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대한안과학회지 2015 년제 56 권제 5 호 J Korean Ophthalmol Soc 2015;56(5):687-693 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) http://dx.doi.org/10.3341/jkos.2015.56.5.687 Original Article 반복각막진무름에서 Nd:YAG Laser 치료와보존적치료의비교 Comparison of Nd:YAG Laser versus Conservative Management in the Treatment of Recurrent Corneal Erosion 최문정 정지원 서경률 김응권 김태임 Moonjung Choi, MD, Ji Won Jung, MD, Kyoung Yul Seo, MD, PhD, Eung Kweon Kim, MD, PhD, Tae Im Kim, MD, PhD 연세대학교의과대학안과학교실시기능개발연구소 Institute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea Purpose: To compare the treatment effects of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser and conservative management in treatment of recurrent corneal erosion. Methods: Twenty-three eyes that received Nd:YAG laser treatment and 24 eyes that underwent conservative management including hyperosmotic agent were retrospectively reviewed for the rate and frequency of recurrence, presentation, time to recurrence, final visual acuity and complications. Results: The rate of recurrence in eyes treated with Nd:YAG laser was 56.5% and that in eyes with conservative management was 50.0%. The difference was not statistically significant (p = 0.654). However, 10 of 12 eyes that recurred after conservative treatment presented with macroform erosion at the time of recurrence, whereas 5 of 13 eyes that recurred after Nd:YAG laser had an accompanying epithelial defect (p = 0.041). After the Nd:YAG laser treatment or conservative treatment, 64.1% and 60.5% of the eyes, respectively, remained free from recurrence 1 year after treatment, however the success rate decreased over time (p = 0.649). The final visual acuity in the group that received Nd;YAG laser treatment was 0.05 ± 0.06 log MAR and 0.09 ± 0.08 log MAR (p = 0.649) in the group that received conservative management. None of the patients in either group experienced complications of corneal scarring. Conclusions: The difference in the recurrence rates between Nd:YAG laser treatment and conservative treatment were not statistically different, however, the severity of recurred episodes were milder in the eyes that received Nd:YAG laser treatment. J Korean Ophthalmol Soc 2015;56(5):687-693 Key Words: Hyperosmotic agent, Nd:YAG laser, Recurrent corneal erosion 반복각막진무름 (recurrent corneal erosion) 은각막상피와각막상피바닥막사이, 바닥막과실질층사이의바닥막복합체 (basement membrane complex) 의약화로반복적으로각 Received: 2014. 5. 1. Revised: 2014. 10. 14. Accepted: 2015. 4. 20. Address reprint requests to Tae Im Kim, MD, PhD Department of Ophthalmology, Severance Hospital, #50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea Tel: 82-2-2228-3570, Fax: 82-2-312-0541 E-mail: TIKIM@yuhs.ac 막의층이분리되는질환이다. 1 각막상피바닥막의결손, 유전적이상으로비정상적인각막상피바닥막의축적, 세포- 기질간의반결합체 (hemidesmosome) 의약화, 2 고정미세섬유 (anchoring fibril) 의결핍, 매트릭스메탈로프로티나제 (matrix metalloproteinase) 에의한각막상피결합체의분해, 3 제7형콜라겐의결손 4 등이원인으로제시되었다. 각막상피바닥막의결손을일으키는관련인자로는기저막이영양증 (epithelial basement membrane dystrophy), 지도-점 -지문각막이영양증 (Map-dot-fingerprint dystrophy) 등의각막상피바닥막자체의내재적인원인과이차적으로각막표면의외상등이 c2015 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. 687

- 대한안과학회지 2015 년제 56 권제 5 호 - 있다. 5 대부분의환자들은주로밤이나자고일어날때갑작스러운안통, 충혈, 눈부심, 눈물흘림, 시력저하등의증상을호소하게되며지속적인치료에도불구하고자주재발하는것으로알려져있다. 6 세극등현미경검사상각막상피의탈락을보이며각막미란의정도와증상의기간은수일간의경과를거치는넓은범위의각막상피결손에서수시간내에호전되는미세한각막미란에이르기까지다양하다. 7 반복각막진무름의보존적치료로는인공누액, 고삼투압제제점안, 치료콘택트렌즈및압박안대, 8 matrix metalloproteinase-9 억제제인독시사이클린제제 9 혹은테트라사이클린제제, 10 스테로이드, 11 자가혈청점안 12,13 등이알려져있다. 수술적치료로는일회용주사바늘을이용한전측각막미세천자술이나 Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser 치료, 14,15 알코올 16 또는다이아몬드드릴 17 을사용한표층각막절제술, 엑시머레이저를이용한치료레이저각막절제술 (Phototherapeutic keratectomy, PTK) 18 등이보고되어있다. 이중 Nd:YAG laser를이용한치료는 1990년성공적인치료증례보고가있은후 15 33안에대한 Nd:YAG laser의치료효과에대해서도보고되었지만 19 국내에서는 Nd:YAG laser를이용한반복각막진무름에대한임상성적을발표한논문은없었다. 이에저자는반복각막진무름환자를대상으로 Nd:YAG laser 치료와고삼투압제제를포함한보존적인치료방법의치료효과및재발률을비교하고자연구를진행하였다. 대상과방법 본연구는후향적연구로서 2007년 10월에서 2014년 3월사이에본원안과에서반복각막진무름의증상과임상적소견을보이는환자 98명의의무기록을검토하여선정기준에적합한환자 43명의 47안중 Nd:YAG laser 치료를받은군 (23안) 과고삼투압제제를포함한보존적인치료를받은군 (24안) 을비교분석하였다. 주사바늘을이용한전측각막실질미세천자술등다른치료를받은경우, 경과관찰기간이 6개월미만인경우, 최대교정시력에영향을미칠수있는다른안과적질환을가지고있는경우제외하였다. 환자의진단당시나이, 성별, 단안성혹은양안성여부, 각막외상을포함한원인, laser-assisted in situ keratomileusis (LASIK), Photo Refractive Keratectomy (PRK) 를포함한안과적수술의기왕력, 병변의위치및양상에대해조사하였다. 병변의위치는각막중심부반경 3 mm를침범하는경우중심부 (center) 로정의하고그외의병변은주변부 (periphery) 로정의하였다. 병변의양상은수일간의경과를거치는넓은 범위의각막상피결손 (macroform erosion) 과미세한각막미란, 미세낭포 (microcysts) 를보이고단시간내호전되는병변 (microform erosion) 으로분류하여치료전과재발했을때각각의양상에대해두군을비교하였다. 재발의유무, 빈도, 치료후최대교정시력, 합병증의유무에대해서도비교분석을진행하였다. Nd:YAG laser 치료는시술전환자의동의하에 0.5% Proparacaine (Alcaine, Alcon, Fort Worth, TX, USA) 를이용하여점안마취후각막중심부 3 mm 이내병변을제외하고각막상피결손또는탈락부위의 1 mm 바깥경계부까지시행하되 Nd:YAG laser 는 0.5-1.0 mj 에너지를사용하여 2 mm 지름당약 100회정도레이저를조사하는것을기준으로병변크기에따라다양한횟수로시행되었다. 시술후치료콘택트렌즈를삽입하였고각막재상피화가이루어질때까지 Levofloxacin 5 mg/ml (Cravit, Santen, Osaka, Japan), 5% sodium chloride (Muro128, Bausch & Lomb, Rochester, NY, USA) 등과 0.1% hyaluronic acid (Kynex, Alcon, Fort Worth, TX, USA) 인공누액점안액을사용하였고, 이후에도 5% sodium chloride와 0.1% hyaluronic acid를수개월간점안하였다. 각막상피의재생및반복각막진무름의재발에대해정기적으로외래경과관찰하였다. 보존적치료를시행한군에서는 5% sodium chloride (Muro128, Bausch & Lomb, Rochester, NY, USA) 와인공누액을 2개월이상사용하면서정기적으로재발여부를확인하였다. 세극등현미경검사상각막상피의탈락이있고환자가통증을호소하는경우각막상피가회복될때까지치료용콘택트렌즈를사용하였다. 재발은통증, 충혈, 눈부심, 눈물흘림등의환자의증상의재발및세극등현미경검사상동일한부위의각막상피결손을보일때로정의하였고, 치료후재발까지의기간및경과관찰기간동안재발횟수, 재발할때의소견, 치료시작후 1년뒤의최대교정시력을비교하였다. 재발할때의소견의경우각막상피결손을동반한형태 (macroform erosion) 와증상의재발이나 2 mm 이하의미세한각막미란, 상피내소수포 (intraepithelial microcysts), 불규칙한각막표면, 국소적인상피부종의 microform erosion 으로나누어분석하였다. 기술통계결과는연속형자료인경우평균 ± 표준편차로표기하고 paired t-test와 Mann-Whitney test를이용하여두군을비교하였다. 범주형자료는빈도 (%) 로표기하였으며, 분석에는 chi-square test와 Fisher s exact test를사용하였다. 각군에대해경과관찰기간동안의재발률을 Kaplan Meier survival curve를사용하여도식화하였다. 모든통계분석은 SPSS (version 20.0, software for Windows; SPSS Inc., Chicago, IL, USA) 를이용하였으며, p<0.05를통계적으로유의미한 688

- 최문정외 : 반복각막진무름과 Nd:YAG 레이저 - 것으로간주하였다. 결과 반복각막진무름으로진단받은 47안중 23안은 Nd:YAG laser 치료를시행하였고 24안은고삼투압제제를포함한보존적치료를유지하였다. 나이, 성별, 단안성혹은양안성여부, 외상등의원인, LASIK 이나 PRK를포함한안과적수술력, 그리고경과관찰한기간은두군간통계적으로유의미한차이를보이지않았다 (Table 1). 병변을비교해보면보존적치료를받은환자에서각막중심부에있는환자가 33.3% 로 Nd:YAG laser 환자의 8.7% 보다많았고 (p=0.072) Nd:YAG laser를받은환자의 73.9% 가 macroform erosion을보였던반면, 보존적치료를한환자는 54.2% 가 macroform erosion을보였다 (p=0.159). 각막의중심부에병변이있을때는 laser보다는보존적치료를시도하고병변이심할수록 laser를하는경향이있다는것을보여주는결과였으나두군간의차이는통계적으로유의하지않았다. Nd:YAG laser를받은 23안중 13안 (56.5%), 보존적치료를한 24안중 12안 (50.0%) 에서재발률을보였고, 이차이는통계적으로유의미하지않았다 (p=0.654) (Table 2). 재발한환자중 Nd:YAG laser 를받은환자 13안중 5안에서각막상피의결손을동반한 macroform erosion이었던반면에보존적치료를받은환자군에서는 12안중 10안이 macroform erosion으로재발하여 Nd:YAG laser를받을수록재발의정도가심하지않음을시사하였고이차이는통계적으로유의하였다 (p=0.041). 치료후처음으로재발하기까지의기간도 Nd:YAG laser 군에서 17.00 ± 20.34개월, 보 Table 1. Demographic characteristics and clinical features of the patients treated for recurrent corneal erosion Variables Nd:YAG laser treatment Conservative management (n = 23) (n = 24) p-value Age (years) 41.39 ± 14.15 37.63 ± 18.40 0.437 * Sex (n, %) Male Female 9 (39.1) 14 (60.9) 14 (58.3) 10 (41.7) 0.188 Laterality (n, %) Unilateral Bilateral Cause (n, %) Trauma Nontraumatic or unknown 16 (69.6) 7 (30.4) 21 (87.5) 3 (12.5) 12 (52.2) 14 (58.3) 0.671 11 (47.8) 10 (47.7) Prior ocular surgical history (%) 2 (8.7) 2 (8.3) 1.000 Location of the lesion (n, %) Center Periphery 2 (8.7) 21 (91.3) 8 (33.3) 16 (66.7) 0.072 Initial presentation (n, %) Macroform erosion 17 (73.9) 13 (54.2) 0.159 Microform erosion 6 (26.1) 11 (45.8) Follow-up (range, months) 29.52 ± 19.47 (6-59) 20.46 ± 13.20 (6-49) 0.096 Values are presented as mean ± SD unless otherwise indicated. Nd:YAG = neodymium:yttrium-aluminum-garnet. * Paired t-test; Chi-square test; Fisher s exact test; Mann-Whitney test. 0.168 Table 2. Outcomes of Nd:YAG laser treatment and conservative management Variables Nd:YAG laser treatment Conservative management (n = 23) (n = 24) p-value Recurrence (n, %) 13 (56.5) 12 (50.0) 0.654 * Presentation at recurrence Macroform erosion 5 10 0.041 Symptoms only or microform erosion 8 2 Time to recurrence (months) 17.00 ± 20.34 11.67 ± 11.90 0.437 Postoperative frequency (episodes/year) 0.72 ± 1.25 0.52 ± 0.72 0.495 Final visual acuity (log MAR) 0.05 ± 0.06 0.09 ± 0.08 0.110 Values are presented as mean ± SD unless otherwise indicated. Nd:YAG = neodymium:yttrium-aluminum-garnet. * Chi-square test; Fisher s exact test; Paired t-test. 689

- 대한안과학회지 2015 년제 56 권제 5 호 - Table 3. Percentage of eyes without recurrence over time after treatment with either Nd:YAG laser and conservative management Percentage of eyes without recurrence Nd:YAG laser treatment Conservative management (n = 23) (n = 24) 1 year after treatment (%) 64.1 60.5 2 years after treatment (%) 46.1 45.4 Overall comparison: p-value = 0.649. Nd:YAG = neodymium:yttrium-aluminum-garnet. Figure 1. Kaplan-Meier survival curve demonstrating the time to recurrence after treatment with Nd:YAG laser (bold line) and after conservative management (dashed line). Nd:YAG = neodymium:yttrium-aluminum-garnet. 존적치료를한군에서 11.67 ± 11.90개월로차이를보이지않았고 (p=0.437), 치료후재발빈도 ( 재발횟수 / 경과관찰기간 ) 또한 Nd:YAG laser군에서 0.72 ± 1.25, 보존적치료를한군에서 0.52 ± 0.72로통계적으로유의미하지않았다 (p=0.495). 치료후최대교정시력은 Nd:YAG laser 군에서는 0.05 ± 0.06 logmar, 보존적치료를한군에서는 0.09 ± 0.08 logmar로두군간에차이를보이지않았다 (p=0.110). 치료후경과한시간에따른재발률을비교해보았을때에도두군간의차이를보이지않았고 (p=0.649) 재발하지않은경우를성공으로정의했을때치료시작후 1년까지는 Nd:YAG laser 를받은군에서는 64.1%, 보존적치료를시행한군에서는 60.5% 의성공률을보였지만시간이지날수록재발률이높아짐을알수있었다 (Table 3, Fig. 1). 고 찰 반복각막진무름은각막상피세포와바닥막을연결하는 반결합체 (hemidesmosome) 와바닥막과각막실질사이를부착시키는고정미세섬유 (anchoring fibril) 로구성된바닥막복합체 (basement membrane complex) 의부착력약화로인해표층각막의외상에의해바닥막이손상되거나각막이영양증등의유전적이상으로인해반복적으로각막상피의탈락이일어나는질환이다. 1,11 급성적으로통증, 눈물흘림, 시력저하등의증상을일으키고만성적으로호전과재발을반복하게된다. 그러므로반복각막진무름의치료는증상을완화하고재발을예방하기위해각막상피와바닥막의부착력을증가시키는것을목표로한다. 19세기말경항생제연고와압박안대로치료하는것을시작으로 1900년대초반염소수 (chlorine water), 사염화초산액 (trichloracetic acid), 요오드 (iodine) 등을이용하여탈락된각막상피를제거하는화학적소작술 (chemical cauterization) 이소개되었다. 7,11 1960 년대와 70년대에이르러인공누액, 항생제안약, 연고등의윤활제, 안대등보존적치료를선호하게되었고지금까지도 50% 20 에서 95% 5 에이르기까지의성공률을보이며현재에도급성기치료로널리쓰이고있다. 5,21 그러나이러한치료는대부분의환자에서 4년이상의오랜치료기간을필요로하였고장기적인치료에도불구하고 50% 이상의환자에서재발하였다. 5,22 본연구에서도보존적치료를시행한환자군에서치료시작후 1년까지의재발률은 39.5% 였으나시간에따라치료후 2년뒤에는재발률이 54.6% 까지증가하였다. 보존적치료에반응하지않는환자들에대해서적극적인치료방법의필요성이강조되었고 1980년대에기저막이영양증에대해표층각막절제술 (superficial keratectomy), 23 외상과관련된반복각막진무름에대해서는전측각막미세천자술 (anterior stromal puncture) 이도입되었다. 전측각막미세천자술은각막상피와전방기질사이에반흔조직을유도하여부착력을강화시키는방법이다. 1986년 McLean et al 14 에의해처음소개되어 20 gauge 주사바늘을이용하여탈락된각막상피세포, 보우만막, 각막기질의전방 1/2까지수직으로각막을천자하였으며깊은천자로인해각막에영구적인반흔이남는단점이있었다. 그후 27 gauge 또는 30 gauge 등의얇은주사바늘을이용하여 0.1 mm 정도깊이의천자로도부착력을강화시키는섬유낭종성변화를일 690

- 최문정외 : 반복각막진무름과 Nd:YAG 레이저 - 으킬수있다고보고되었으며 76% 에서 94% 에이르기까지재발을하지않은성공률이보고되었다. 24 다이아몬드드릴을이용한표층각막절제술 17 은비정상적인각막상피를제거하고보우만막표면을부드럽게하여반응성섬유화로재상피를촉진시키는방법으로성공적인치료효과가보고되었지만 17,25 각막염, 각막반흔, 난시증가 26 등의합병증이생길수있고, 시술후통증이심하며재상피화되기까지시간이오래걸린다는단점이있다. Alcohol 을이용한화학적박리법 (alcohol delamination) 의경우, 각막상피와바닥막사이의부착력을약화시키는각막상피하침전물을제거하여부착력을강화시키는방법으로, 16 빠르고경제적이지만굴절력이상, 각막혼탁, 각막염등의부작용이있을수있다. 엑시머레이저를이용한치료레이저각막절제술 (PTK) 은주변조직의손상을최소화한미세한조직제거가가능하며동시에넓은병변을시술할수있는장점이있고 27 국내보고에서도시술한 12안모두에서각막진무름이소실되었고 1안을제외하면경과관찰동안재발이없었던성공적인결과를보여주었다. 28 그러나일시적인각막혼탁, 원시화등굴절력변화등이부작용으로제시되었고 29 레이저기계를필요로하며고비용이라는점이다른방법에비해단점으로작용한다고하겠다. 이에비해 Nd:YAG laser 를이용한치료는비교적간단하게시행할수있으며, 수술후통증이나굴절력변화등의합병증가능성이적다. Nd:YAG laser를이용한방법은 1990년대 Geggel에의해처음소개되었다. 15,30 레이저로각막상피하조직을응고시켜섬유화로부착력을증가시키는방법으로예전방법과는달리미세하고일정한시술이가능하였고각막반흔, 천공등의합병증의가능성이낮았으며재발을각막상피의결손 (macroform erosion) 으로정의하였을때성공률은 85% 로다른방법과유사하게보고되었다. 19 또한각막외상의과거력이있는환자에서재발률이낮게나타났고이는유전적이상과다르게바닥막의이상을동반하지않고비교적정상적인미세구조를갖고있기때문으로추정되었다. 19 그러나주사바늘을이용한전측각막미세천자술의경우외상의유무가치료의성공률에의미있는영향을미치지않았으며, 31 이는본연구결과에서도동일하였다. Nd:YAG laser 치료를받은환자들의치료성적을보고한예전연구와달리본연구에서는 Nd:YAG laser를받은군과고삼투압제제를포함한보존적치료를받은군을비교하였다. 재발률은각각 56.5%, 50.0% 로통계학적으로유의미한차이를보이지않았으며, 재발하기까지걸린시간은 Nd:YAG laser를받은군에서 17.00 ± 20.34개월, 보존적치료를한군에서 11.67 ± 11.90개월로통계학적으로유의미한차이를보이지않았 다. Nd:YAG laser 후재발의빈도와통증이감소했다는이전연구결과에비해본연구에서는 Nd:YAG laser를받은환자중재발한 13안중 5안에서각막상피를동반한 macroform erosion 형태로재발한것에비해보존적치료를받은환자에서는 12안중 10안에서각막상피결손을동반하여보존적치료를받은환자가재발할때정도가더심한경향이있음을보여주었다. 두군모두시술후 1년까지는치료성공률이각각 64.1%, 60.5% 였으나시간이지나면서재발률이상승하였고, 시술 1년뒤최대교정시력은각각 logmar 0.05 ± 0.06, 0.09 ± 0.08로두군모두양호하였다. Nd:YAG laser를받은군에서각막반흔이나각막천공등합병증의소견은보이지않았다. 본연구결과에따르면 Nd:YAG laser 를받은군에서최종재발률이 56.5% 로이전에보고된연구결과보다다소높은수치를나타내었다. 이는본연구에서는각막상피의결손및환자의증상을재발로정의한것에비해기존연구에서는각막상피의탈락 (macroform erosion) 만으로비교하였는데이때성공률은 85% 였지만그외 51% 의환자에서통증이재발된미세각막미란 (microform erosion) 이있었다는점 19 을보면두연구결과의차이는재발의정의의차이에따른결과로보인다. 본연구에서도 macroform erosion으로만재발률을계산하면 23안중 5안, 즉 21.7% 에서재발하여 85% 의성공률을보고한이전결과와크게다르지않음을알수있다. 또한각막외상의과거력이있는환자에서재발률이낮았다는이전연구결과를볼때, 본연구에포함된환자들중반복각막진무름의원인이외상과연관이없었던비율이다른연구에서보다높았다는점 (Nd:YAG laser군에서 47.8%, 보존적치료를받은군에서 47.7%) 에서본연구의재발률이다른연구결과보다높았던차이점을설명할수있겠다. 본연구는 Nd:YAG laser 치료와고삼투압제제를포함한보존적치료간의재발률, 재발하기까지의기간, 재발빈도에통계학적으로유의한차이가없다는결과를보여주었다. 이는 Nd:YAG laser 치료군이보존적치료군과차이가없다기보다는, 임상적으로 Nd:YAG laser를받는환자들은대부분정도가심하거나보존적치료에반응을하지않는환자라는점에서선택오차 (selection bias) 가작용하였다고판단되며, 후향적연구로인해환자군을무작위로나눌수없었고, 각막진무름의정도를객관적으로평가할수없었기때문일것으로생각된다. 그러나 Nd:YAG laser 치료군에서재발시각막상피결손을동반한형태가더적은경향으로볼때, 심한재발을막는데에는보존적치료보다 Nd:YAG laser 치료가더효과가있을것으로생각된다. 본연구는국내에서 Nd:YAG laser를이용한반복각막진무름에대한치료효과에대한첫보고이고보존적치료의 691

- 대한안과학회지 2015 년제 56 권제 5 호 - 대조군과비교했다는점에서그의의가있다고하겠다. 두치료군간의재발률차이는없었으나, 두가지치료모두예전에발표된성공률과유사한치료결과를보였고시력감소가미미한안전한방법이며 Nd:YAG laser 치료군에서재발의정도가심하지않았다는것을볼때보존적치료에반응하지않은환자를대상으로할때유용할것으로생각된다. REFERENCES 1) Ramamurthi S, Rahman MQ, Dutton GN, Ramaesh K. Pathogenesis, clinical features and management of recurrent corneal erosions. Eye (Lond) 2006;20:635-44. 2) Tripathi RC, Bron AJ. Ultrastructural study of non-traumatic recurrent corneal erosion. Br J Ophthalmol 1972;56:73-85. 3) Sakimoto T, Sawa M. Metalloproteinases in corneal diseases: degradation and processing. Cornea 2012;31 Suppl 1:S50-6. 4) Chen YT, Huang CW, Huang FC, et al. The cleavage plane of corneal epithelial adhesion complex in traumatic recurrent corneal erosion. Mol Vis 2006;12:196-204. 5) Hykin PG, Foss AE, Pavesio C, Dart JK. The natural history and management of recurrent corneal erosion: a prospective randomised trial. Eye (Lond) 1994;8 (Pt 1):35-40. 6) Eke T, Morrison DA, Austin DJ. Recurrent symptoms following traumatic corneal abrasion: prevalence, severity, and the effect of a simple regimen of prophylaxis. Eye (Lond) 1999;13 (Pt 3a):345-7. 7) Chandler PA. Recurrent Erosion of the Cornea. Trans Am Ophthalmol Soc 1944;42:355-71. 8) Watson S, Lee H. Interventions for recurrent corneal erosion: a Cochrane Systematic review. Eye (Lond) 2013;27:1330-1. 9) Dursun D, Kim MC, Solomon A, Pflugfelder SC. Treatment of recalcitrant recurrent corneal erosions with inhibitors of matrix metalloproteinase-9, doxycycline and corticosteroids. Am J Ophthalmol 2001;132:8-13. 10) Hope-Ross MW, Chell PB, Kervick GN, et al. Oral tetracycline in the treatment of recurrent corneal erosions. Eye (Lond) 1994;8 (Pt 4):384-8. 11) Das S, Seitz B. Recurrent corneal erosion syndrome. Surv Ophthalmol 2008;53:3-15. 12) del Castillo JM, de la Casa JM, Sardiña RC, et al. Treatment of recurrent corneal erosions using autologous serum. Cornea 2002;21: 781-3. 13) Ziakas NG, Boboridis KG, Terzidou C, et al. Long-term follow up of autologous serum treatment for recurrent corneal erosions. Clin Experiment Ophthalmol 2010;38:683-7. 14) McLean EN, MacRae SM, Rich LF. Recurrent erosion. Treatment by anterior stromal puncture. Ophthalmology 1986;93:784-8. 15) Geggel HS. Successful treatment of recurrent corneal erosion with Nd:YAG anterior stromal puncture. Am J Ophthalmol 1990;110:404-7. 16) Singh RP, Raj D, Pherwani A, et al. Alcohol delamination of the corneal epithelium for recalcitrant recurrent corneal erosion syndrome: a prospective study of efficacy and safety. Br J Ophthalmol 2007;91:908-11. 17) Soong HK, Farjo Q, Meyer RF, Sugar A. Diamond burr superficial keratectomy for recurrent corneal erosions. Br J Ophthalmol 2002; 86:296-8. 18) Ohman L, Fagerholm P. The influence of excimer laser ablation on recurrent corneal erosions: a prospective randomized study. Cornea 1998;17:349-52. 19) Tsai TY, Tsai TH, Hu FR, Hou YC. Recurrent corneal erosions treated with anterior stromal puncture by neodymium: yttrium-aluminum-garnet laser. Ophthalmology 2009;116:1296-300. 20) Reidy JJ, Paulus MP, Gona S. Recurrent erosions of the cornea: epidemiology and treatment. Cornea 2000;19:767-71. 21) Williams R, Buckley RJ. Pathogenesis and treatment of recurrent erosion. Br J Ophthalmol 1985;69:435-7. 22) Heyworth P, Morlet N, Rayner S, et al. Natural history of recurrent erosion syndrome-a 4 year review of 117 patients. Br J Ophthalmol 1998;82:26-8. 23) Itty S, Hamilton SS, Baratz KH, et al. Outcomes of epithelial debridement for anterior basement membrane dystrophy. Am J Ophthalmol 2007;144:217-21. 24) Rubinfeld RS, Laibson PR, Cohen EJ, et al. Anterior stromal puncture for recurrent erosion: further experience and new instrumentation. Ophthalmic Surg 1990;21:318-26. 25) Sridhar MS, Rapuano CJ, Cosar CB, et al. Phototherapeutic keratectomy versus diamond burr polishing of Bowman's membrane in the treatment of recurrent corneal erosions associated with anterior basement membrane dystrophy. Ophthalmology 2002;109:674-9. 26) Yoo JH, Choi DM. Induced astigmatism after diamond burr superficial keratectomy for recurrent corneal erosion. Eye Contact Lens 2009;35:341-4. 27) O'Brart DP, Muir MG, Marshall J. Phototherapeutic keratectomy for recurrent corneal erosions. Eye (Lond) 1994;8 (Pt 4):378-83. 28) Ko BY, Lee GW. Clinical Results of phototherapeutic keratectomy for refractory recurrent corneal erosion. J Korean Ophthalmol Soc 2011;52:392-400. 29) Baryla J, Pan YI, Hodge WG. Long-term efficacy of phototherapeutic keratectomy on recurrent corneal erosion syndrome. Cornea 2006;25:1150-2. 30) Geggel HS, Maza CE. Anterior stromal puncture with the Nd:YAG laser. Invest Ophthalmol Vis Sci 1990;31:1555-9. 31) Avni Zauberman N, Artornsombudh P, Elbaz U, et al. Anterior stromal puncture for the treatment of recurrent corneal erosion syndrome: patient clinical features and outcomes. Am J Ophthalmol 2014;157:273-9.e1. 692

- 최문정외 : 반복각막진무름과 Nd:YAG 레이저 - = 국문초록 = 반복각막진무름에서 Nd:YAG Laser 치료와보존적치료의비교 목적 : 반복각막진무름에서 Neodymium:Yttrium-Aluminum-Garnet (Nd:YAG) laser 치료와보존적치료의효과를비교하고자한다. 대상과방법 : 반복각막진무름을진단받은환자에서 Nd:YAG laser 를시행한 23 안과고삼투압제제를포함한보존적치료를시행한 24 안을대상으로재발유무, 양상, 빈도, 재발하기까지의시간, 치료후최대교정시력, 합병증유무에대해후향적연구를시행하였다. 결과 : 재발률은 Nd:YAG laser 를받은군에서 56.5%, 보존적치료를시행한군에서 50.0% 로통계학적으로유의미한차이를보이지않았으나 (p=0.654) 보존적치료를한환자중재발한 12 안중 10 안은각막상피결손을동반한형태로재발하여 Nd:YAG laser 군에서의 13 안중 5 안보다재발의정도가심함을보여주었다 (p=0.041). 두군모두시술후 1 년까지는치료성공률이각각 64.1%, 60.5% 였으나시간이지나면서재발률이상승하였고 (p=0.649), 치료후최종시력은 Nd:YAG laser 를받은환자에서 0.05 ± 0.06 logmar, 보존적치료를받은환자에서 0.09 ± 0.08 logmar 로유의한차이를보이지않았으며 (p=0.110) 두군모두에서각막반흔등의합병증은없었다. 결론 : 반복각막진무름에서 Nd:YAG laser 치료와보존적치료의재발률은유의한차이를보이지않았으나재발후중증도는 Nd:YAG laser 치료가보존적치료보다경미하였다. < 대한안과학회지 2015;56(5):687-693> 693