the 148 patients, groupⅠconsisted of 38 patients (26%) and group Ⅱ of 110 patients (74%). The average amount of preoperative hypertropia angle in primary gaze was 9.58 ± 3.89 PD and 6.62 ± 2.69 PD in group Ⅰ and Ⅱ, respectively. Group Ⅰ included 12 patients with dissociated vertical deviation (DVD), 10 patients with unilateral inferior oblique overaction, 13 patients with asymmetric bilateral inferior oblique overaction and 3 patients with superior oblique overaction. Group Ⅱ included 19 patients with comitant hypertropia (17%), head tilt positive pattern (simulated superior oblique palsy) was found in 84 patients (76.3%) and variable incomitance was observed. In groupⅠ, 29 patients received simultaneous horizontal muscle with hypertropia surgery. Postoperative hypertropia angle in groupⅠ was 1.41 ± 2.93 PD and 4 cases were considered surgical failure. In groupⅡ, hypertropia was resolved with horizontal muscle surgery only and the amount of postoperative hypertropia was 0.45 ± 1.60 PD. Conclusions: In this study, vertical deviations in intermittent exotropia with concomitant hypertropia related to obvious oblique muscle dysfunction or DVD were corrected effectively by oblique or vertical rectus muscle surgery. Nonspecific hypertropia can be resolved after horizontal muscle surgery alone, however, for precise differential diagnosis, careful examination for variable clinical features is necessary before determining surgery. J Korean Ophthalmol Soc 2014;55(12):1883-1889 Key Words: Hypertropia, Intermittent exotropia, Oblique muscle dysfunction, Simulated superior oblique palsy Received: 2014. 5. 1. Revised: 2014. 9. 18. Accepted: 2014. 11. 17. Address reprint requests to Joo Yeon Lee, MD Department of Ophthalmology, Hallym University Sacred Heart Hospital, #22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 431-796, Korea Tel: 82-31-380-3834, Fax: 82-31-380-3837 E-mail: kimleejy@hallym.or.kr * This study was presented as an e-poster at the 107th Annual Meeting of the Korean Ophthalmological Society 2012. 간헐외사시에수직사시가동반된경우는약 50% 정도로알려졌다. 1 간헐외사시와동반된수직사시의치료에대한과거연구를살펴보면적은양의상사시각을가진환자를대상으로치료의초점을수평근수술자체의수직사시상쇄효과혹은수평근의수직이동 (vertical offset) 을통한수직사시감소효과를발표한것이대부분이었다. 2-5 Struck and Daley 6 는주관적회선사시혹은이상두위가없는외사시에동반된수직사시에대한수술은지양해야한다고하 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. 1883
- 대한안과학회지 2014 년제 55 권제 12 호 - 였다. Struck et al 7 의연구에서는외사시에동반된수직사시에대해수평근수술과함께시행한수직근수술의결과를보고하면서과교정의빈도가높아주의해야한다고말한바있다. 이처럼외사시에동반된적은양의상사시가수평근수술에의한외사시의교정만으로도제거되는경우가많다는것이많이알려졌으나동반된수직사시와관련하여외사시수술과상사시수술의동시수술에대해서는연구가많지않다. 2-7 실제임상에서간헐외사시를수술할때회선사시나이상두위등으로확진할수있는상사근마비가동반된환자를제외하고는수직사시에대한동시수술을할것인지아닌지에대해고민하게되는경우를드물지않게만날수있다. 이에저자들은상사시를동반한간헐외사시로수평근수술과함께사근이나수직근의수술을동시시행한환자와수평근수술만시행한경우를모두포함한환자들의의무기록을후향적으로분석하여, 외사시에수직사시가동반되어있는임상적형태와더불어수술자의수직사시진단에의거한회선수직근동시수술의상사시교정효과도알아봄으로써상사시를동반한간헐외사시에서의치료방법결정등에도움을주고자한다. 대상과방법 2008년 1월부터 2011년 12월까지 1인의소아안과전문의에의해간헐외사시수술을받은환자중 6개월이상추적관찰이가능하였던환자들의의무기록을후향적으로분석하여수술전일차안위에서 4 prism diopter (PD) 이상 ( 4 PD) 의상사시가있었던환자 148명을연구대상으로선정하였다. 초진방문이전에사시수술기왕력이있는경우, 마비사시, 제한사시, 듀안증후군이나브라운증후군과같은특수형태사시, 약시, 신경학적질환이나염색체이상이있는환아, 술후추적관찰기간이 6개월미만인경우는대상에서제외하였다. 모든환자는초진시 1% Cyclopentolate를점안하여조절마비시킨뒤굴절검사를시행하였고이를토대로외래방문시마다최대교정시력을측정하였고필요한경우교정안경을착용시켰다. 단안및양안운동검사를통해외안근의기능항진이나기능저하를검사하였고, 사시각은조절시표를이용하여 6 m 원거리와 33 cm 근거리에서교대프리즘가림검사로측정하였다. 수술전날모든환자에서 60분간한눈을가려융합을차단한후다시한번원거리와근거리의사시각을측정하여수평근수술량을결정하였다. 동반된상사시에대해수술자가회선수직사시진단기준에맞게양안해리수직편위, 비대칭하사근기능항진, 비대 칭상사근기능항진등의진단을내릴수있었던 I군과그렇지않은단순상사시를동반한 II군으로나누었다. 일차하사근기능항진과상사근마비는회선사시동반, 머리기울임검사, 이상두위및안면비대칭등에대해자세히검사하여수술자가임상적으로감별진단하였다. 8,9 I군에서는, 진단에따른사근약화수술을외사시수술과동시에시행하고해리수직편위의경우임상적으로빈번한비주시안의상전이나타나면서그눈의해리수직편위양이 10 PD 이상이면외사시수술과함께해리수직편위교정수술을동시에시행하는것을원칙으로하였다. 해리수직편위가잠복해있거나편위각이적은경우는수평근수술만시행하였다. 상사시수술실패의기준은술후 >1 PD와교정된경우, >4 PD 부족교정이된경우로정의하였다. II군은상사시각의크기와상관없이외사시수술만시행하였다. II군은해리수직편위나뚜렷한사근기능항진은없었던경우지만상, 하, 좌, 우, 정면주시의 5방향원거리사시각검사및고개기울임검사에서나타난불일치 (incomitance) 형태의분포를기준으로 4가지 pattern으로분류하였다. 양측방주시검사에서상사시안쪽으로고개돌림시상사시각이정위에비해 >4 PD 증가하는형태를 pattern 1, 상사시안반대쪽으로고개돌림시상사시각이 >4 PD 증가하는형태를 pattern 2, 고개기울임검사양성 ( 상사시안쪽으로고개를기울일때, 상사시각이반대쪽으로고개를기울일때상사시각보다 >8 PD 큰경우 ) 의형태를 pattern 3, 역고개기울임검사양성 ( 상사시안의반대쪽으로고개를기울일때, 상사시각이상사시안쪽으로고개를기울일때상사시각보다 >8 PD 큰경우 ) 의형태를 pattern 4로분류하였다 (Fig. 1). 수술후상사시각의통계처리는각환자의마지막추적관찰시점의데이터를기준으로하였다. 통계학적분석은 SPSS version 12.0 (SPSS Inc., Chicago, III) 의기술통계를이용하여집단별평균분석을시행하였다. Selecting 4 PD HT coexisting with IXT through retrospective chart review Paralytic or restrictive HT (ex. SO palsy, MED) was excluded Eligible patients (if there was no paralytic or restrictive HT) Group I: Clinically diagnosed HT (DVD, unilateral IOOA, Asymmetric bilateral IOOA with V pattern, Asymmetric bilateral SOOA with A pattern) Group II: Non-specific HT Figure 1. Flow diagram summarizing the stepwise categorization of the patients with hypertropia coexisting with intermittent exotropia. PD = prism diopter; HT = hypertropia; IXT = intermittent exotropia; SO = superior oblique; MED = monocular elevation deficiency; DVD = dissociated vertical deviation; IOOA = inferior oblique overaction; SOOA = superior oblique overaction. 1884
- 조관혁 이주연 : 상사시를동반한간헐외사시의치료 - Table 1. Clinical characteristics of patients Demographics Results N 148 Sex (M:F) 70:78 Mean age at surgery (years) 12.47 ± 9.98 Mean amount of preoperative exodeviation (PD) 30.15 ± 1.76 Mean amount of postoperative exodeviation (PD) 7.17 ± 8.14 Mean amount of preoperative hypertropia (PD) 12.47 ± 9.89 Laterality of the coexisting hypertropia (n) RHT 78 LHT 58 DVD (both) 12 Same as exotropic eye * 49 Opposite to exotropic eye * 38 Values are presented as mean ± SD unless otherwise indicated. PD = prism diopter; RHT = right hypertropia; LHT = left hypertropia; DVD = dissociated vertical deviation. * Patients who had alternating fixation were excluded. Table 2. Distribution of surgery in clinically diagnosed hypertropia Surgery No. of cases DVD Bilateral IO anteriorization 2 SR recession 2 Oblique muscle Bilateral IO recession 14 dysfunction Unilateral IO recession 8 Bilateral IO myectomy 1 Bilateral SO recession 1 Bilateral SO tenotomy 1 Total 29 DVD = dissociated vertical deviation; IO = inferior oblique muscle; SR = superior rectus muscle; SO = superior oblique muscle. 결 과 전체 148명중남자는 70명 (47%), 여자는 78명 (53%) 이었으며, 첫수술시평균연령은 12.47 ± 9.98세였다. 수술시부터마지막추적관찰시까지의기간은평균 3.28 ± 1.43 년이었다. 전체환자의술전외사시각은평균 30.15 ± 1.76 PD이었고술후최종외사시각은평균 7.17 ± 8.14 PD였다. 술전상사시각의평균은 7.26 ± 3.14 PD로 4-7 PD 사이가 75명 8-15 PD 사이가 73명이었다. 우안상사시를보이는경우는 78명, 좌안상사시를보이는경우는 58명, 양안해리수직편위형태를보이는경우는 12명이었다. 주시안이분명한경우외사시를자주보이는비주시안에서상사시를보인경우가 49명, 주시안에서상사시를보인경우는 38명이었다 (Table 1). I군은 38명, II군은 110명이었고, I군에서 29명이외사시수술과동시에상사시수술을받았고시행한수술의종류는 Table 2와같았다. 상사시와관련된진단과상사시동반수술여부및수술전후상사시각은 Table 3과같았다. I군에서총 4예에서수술실패를보였다. 2예에서 >1 PD 상사시과교정을보였으며 2예에서 >4 PD 부족교정을보였다 (Table 4). 2예의과교정은모두단안하사근후전후발생한것으로, 외사시수술과동시시행한단안하사근후전 8예에서 25% 의과교정률을나타내었다. II군의각 pattern별사시각의불일치정도는 Table 5에나타낸것과같았다. 일치상사시는 19명이었고, 고개기울임검사양성의불일치성을가진 pattern 3이 57명으로가장많은분포를보였다 (Table 6). 측방주시불일치와고개기울임불일치를모두보이는복합적형태를보인경우중에서는 pattern 2와 pattern 3이같이나타난형태가 16명으로가장많았다 (Table 6). II군에서는상사시수술없이외사시수술만으로상사시각이감소되는것을볼수있었는데, 술전상사시각이비교적큰 12-15 PD를보였던 9명의환자에서도외사시단독수술후평균잔여상사시각이 1.0 ± 2.12 PD로교정되었다 (Table 7). II군에서외사시수술후잔여상사시각이 0-3 PD인환자가 102명, 4-7 PD인환자가 8명이었고 8 PD 이상남은환자는없었다. 고찰 기존연구에서상사시는외사시환자에서 40-63% 의빈도로동반된다고알려졌다. 7,10 Pratt-Johnson and Tillson 11 은외사시에서 5PD 이하의상사시의치료는의미가없다고말하였으며, 최근의국내연구로 Cho and Kim 12 의연구에서도 93명의외사시에동반된상사시환자에서수평근수술만으로의효과적인상사시상쇄효과를발표한바있으나술전평균상사시각이 3.8 ± 1.60 PD로상대적으로작은것이본연구와의차이점이라할수있겠다. Jampolsky 13 는 1885
- 대한안과학회지 2014 년제 55 권제 12 호 - Table 3. Distribution of hypertropia coexisting with intermittent exotropia Corrective surgery of HT N Preoperative HT (PD) Postoperative HT (PD) Clinically diagnosed HT 38 9.58 ± 3.89 1.41 ± 2.93 DVD + 4 10.0 ± 4.32 1.25 ± 2.5-8 6.75 ± 1.38 0.5 ± 1.41 Unilateral IOOA + 10 11 ± 3.74 2.33 ± 4.47-0 Asymmetric bilateral IOOA with V pattern + 13 9.0 ± 3.92 1.15 ± 1.91-0 Asymmetric bilateral SOOA with A pattern + 2 9.87 ± 2.84 0-1 12 7 Non-specific HT + 0-110 6.62 ± 2.69 0.45 ± 1.60 Values are presented as mean ± SD. HT = hypertropia; PD = prism diopter; DVD = dissociated vertical deviation; IOOA = inferior oblique overaction; SOOA = superior oblique overaction. Table 4. Surgical failure of hypertropia in clinically diagnosed hypertropia Clinically diagnosed HT Surgical management Overcorrection (>1 PD) 2 cases Unilateral IOOA Unilateral IO recession Unilateral IOOA Unilateral IO recession Undercorrection (>4 PD) 2 cases Unilateral IOOA Unilateral IO recession Asymmetric bilateral IOOA Bilateral IO myectomy HT = hypertropia; PD = prism diopter; IOOA = inferior oblique overaction; IO = inferior oblique muscle. Table 5. Classification of incomitance patterns in non-specific hypertropia N HT in primary gaze (PD) HT in ipsilateral gaze (PD) HT in contralateral gaze (PD) Pattern 1 13 6.07 ± 2.53 1.46 ± 3.01 5.76 ± 3.76 Pattern 2 19 6.52 ± 2.64 8.47 ± 3.43 1.84 ± 3.81 HT in primary gaze (PD) HT in ipsilateral HTT (PD) HT in contralateral HTT (PD) Pattern 3 84 6.82 ± 2.85 11.80 ± 4.08 2.52 ± 3.91 Pattern 4 3 7.5 ± 2.51 3.75 ± 3.30 13.25 ± 2.21 Values are presented as mean ± SD; Pattern 1: increment of HT angle on contralateral gaze, contralateral side gaze PD-ipsilateral side PD >4 PD; Pattern 2: increment of HT angle on ipsilateral gaze, ipsilateral side gaze PD-contralateral side PD >4 PD; Pattern 3: Bielschowsky HTT positive (increment of HT angle on ipsilateral HTT), ipsilateral HTT PD contralateral HTT PD>8 PD; Pattern 4: reversed Bielschowsky HTT positive (increment of HT angle on contralateral HTT), contralateral HTT PD-ipsilateral HTT PD >8 PD. HT = hypertropia; PD = prism diopter; HTT = head tilt test. 외사시에서상사시가동반되는기전으로눈이외전된상태에서는상직근이상전의역할만을하여상직근기능항진이발생되기때문이라고설명하였고, Kushner 14 는간헐외사시와함께 Bielschowsky 머리기울임검사에서양성을보이는각각 10 PD와 25 PD의상사시를가진두명의환자에서수평사시수술만하여외사시는물론상사시까지도교정이되었음을보고하면서이를고개기울임과회선사시, 그리고상사근기능저하가없는것이특징인유사상사근마비 (Simulated superior oblique palsy) 라명명하였다. 본연구에서도특정한회선수직사시로진단되지않은 II군의비특이상사시환자 110명에대하여외사시수술만을시행하여평균 6.62 ± 2.69 PD의술전상사시를술후평균 0.45 ± 1.60 PD로효과적으로교정하였고, 최대술전 15 PD의상 사시였던경우도외사시수술만으로교정됨을볼수있었다. 또한 II군의술전상사시형태분석을보면 Kushner의유사상사근마비형태로 Bielschowsky 머리기울임검사양성을보인환자들이가장많은부분을차지하고있는것을볼수있다. 본연구에서는외사시에동반된비특이적상사시의불일치성을머리기울임검사뿐아니라측방주시사시각도함께분석하였는데, 머리기울임검사양성인유사상사근마비환자에서양측방검사의불일치성은없는경우가가장많았고상사근마비에서와같은형태로상사시안내전시상사시가증가하는 pattern 1보다외전시상사시가증가하는 pattern 2가더많았다. 이러한결과는 Jampolsky가주장한외사시에동반된상사시의원인이상직근때문이고이것이 Bielschowsky 검사양성을나타내는 1886
- 조관혁 이주연 : 상사시를동반한간헐외사시의치료 - Tablel 6. Distribution of incomitance pattern in non-specific hypertropia Distribution of incomitance patterns No. of patterns (%) Pattern 1 only 2 (2) Pattern 2 only 2 (2) Pattern 3 only 57 (52) Pattern 4 only 2 (2) Pattern 1 & 3 11 (10) Pattern 2 & 3 16 (14) Pattern 1 & 4 0 (0) Pattern 2 & 4 1 (1) Comitant hypertropia (no pattern) 19 (17) Total 110 (100) Pattern 1: increment of hypertropia (HT) angle on contralateral gaze, contralateral side gaze prism diopter (PD)-ipsilateral side PD >4 PD; Pattern 2: increment of HT angle on ipsilateral gaze, ipsilateral side gaze PD-contralateral side PD >4 PD; Pattern 3: Bielschowsky head tilt test (HTT) positive (increment of HT angle on ipsilateral HTT), ipsilateral HTT PD-contralateral HTT PD >8 PD; Pattern 4: reversed Bielschowsky HTT positive (increment of HT angle on contralateral HTT), contralateral HTT PD-ipsilateral HTT PD >8 PD. Table 7. Outcomes of non-specific hypertropia after the intermittent exotropia correction Distribution of preoperative Postoperative N hypertropia hypertropia (PD) 4-7 PD 67 0.22 ± 1.05 8-11 PD 34 0.76 ± 2.20 12-15 PD 9 1.0 ± 2.12 Values are presented as mean ± SD. PD = prism diopter. 가장흔한원인중하나라는주장을뒷받침한다고할수있겠다. 13 술전검사상 Bielschowsky 머리기울임검사양성을보이는외사시환자에서는특히유사상사근마비와진성상사근마비를구분하기위해술전에뚜렷한상사근의기능저하, 하사근의기능항진, 안저의외회선, 머리기울임의병력등과더불어내전시와외전시상사시각의불일치성을같이고려하는것도진단에도움이될것으로생각한다. Moore and Stockbridge 15 의연구에서는외사시환자에서외사시만을위한프리즘치료만으로상사시의자연호전이이루어짐에대해발표한바있다. 이들은간헐외사시와동반된상사시에서수술전간헐외사시에대한프리즘적응만으로상사시의많은부분이상쇄되는효과가있어술전프리즘적응훈련만으로도수술을시행한후상사시의교정효과와거의같은상쇄효과를예측할수있다고주장하였고, 이를근거로동반된상사시의수술적치료의불필요성에대해역설하였다. 이와유사하게상사시를동반한외사시환자에서상사시수술의필요성에대해 Struck et al 7 의연구에서상사시동반수술의위험성에대해말한바있다. 이들은간헐외사시와함께평균 8.9 PD의동반된상사시에대한수직근후전을시행한결과 29% 에서상사시가과교정되었다고발표하면서, 이런환자들에대해서는 Moore and Stockbridge 15 가주장한술전외사시의프리즘적응과정이수술여부결정에도움이된다고말하고있다. 하지만본연구에서는술전프리즘적응훈련없이도수술전에충분한임상적검사를통하여사근기능이상이나해리수직편위가동반되지않은경우를감별한후남은모든비특이상사시에대해술전최대 15 PD의상사시까지수평근의수직이동 (vertical offset) 이나수직사시수술없이외사시수술로좋아지는결과를얻을수있었고, 이러한과정으로보아상사시를동반한간헐외사시의많은환자에게적용하기에비용대비효과가떨어지는프리즘적응훈련이필요하지는않다고생각한다. 만약일부환자에서외사시교정후상사시가임상적으로문제가될만큼남는다면그러한경우에만이차로상사시교정술을시행하는것이더합리적인대안이라생각하며, 본연구에서는 II군의환자 110명중 8명에서 4-7 PD 사이의상사시가남았지만모두사위정도로재수술이필요한경우는발생하지않았다. 간헐외사시에서사근기능항진은 32% 에서동반된다고보고된바있다. 16 중등도이상의사근기능항진을동반하는경우수평근단독수술이나수직이동만으로는부족하고사근수술을병행해야한다는보고들이있으나주로 V형사시의교정에중점을둔연구였다. 17-19 본연구에서외사시와동반된상사시와관련하여양안에비대칭으로존재하는사근기능항진으로진단한 26명의환자중 25명에대해사근약화수술을병행하였다. 수술을시행하지않은 1명의경우 A형외사시를동반한비대칭양안상사근기능항진환자였는데술전해리수직편위가의심되고융합에의한상사시각의변동이심하여외사시수술후필요시이차수술을할계획으로외사시와동시에상사근기능항진에대한교정수술을시행하지않았으나, 외사시단독수술후해리수직편위는발견되지않았지만 8 PD의상사시가지속되어 (Table 3) 비대칭사근기능항진이명백하고일차안위에서 4 PD 이상의상사시를보일경우사근수술을해주는것이상사시각의교정에유리함을시사하였다. I군에서수술실패의경우는사근약화술을시행한 25명의환자중 4명에서관찰이되었는데 2명은 >1 PD 과교정, 2명은 >4 PD 부족교정이었다. 수직사시수술후부족교정보다더나쁜결과로간주되는과교정문제에있어서단안하사근후전을한 8 명중 2명이과교정을보여 25% 의과교정률을보였는데, 기존의연구들에서도한눈하사근기능항진이나심한비대칭하사근기능항진으로판단하여한눈하사근만수술하는경우적도뒤쪽에위치하던하사근의부착부위치가적도 1887
- 대한안과학회지 2014 년제 55 권제 12 호 - 쪽으로바뀌면서안구에작용하는힘의방향이하전쪽으로작용하게되어, 술후반대편하사근의기능항진이나수직사시의과교정을야기할수있다고보고된바있다. 20-22 이처럼외사시에동반된수직사시에서하사근기능항진이있을때단안만하사근약화술을하면과교정위험이있으므로동시수술로단안하사근약화술을하는것은신중하게결정하는것이좋을것이라사료되며, 하사근기능항진의양안성여부를잘확인하여하사근기능항진정도에따라미약한하사근기능항진이있는눈에하사근후전량을줄이는단계적하사근후전 (Graded inferior oblique recession) 등을이용한양안수술을고려하는것이필요하다고생각한다. 한편사근기능항진뿐아니라해리수직편위역시간헐외사시와동반되는데, Lim et al 23 은 234명의외사시환자중약 22% 에서해리수직편위를동반한다고발표하였으며본연구에서는대상선정등에차이가있어, 148명중 12명 (8%) 으로앞의연구보다빈도가조금낮았다. 앞의연구에서는동반된해리상사시의치료에대해서수평근수술의상사시상쇄효과를강조하며별도의상사시수술을시행하지않았는데, 10 PD 미만의작은각의해리수직편위는수평근수술후개선된일차안위에서의눈모음기전으로자연해소된다고하였다. 본연구도수술을시행하지않은환자에서는술전해리수직편위가평균 6.75 ± 1.38 PD에서술후 0.5 ± 1.41 PD를보여상기연구와비슷한결과를보였고, 본연구에서는술전자주나타나는 10 PD 이상의해리수직편위에서외사시수술과동시에해리수직사시수술을시행하여좋은결과를얻어이러한경우해리수직편위의동시수술이효과적임을보여주었다. 이연구는후향적연구이기때문에사근수술이나해리수직편위수술의방법에있어일관되게지정하고시행한것이아니라환자의진단에맞게수술자가적절히선택하여시행하였다는점과, 사근기능항진이나 10 PD 이상의해리수직편위가있지만수술을시행하지않은대조군, 비특이상사시가있지만상사시교정수술을시행한대조군을각각설정할수없었던점등은주된제한점이라할수있다. 뚜렷한상사시를동반한간헐외사시에서수직사시교정수술을함께시행해야하는지에대해고민스러운경우가많다. 이러한경우철저한술전검사를통하여회선수직근의동시수술여부를결정해야하는데본연구결과뚜렷한비대칭사근기능항진이있는경우나 10 PD 이상의현성해리수직편위에있어서는사근이나수직근수술을동시시행함으로써좋은결과를얻을수있었다. 다만외사시수술과동시시행한단안하사근후전은과교정의빈도가높아수술을결정할때주의해야할것으로보인다. 그외의비특 이상사시에서는상사시량에관계없이외사시수술만단독시행하여최대 15 PD까지상사시가자연호전된결과를보여, 동시수술여부의결정은상사시각의과소가기준이아닌수직사시의임상적감별진단이중요하다고생각한다. 비특이상사시에있어기존보고된유사상사근마비양상뿐아니라머리기울임검사나양측방주시검사에서의다양한불일치형태를보였으며이와같은경우의감별진단에유의하여야할것으로생각한다. REFERENCES 1) DUNLAP EA. VERTICAL DISPLACEMENT OF THE HORIZONTAL RECTI. Pac Med Surg 1964;72:360-2. 2) O'Neill JF. Surgical management of small-angle hypertropia by vertical displacement of the horizontal rectus muscles. Am Orthopt J 1978;28:32-42. 3) Paque JT, Mumma JV. Vertical offsets of the horizontal recti. J Pediatr Ophthalmol Strabismus 1978;15:205-9. 4) Metz HS. The use of vertical offsets with horizontal strabismus surgery. Ophthalmology 1988;95:1094-7. 5) Scott WE, Drummond GT, Keech RV. Vertical offsets of horizontal recti muscles in the management of A and V pattern strabismus. Aust N Z J Ophthalmol 1989;17:281-8. 6) Struck MC, Daley TJ. Resolution of hypertropia with correction of intermittent exotropia. Br J Ophthalmol 2013;97:1322-4. 7) Struck MC, Hariharan L, Kushner BJ, et al. Surgical management of clinically significant hypertropia associated with exotropia. J AAPOS 2010;14:216-20. 8) Lee JY, Kim SH, Yi ST, et al. Contemplation of the surgical normogram of lateral rectus recession for exotropia associated with superior oblique palsy. Korean J Ophthalmol 2012;26:195-8. 9) Shimko JF. Binocular Vision and Ocular Motility Theory and Management of Strabismus Gunter K. vonnoorden, M.D.; Emilio C. Campos, M.D. Mosby Inc., Sixth Edition 2002, $149.00; 631 pages, 315 illustrations. Am Orthopt J 2001;51:161-2. 10) Moore S, Stockbridge L, Knapp P. A panoramic view of exotropias. Am Orthopt J 1977;27:70-9. 11) Pratt-Johnson JA, Tillson G. Management of the vertical associated with horizontal strabismus. Am Orthopt J 1978;28:24-7. 12) Cho YA, Kim SH. Surgical outcomes of intermittent exotropia associated with concomitant hypertropia including simulated superior oblique palsy after horizontal muscles surgery only. Eye (Lond) 2007;21:1489-92. 13) Jampolsky A. Management of vertical strabismus. Trans New Orleans Acad Ophthalmol 1986;34:141-71. 14) Kushner BJ. Simulated superior oblique palsy. Ann Ophthalmol 1981;13:337-43. 15) Moore S, Stockbridge L. Fresnel prisms in the management of combined horizontal and vertical strabismus. Am Orthopt J 1972; 22:14-21. 16) Wilson ME, Parks MM. Primary inferior oblique overaction in congenital esotropia, accommodative esotropia, and intermittent exotropia. Ophthalmology 1989;96:950-5; discussion 956-7. 17) Akar S, Gökyiğit B, Yilmaz OF. Graded anterior transposition of 1888
- 조관혁 이주연 : 상사시를동반한간헐외사시의치료 - the inferior oblique muscle for V-pattern strabismus. J AAPOS 2012;16:286-90. 18) Bakunowicz-Lazarczyk A, Urban B, Lazarczyk J. [The surgical results of correcting strabismus with inferior oblique hyperfunction]. Klin Oczna 2003;105:398-400. 19) Kumar K, Prasad HN, Monga S, Bhola R. Hang-back recession of inferior oblique muscle in V-pattern strabismus with inferior oblique overaction. J AAPOS 2008;12:401-4. 20) Raab EL, Costenbader FD. Unilateral surgery for inferior oblique overaction. Arch Ophthalmol 1973;90:180-2. 21) Stein LA, Ellis FJ. Apparent contralateral inferior oblique muscle overaction after unilateral inferior oblique muscle weakening procedures. J AAPOS 1997;1:2-7. 22) Kim SH, Na JH, Cho YA. Inferior oblique transposition onto the equator: the role of the equator in development of contralateral inferior oblique overaction. J Pediatr Ophthalmol Strabismus 2012; 49:98-102. 23) Lim HT, Smith DR, Kraft SP, Buncic JR. Dissociated vertical deviation in patients with intermittent exotropia. J AAPOS 2008;12: 390-5. = 국문초록 = 상사시를동반한간헐외사시에서상사시교정에대한임상적고찰 목적 : 상사시를동반한간헐외사시에서동반된수직사시의임상적형태와함께사근과수직근의동시수술또는수평근수술만시행후의상사시교정효과를알아보고자한다. 대상과방법 : 간헐외사시로수술받은환자중 4 prism diopter (PD) 의상사시가있었던 148 명의의무기록조사를통한후향적연구로, 마비사시는대상에서제외하였다. 동반된상사시에대해임상적진단을내릴수있었던 I 군과단순상사시를동반한 II 군으로나누어, 동반된상사시의임상적형태와수술결과를분석하였다. 결과 : I 군은 38 명, II 군은 110 명이었고, 술전평균상사시각은각각 9.58 ± 3.89 PD, 6.62 ± 2.69 PD 이었다. I 군은해리수직편위 12 명, 단안하사근기능항진 10 명, 비대칭양안하사근기능항진 13 명, 비대칭양안상사근기능항진 3 명이었다. II 군에서일치상사시는 19 명이었고, 고개기울임검사양성인유사상사근마비형태가 84 명으로가장많았으며기타다양한불일치성을보였다. I 군의 29 명이외사시수술과동시에상사시수술을받았고 4 예에서 >1 PD 의과교정혹은 >4 PD 의부족교정을보였다. I 군의술후상사시각은 1.41 ± 2.93 PD, II 군은외사시수술만시행한후상사시각 0.45 ± 1.60 PD 로교정되었다. 결론 : 상사시를동반한간헐외사시에서사근기능이상혹은해리수직편위를술전에진단하여사근이나수직근수술을동시시행함으로써좋은결과를얻었다. 비특이상사시에서는외사시수술만으로상사시가교정되었으나, 다양한불일치사시를보이므로감별진단에유의해야할것으로생각한다. < 대한안과학회지 2014;55(12):1883-1889> 1889