대한안과학회지 2014 년제 55 권제 11 호 J Korean Ophthalmol Soc 2014;55(11):1651-1658 pissn: 0378-6471 eissn: 2092-9374 http://dx.doi.org/10.3341/jkos.2014.55.11.1651 Original Article 녹내장수술후발생한지연성안내염 Late-Onset Endophthalmitis Associated with Glaucoma Surgery 김선영 1 노영정 2 김수영 1 Sun Young Kim, MD 1, Young Jung Rho, MD 2, Su Young Kim, MD, PhD 1 가톨릭대학교의과대학의정부성모병원안과및시과학교실 1, 가톨릭대학교의과대학여의도성모병원안과학교실 2 Department of Ophthalmology and Visual Science, Uijeongbu St. Mary s Hospital, The Catholic University of Korea College of Medicine 1, Uijeongbu, Korea Department of Ophthalmology, Yeouido St. Mary s Hospital, The Catholic University of Korea College of Medicine 2, Seoul, Korea Purpose: To report cases of late-onset endophthalmitis associated with glaucoma surgery. Methods: We retrospectively reviewed the medical records of 4905 consecutive patients who underwent glaucoma surgery (trabeculectomy or valve implant surgery) from January 1, 1988 to March 31, 2013. Results: There were a total of 14 late-onset endophthalmitis (0.29%) cases associated with glaucoma surgery occurring at 1 year to 21 years postoperatively. Six cases (6/993, 0.60%) occurred after valve and the other 8 cases (8/3912, 0.20%) occurred after trabeculectomy (p = 0.046). All but one patient were injected with fortified vancomycin and ceftazidim. Four patients also received a vitrectomy with the injection. The implanted valve was removed in 2 cases. In four cases, organisms were found in the culture (staphylococcus.aureus, streptococcus viridians, propionibacterium acnes and candida parapsilosis). After 1 year, only 4 patients achieved a visual acuity above 4/200 compared with other patients who had a final visual acuity of hand motion or worse. Three patients (33%) who developed endophthalmitis underwent other intraocular procedures. Conclusions: Late-onset endophthalmitis associated with glaucoma surgery can often occur with fulminant sight-threatening complications. Due to devastating sequelae, the surgeon should carefully check the surgery site in the patients who underwent glaucoma surgery at every follow-up visit. Delayed endophthalmitis after glaucoma surgery still carries a poor visual prognosis and its onset is difficult to predict. Therefore, patients who undergo glaucoma surgery should be educated and carefully evaluated during regular follow-ups. J Korean Ophthalmol Soc 2014;55(11):1651-1658 Key Words: Endophthalmitis, Glaucoma, Glaucoma surgery 녹내장수술은난치성녹내장환자의안압을조절할수있는치료법이며여러여과장치및술기들의발달로발전을거듭하고있다. 녹내장수술후발생할수있는합병증은저안압, 전방소실, 각막내피세포의감소, 주변부홍채앞유착, 여과포소실, 맥락막상강출혈, 백내장, 안내염등이있다. Received: 2013. 9. 23. Revised: 2014. 3. 10. Accepted: 2014. 10. 27. Address reprint requests to Su Young Kim, MD, PhD Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Uijeongbu St. Mary s Hospital, #271 Cheonbo-ro, Uijeongbu 480-717, Korea Tel: 82-31-820-3110, Fax: 82-31-847-3418 E-mail: cassiopeia-su@hanmail.net 안과수술이나안외상후안내염은드물게발생하지만일단발생하면시력예후가매우불량하다고알려져왔다. 여러후향적연구들에의하면안과적수술을받은뒤발생한안내염의빈도는 0.05-0.19% 이다. 1-4 반면외국의보고에의하면녹내장수술후안내염의빈도는그보다 10배가량많은 0.2-9.6%( 평균 2.0%) 로보고되고있다. 5-8 Endophthalmitis vitrectomy study (EVS) 에의하면안내염후최종시력이 10/20 이상을보이는환자는 53.1% 이다. 9 반면다른수술후안내염과는달리녹내장수술후발생하는안내염은술후 6주가지난뒤발생하는것으로정의되는지연성안내염인경우가많고진행이빠르며 20/100 이상의시력을보이는환자가 1/3 정도로예후가특히나쁜것으로보고되고있다. 10 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. 1651
- 대한안과학회지 2014 년제 55 권제 11 호 - 더욱이녹내장수술성공률을높이기위한방법으로시도되는술후초기 5-플루오로우라실주사나수술중마이토마이신씨 (mitomycin-c, MMC) 의사용은얇은벽의여과포를형성함으로써방수유출은높였지만수술후안감염의발생은증가시키고있다. 11-13 저자들은녹내장수술을받은환자에서발생한안내염유병률을조사하고발생한 14안의임상증상, 위험인자, 치료경과에대하여문헌고찰과아울러보고하고자한다. 대상과방법 1988년 1월부터 2013년 3월까지녹내장수술을시행한환자중에서최소 6개월이상경과관찰이가능했던 4,905안을대상으로조사하였다. 이중수술후안내염으로진행한환자는 14명 14안이었다. 환자들의성별, 연령, 동반된전신질환, 진단명, 수술날짜및수술의종류, 녹내장수술이외의다른수술의기왕력, 안내염진단전증상의내용과기간, 안내염의진단전및진단당시시력, 안압, 결막충혈, 녹내장수술부위의상태, 여과포누출유무, 전방내염증세포및전방축농, 그리고유리체혼탁등의임상증상을정리하였고수술기록을검토하여항대사제의유무, 수술합병증의유무를기록하였다. 모든환자들에게시행된진단적전방천자균의도말및배양검사의결과, 치료방법, 임상적경과, 추적관찰기간을조사하였다. 안내염발생환자와대조군사이에서다른수술의기왕력, 당뇨유무와항대사제사용의유무와안내염의발생의관련성에대해통계학적분석을시행하였다. SPSS (IBM SPSS Statistics version 19) 를이용하여 Pearson's Chi-square test를사용하였고각각의모든경우에 p<0.05인경우를통계적으로의미있는것으로간주하였다. 결과 25년간전체녹내장수술을받은환자총 4905안중밸브삽입술을시행한환자는 993안, 섬유주절제술을시행한환자가 3,912안이었다. 이중안내염으로진행한환자는총 14 안으로그유병률은 0.29% (14/4,905) 였다 (Table 1). 이는한 기관의의무기록을바탕으로하였으므로안내염발생후타병원으로내원한환자들에대한누락의가능성을배제할수는없겠다. 그러나녹내장은만성질환으로녹내장수술후안내염이발생시본원이아닌다른병원으로이동했을가능성은그리많지않을것으로생각한다. 혹여그럴가능성이있다면이미기존에발표된안과수술후발생하는급성안내염 (0.093%) 보다그유병률이수십배가량높게측정된녹내장수술후안내염의유병률이실제로는더높을수있겠다. 1 방수유출장치를삽입한 993안중안내염이발생한경우가 6안 (0.60%), 섬유주절제술을시행받은 3,912 안중 8안 (0.20%) 으로방수유출장치를삽입한경우에그유병률이통계적으로유의하게더높았다 (p=0.046). 4,905안의평균연령은 55.15세였고, 남자 2,717안 (55.39%), 여자 2,188안 (44.61%) 으로성비가비슷하였다 (Table 2). 당뇨의기왕력이있던환자는 815안 (16.62%) 이었으며녹내장의진단별분류는 Table 2에서정리하였다. 전체환자중 2,798안 (2,798/4,905, Table 2. Baseline demographic and clinical features for the 4,905 patients with glaucoma filtering surgery Characteristics Values Age (years) Mean ± SD 55.15 ± 17.24 Sex (n, %) Female 2,188 (44.61) Male 2,717 (55.39) Systemic diseases (n, %) Diabetes mellitus 815 (16.62) Glaucoma type (n, %) Primary open-angle glaucoma 2,147 (43.77) Primary angle closure glaucoma 669 (13.64) Normal tension glaucoma 18 (0.37) Secondary glaucoma 1,447 (29.50) Neovascular glaucoma 564 (11.50) Primary congenital glaucoma 60 (1.22) Glaucoma surgery type (n, %) Trabeculectomy 3,912 (80.00) Tube 993 (20.00) Presence of other ocular surgery (n, %) 2,798 (57.00) Antimetabolite (MMC) used (n, %) 1,917 (49.00) Values are presented as mean ± SD unless otherwise indicated. MMC = mitomycin-c. Table 1. Incidences of endopthalmitis associated with glaucoma surgery Type of surgery Total cases (n) Infected cases (n) Trabeculectomy 3,912 8 (0.20%) Valve implant surgery 993 6 (0.60%) Total 4,905 14 (0.29%) p-value - 0.046 * * p-value by Fisher s exact test: means statistically significant difference (p<0.05). 1652
- 김선영외 : 녹내장수술환자에서발생한안내염 - Table 3. Summary of patients Case no. Sex /Age (years) Associated systemic disease Glaucoma diagnosis * Symptom duration Presenting visual acuity Mitomycin-C Interval Type of surgery use 1 M/68 HBP 2nd glaucoma 1 day 8/200 16 years Trabeculectomy Yes Status of glaucoma surgery site Nearly melted conjunctiva, leak (+) 2 M/49 none CACG 2 days LP (+) 21 years Trabeculectomy Yes Pus tinged bleb 3 M/33 none POAG the day CF 9 years Trabeculectomy Yes 4 M/49 none POAG 1 day HM 2 years and 6 months Bleb thinning, leak (+) Trabeculectomy Yes Pus tinged bleb 5 M/50 none POAG 1 day HM 19 years Trabeculectomy No Pus tinged bleb 6 M/56 none 2nd glaucoma 2 days 12/200 13 months 7 M/59 none 2nd glaucoma the day LP (+) 8 years and 6 months 8 M/80 DM POAG 1 year 1 year 9 M/68 none 10 M/56 none 11 M/34 none Advanced glaucoma (NVG + AACG) Uveitic glaucoma Secondary glaucoma 1 day HM 5 years + scleral graft Molteno tube No No NR No Thin conjunctiva on valve Conjunctival inflammation with exposed valve Bullae on conjunctiva Well positioned valve 2 days HM 8 months Trabeculectomy Yes Pus tinged bleb 2 days HM 1 year 12 M/64 none POAG 10 days 0.16 12 years 13 F/69 DM POAG 30 days 7 years + Trabeculectomy + pressure regulator insertion 14 F/36 none POAG 2 days CF 13 years Trabeculectomy Yes NR NR No Well positioned valve tip exposure Exposed tube with whitish pus Bleb thinning, leak (+) Treatment Intravitreal, intracameral and subconjunctival vancomycin + ceftazidim injection Intravitreal and subconjunctival vancomycin,, removal, evisceration,,, ahmed valve removal Tube removal & AC irrigation & intracameral vancomycin + ceftazidim injection Culture organism Other operation (time) Final visual acuity - 20/200 - HM - 4/200 Staphyococcus. aureus - Phacoemulsification + PCL in sertion (14 years after trabeculectomy) PKP (twice, 3 months prior to ahmed valve ) 1' closure, (1 year prior to ahmed valve ), PKP (3 years after ahmed valve implanatation) LP (+) - Streptococcus viridans Propionibacterium acnes Candida parapsilosis Topical fortified antibiotics (6 months after Molteno tube ) Phacoemulsification + PCL in sertion (8 years prior to trabeculectomy) Ciliary body retension cyst removal (1 year 4 months prior to valve surgery) Trabeculectomy (7 years prior to ahmed valve ) phacoemulsification + PCL in sertion (8 years prior to ahmed valve Trabeculectomy (6 years prior to 2nd trabeculectomy) Trabeculectomy (2 years prior to 2nd trabeculectomy) HM 50/200 40/200 HBP = high blood pressure; CACG = chronic angle closure glaucoma; POAG = primary open angle glaucoma; PCL = posterior chamber lens; AACG = acute angle closure glaucoma; NVG = neovascular glaucoma; DM = diabetes mellitus; LP (+) = light perception; CF = counting fingers; HM = hand motion; = no light perception; = pars plana vitrectomy; NR = not recorded; PKP = penetrating keratoplasty. * Duration of symptom before diagnosis of endophthalmitis; Interval between glaucoma surgery and diagnosis of endophthalmitis; Final visual acuity 6 months after diagnosis. 1653
- 대한안과학회지 2014 년제 55 권제 11 호 - Figure 1. Representative image of slit lamp photograph shows conjunctival injection and hypopyon (case 8). Figure 2. Representative image of B-scan ultrasonograph shows posterior vitreous opacification and multiple abnormal vitreous spikes (case 8). 57.0%) 은녹내장수술전후로녹내장수술을포함하여각막이식, 유리체절제술, 백내장적출술등다른안과적수술을받은기왕력이있었으며섬유주절제술을시행받은 3,912안중술중 MMC를사용한경우가 1,917안 (1,917/3,912, 49.0%) 이었다. 안내염으로진단된 14명 14안의환자들의평균연령은 55.07세 (33-80) 였으며성별은 12안이남자, 2안이여자로남자가많았다 (Table 3). 녹내장의종류는 14안중 7안이개방각녹내장, 5안이이차성녹내장, 1안이만성폐쇄각녹내장, 나머지 1안은신생혈관녹내장과급성폐쇄각녹내장이합병된녹내장이었다. 녹내장수술과안내염이진단된시기간격은평균 8.4년 ( 중위수 7.8년 ) 으로짧게는 8개월에서길게는 21년이었다. 증상발현과진단및치료시작의간격은 4시간에서 1년까지였다. 13명의환자들은시력감소를주호소로내원하였으며진단수개월전부터시력이광각무였던 Figure 3. Representative images of slit lamp photograph shows markedly injected conjunctiva and thin, cystic bleb (case 4). 1명만안통으로내원하였다. 녹내장수술부위의결막미란은 14안중 11안 (79%, 아메드밸브삽입술받은 6안중 4안, 섬유주절제술받은 8안중 7안 ) 에서나타났으며 Siedel 양성인누출소견은 3안 (0.21%, 섬유주절제술받은 8안중 3안 ) 에서관찰되었다. 2안에서아메드밸브의유출관이노출된소견이보였다. 섬유주절제술을시행한 8안중여과수포에삼출물이차있었던환자는 7안이었고전방누출소견이보인환자는 3안, 그중저안압을보인환자는 2안이었다. 모든환자에게전방내염증소견이보였고뚜렷한전방축농이있는환자는 9안중 7안이었다 (Fig. 1). 모두유리체염이관찰되었으며안초음파로유리체강내유리체혼탁물질이차있는소견이뚜렷히관찰된환자는 9안중 7안이었다 (Fig. 2). 모든환자들을안내염으로진단된즉시치료를시작하였다. 14안중 13안의환자들은유리체강내강화항생제주입술을시행받았으며이중 2명은유리체절제술을시행받았다. 정맥내항생제로반코마이신과세프타지딤을처방하였으며목시플록사신혹은레보플록사신, 반코마이신, 세프타지딤을점안제로치료하였다. 치료에도불구하고안내염이조절되지않은 1안에는안구내용물적출술을시행하였다. 균동정은유리체절제술을시행하였던 2안과전방수천자를통해시행하였던 1안, 총 3안에서양성이나왔으며유리체에서 Staphyococcus aureus, streptococcus viridians, propionibacterium acnes가, 전방수에서 candida parapsilosis 가동정되었다. 최종시력예후는 4안만이 4/200 이상이었고나머지환자들은안전수동이하, 7안이광각무였다. 10안 (10/14, 71%) 이녹내장수술전후로다른안과적수술을받은기왕력이있었으며, 이중 8안 (57%) 은녹내장수술을시행한후부터안내염이발생하기전기간에다른안과적수술을받았다. 섬유주절제술시 MMC를사용한경우는 8안 1654
- 김선영외 : 녹내장수술환자에서발생한안내염 - 중 6안으로 6안모두감염전무혈관성낭성의벽이얇은여과포소견을보였다 (Fig. 3). 환자의동반된전신질환으로는 14명중당뇨 2명, 고혈압 1명이었다. 녹내장수술후발생한지연성안내염으로진단된 14명의 14안에대해 Table 3에정리하였다. 고찰 녹내장수술후안내염이다른안과적수술후발생하는안내염에비해매우높은빈도로일어나는이유는여과수포나방수누출장치를통하여정상세균총이직접침투할수있기때문인것으로추정된다. 14 본연구에서의유병률은 0.29% (14/4,905) 로 Eifrig et al 2 이 6년간녹내장수술후발생한안내염에대해그유병률을조사한결과인 0.2% (2/1,970) 와다소유사한결과를보였으며백내장수술후발생하는급성안내염의유병률에비해 10배가량높은수치이다. 방수유출장치를삽입한 993안중안내염이발생한경우가 6안 (0.60%), 섬유주절제술을시행받은 3,912안중 8 안 (0.20%) 으로유병률에차이를보였는데그에대한이유는좀더연구가필요할것으로생각한다 (p=0.046). 대부분의안과수술후안내염과달리지연성으로일어나는것이특징이며그사이기간은평균 19.1개월로 3일에서 9년까지보고되고있다. 10,15-17 Kil et al 18 은섬유주절제술후 3년 4개월후에발생한안내염 1예를보고하였고 Cha et al 19 은섬유주절제술후각 13년및 15년후에발생한안내염 2예를보고하였다. 최근안내염발생률은항대사제의사용으로증가하고있는데이는항대사제가얇아진수포성의무혈관성결막을초래하여방수누출의빈도를증가시키고감염에취약한환경을조성하기때문이다. 12 보고된바에의하면 MMC를사용후안내염발생의연간발생률이 2.1-2.6%, 5- 플루오로우라실사용후가 1.7% 로높다. 11,12 본연구에서도섬유주절제술시 MMC를사용한경우가 8안중 6안 (75%) 으로전체환자의비율인 49% (1917/3912) 보다높은비율을차치하였으나통계적으로유의한상관성을찾을수는없었다 (p=0.142). Uhm et al 13 은 MMC를사용한섬유주절제술후얇은벽의여과포가발생되기쉬운경우는얇은결막과테논낭, 난치녹내장보다는비합병녹내장, 고혈압이있었던경우라고하였으며, 수술후관찰기간이길수록 (1년미만 14%, 1년이상 31%), 얇은벽의여과포발생이증가했다고하였다. 국내에서 MMC를이용한섬유주절제술후발생한안내염에관해 Kil et al 18 과 Kim et al 20 이 2예씩보고하였는데, 총 4예의증례들모두감염전여과포가무혈관성의벽이얇고낭성이었다고하였다. 그러므로얇은여과포가발생하기쉬운환자에는안내염의위험성이높아질수있어 MMC 사용에신중을기해야할것으로생각한다. 항대사제의사용이외에녹내장수술후안내염가능성을높이는위험요인으로코쪽이나아래쪽에위치하는여과포, 동반된안검염, 높은여과포, 후기에발생한여과포누출, 방수유출장치주변결막의미란으로인한관노출, 레이저봉합사융해술 (Laser suture lysis), 유출관위치조정술 (tube repositioning), 여과포복원술 (bleb revision) 및 needling, 자가혈액주입술, 윤부기저결막편 (limbus-based conjunctival flap), 남성, 소아, 전신스테로이드투여기왕력, 녹내장수술이전에수술받은기왕력, 수술직후시기가지난후에항생제의지속적사용, 얕은전방과상공막하출혈과같은수술초기의합병증, 콘택트렌즈사용등이알려졌다. 7,8,14,16,21-27 증상은갑작스런시력감소및안통, 충혈이있다. 여과포감염과안내염은유리체염의유무로감별되며유리체염은주로전방축농과동반하여시력감소, 안통을유발시킨다. 결막충혈및화농성의여과수포는대부분에서나타나나여과포누출은 25% 가량나타난다고하며본연구에서도섬유주절제술을시행받은 8안중 7안 (88%) 에서여과포삼출물이, 3안 (38%) 에서누출이관찰되었다. 21 녹내장수술후발생하는안내염을일으키는원인균으로는연쇄상구균종이 31-57% 로가장많았으며그밖에포도상구균, Moraxella 균, 녹농균, 인플루엔자균및 Fusarium species가있으며이들주원인균주가독력이강한점이불량한예후와도연관이있다. 14,15,23 Cha et al 19 이보고한 2 증례중 1예에서 Staphylococcus epidermidis가유리체에서동정되었는데최종교정시력도안전수지 1 m로균동정이나오지않은다른 1예의시력 0.2보다더나빴다. 이전문헌에따르면녹내장수술후발생한안내염의배양검사양성률은 59-69.2% 이다. 11,15 본증례에서도 3안 (21%) 에서배양되었으며 3안모두최종시력이광각무로나빴다. 배양률이낮은이유는문헌에보고된배양검사양성률이유리체를동정을한결과이고본증례에서는유리체절제술을시행한 3안을제외하고모두방수에서만동정을하였기때문일것으로생각한다. 그리고방수천자를시행하기전항생제점안을시작한점이균동정을어렵게하였을것으로추정된다. 대부분의안내염환자의치료는항생제유리체강내주입술이권장된다. 본증례에서는 1안을제외한환자들에게진단즉시 Vancomycin (1 mg/0.1 ml) 및 ceftazidime (2.25 mg/ 0.1 ml) 를유리체강내로주입하였다. Ceftazidime 대신 amikacin (400 ug/0.1 ml) 을유리체강내주입을할수도있다. 염증이조절되지않으면조기유리체절제술을시행해볼수있으며효과에대해서는논란이있다. Song et al 23 은유리체절제술후 20/400 이상의시력을회복한환자가 36% 로유리체강내주입술을시행한환자 69% 보다낮다고보고하였다. Morad 1655
- 대한안과학회지 2014 년제 55 권제 11 호 - et al 8 은방수유출장치제거, 유리체절제술, 유리체강내항생제주입술을모두시행한 3예를발표하였는데이들중 2안에서안구위축이발생하였다. 본증례에서는 4안 (29%) 에서유리체절제술을시행하였으며모두최종시력이광각무였다. 본연구에서안초음파에서뚜렷한유리체염소견을보이지않았던 2안에있어서도조기안내염에준하여유리체강내항생제주입술을시행하였는데수일내빠른회복을보였고술전시력이각각 8/200, 안전수지에서최종시력이 20/200, 4/200으로호전되었다. 2안은전방수흐림및백내장으로안저관찰이명확하지않았고안초음파소견에서뚜렷한고에코성병변이관찰되지않으며전방축농이없었다는점으로미루어안내염초기보다여과포감염에국한되었을가능성이있다. 이들이다른안내염환자에비해최종시력예후가좋은이유는진단시시력이좋고전방축농이없고유리체혼탁소견이뚜렷하지않았던점때문으로분석해볼수있다. 본연구증례와같이섬유주절제술후전방축농이없더라도여과포감염이의심되면서전방세포및전방흐림이관찰되면전방축농으로진행된후주사를시행하는것보다는좀더조기에유리체강내항생제주사를시도해볼수있겠다. 또한섬유주절제술을시행받고안내염이발생한환자중에시력이 4/200 이상으로양호했던 3명의환자가모두전방수유출이관찰되는공통점을보였는데이는전방허탈및저안압으로인한갑작스런시력감소의증상발현으로빠른병원내원및조기치료가가능하여양호한결과를나타내었을가능성으로추측해볼수있다. 방수유출장치의제거에대한효과는명확하지않은데 Gedde 와 Perkins 는방수유출장치가감염원이될수있어제거를해야한다고권유하였고반대로방수유출장치제거없이유리체강내항생제주입술만으로치료를하여좋은예후를보고한논문도있었다. 18,28-31 본연구에서는 2안에서방수유출장치를제거하였는데이는내원당시시력이광각무인환자와항생제유리체강내주입술을시행하고도염증이악화되었던환자에서시행되었다. 경구 4세대퀴놀론제제도좋은안내침투력과연쇄구균및헤모필러스와같은그람음성균등의효능으로권장되고있다. 31 녹내장수술후안내염은이전연구에서그최종시력이매우불량한것으로보고되고있다. Mandelbaum and Forster 15 는섬유주절제술후발생한안내염의예후로 20/40 이상의시력을보인경우는 13%, 안전수지이하의시력인경우는 66% 였다고하였으며 Song et al 23 은최종시력이 5/200 이하인경우가 45% 라고보고되었을정도로예후가불량하다. 이는백내장수술후발생한초기안내염환자를 대상으로한 EVS에서 20/40 이상의시력을보인경우가 53% 인점과도비교시대조적이다. 32 방수유출장치삽입술후안내염의예후또한마찬가지로불량하였는데아메드밸브의경우에는 20/200 이상의시력을보인환자가아무도없었으며 Baerveldt 장치의경우 4명중 1명만이보였다고보고되고있다. 5,6,10,12,16,33,34 본증례들에서도안내염이발생하기이전의시력은광각무에서 20/40까지대부분의경우시력이불량하였고, 안내염이치유된후최종시력예후도대부분이불량하였으며 20/200 이상의시력을이룬환자는 14 안중단 3안이었다. 본연구의증례에서는 9예에서다른수술을동반하였는데다른수술에서비롯된안내염의가능성을배제할수는없으나다른수술에의한것보다녹내장수술과연관되어일어났을것이라추측된다. 여과포에누출과여과포감염이동반되었으며, 밸브노출및밸브주변의결막이상이관찰되었고, 다른수술이후바로발생한것이아니라 4년 6개월에서 6년까지의기간이지난후에발생하였다는점이이를뒷받침할수있다. 그렇지만방수유출장치를삽입한 6안중 5안이녹내장수술전후로다른수술을시행받은기왕력이있었고전체 14안중스테로이드를장기간유지요법해야하는각막이식술을시행받은 2안은결막이얇아져있거나유출관이노출되어있었다는점으로보아다른안과수술력이안내염의위험요인으로작용했을것으로생각한다. 그리고녹내장수술을시행받은전체환자에서다른안과적수술을시행받은비율이 57.0% 인반면안내염환자에서의비율은 71.4% 로더높았으나, 통계적으로유의성을찾을수는없었다 (p=0.285). 안내수술후주로사용하는점안스테로이드로인해결막이얇아질수있어특히항대사제로인하여얇아지거나수포성변화가유발된여과포일경우안내염위험성이더높아질가능성이있겠다. 당뇨가안내염의위험요인이라는이전보고가있었는데본연구에서는당뇨환자가 14명중 2명 (14.3%) 이었고이는전체환자의비율 (16.6%) 과차이가없었다 (p=0.817). 35 방수유출장치를삽입한후다른안과수술을받지않았음에도안내염으로진행한나머지 1안이당뇨환자로확인되었다. 이와같이안내염의치료는즉각적인치료를하여도치명적인결과를초래할수있어예방적진료가더중요하다고하겠다. 녹내장수술을받은환자에게눈을자주비비지말고안내감염의증상, 증후가있으면즉시의사에게알려야함을주지시키고수술후장시간이경과하여도감염의위험성이있을수있음을교육하여야할것이다. 지속적인예방적항생제점안은오히려지연성안내염을유발할수있다는보고가있어주의해야한다. 19 본연구에서섬유주절제술을시행받고안내염이발생한 8안중여과포가얇고 1656
- 김선영외 : 녹내장수술환자에서발생한안내염 - 무혈관성을보였던경우가 6 안이었는데이들모두술중 MMC 를사용한환자였으며만약여과포가기능을할수록, 얇고무혈관성의여과포일수록안내염의위험성이높아진다면, 임상적으로낮은안압을유지하며안압약을사용하지않은성공적인수술결과를보이는환자일수록더안내염이발생할가능성이높을수있다는점또한유념해야한다. 경미한결막염의발생에도안내염을염두해두고세심한관찰이필요할것이며예방적진료로정기적외래추적관찰에서감염의증후가있는지주의하여살피는것이중요하다. 또한본연구에서통계적으로유의하진않으나각막이식, 백내장수술등다른안내수술이후에발생한경우가많았으며녹내장수술받은환자에서다른안내수술이후에는좀더면밀한관찰이필요하다. 그리고여과포감염과함께전방염증이동반된환자에있어안내염을명확하게배제하기어렵다면전방축농이없더라도항생제점안만하는치료가아닌유리체강내주입술을시행하여안내염에준해서치료를시작해볼수있겠다. REFERENCES 1) Aaberg TM Jr, Flynn HW Jr, Schiffman J, Newton J. Nosocomial acute-onset postoperative endophthalmitis survey. A 10-year review of incidence and outcomes. Ophthalmology 1998;105:1004-10. 2) Eifrig CW, Flynn HW Jr, Scott IU, Newton J. Acute-onset postoperative endophthalmitis: review of incidence and visual outcomes (1995-2001). Ophthalmic Surg Lasers 2002;33:373-8. 3) Kattan HM, Flynn HW Jr, Pflugfelder SC, et al. Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery. 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- 대한안과학회지 2014 년제 55 권제 11 호 - mitis Vitrectomy Study Group. Arch Ophthalmol 1995;113:1479-96. 33) Tsai JC, Johnson CC, Kammer JA, Dietrich MS. The Ahmed shunt versus the Baerveldt shunt for refractory glaucoma II: longer-term outcomes from a single surgeon. Ophthalmology 2006;113:913-7. 34) Woodcock MG, Richards JC, Murray AD. The last 11 years of Molteno at the University of Cape Town. Refining our indications and surgical technique. Eye (Lond) 2008;22:18-25. 35) Lehmann OJ, Bunce C, Matheson MM, et al. Risk factors for development of post-trabeculectomy endophthalmitis. Br J Ophthalmol 2000;84:1349-53. = 국문초록 = 녹내장수술후발생한지연성안내염 목적 : 녹내장수술받은환자에서발생한지연성안내염의임상경과를보고하고자하였다. 대상과방법 : 1988 년 1 월부터 2013 년 3 월까지녹내장수술을받은 4,905 안을대상으로술후안내염으로진행된 14 명 14 안의의무기록을분석하였다. 결과 : 총 4,905 안중에 14 안 (0.29%) 이녹내장수술후안내염으로진행하였다. 녹내장수술후지연성안내염이발생한시기는평균 8.4 년으로짧게는술후 1 년부터길게는 21 년까지였다. 안내염이발생한환자는방수유출장치삽입술을시행받은 993 안중 6 안 (0.60%), 섬유주절제술 3,912 안중 8 안 (0.20%) 이었다 (p=0.046). 한명을제외한모든환자들은유리체강내강화항생제주입술을시행받았으며 4 명은유리체절제술을시행받았다. 방수유출장치를삽입후안내염이발생한 6 안중 2 안은삽입된방수유출장치를제거하였다. 14 안중 4 안에서균이동정되었다 (staphylococcus.aureus, streptococcus viridians, propionibacterium acnes, candida parapsilosis). 안내염진단후 1 년뒤 4 안만이 4/200 이상의시력을보였으며나머지 10 안은안전수동이하의시력을보였다. 3 안 (33%) 에서녹내장수술후다른안내수술후에안내염이발생하였다. 결론 : 녹내장수술후발생한지연성안내염은시력예후가매우불량하고, 발생시기도예측하기어려워녹내장수술후안내염에대한환자의교육및좀더면밀한정기적안과관찰이필요하다. < 대한안과학회지 2014;55(11):1651-1658> 1658