대한안과학회지 2009 년제 50 권제 2 호 J Korean Ophthalmol Soc 2009;50(2):227-234 DOI : 10.3341/jkos.2009.50.2.227 개방각녹내장환자의황반망막및시신경유두주위망막신경섬유층두께와시야변화와의상관관계 정원도 1 이동은 2 이주화 1 신준우 1 인제대학교의과대학상계백병원안과학교실 1, 인제대학교의과대학서울백병원안과학교실 2 목적 : 개방각녹내장안에서황반망막및시신경유두주위망막신경섬유층의두께와시야변화와의관련성에대해알아보고자하였다. 대상과방법 : 정상군 24 명 40 안, 고안압증군 15 명 30 안, 시야결손전녹내장군 18 명 30 안, 개방각녹내장군 59 명 90 안 ( 초기시야결손군 18 명 30 안, 중등도시야결손군 19 명 30 안, 심한시야결손군 22 명 30 안 ) 을대상으로빛간섭단층촬영 (Stratus OCT TM model 3000, Carl Zeiss Meditec) 을이용하여황반망막및시신경유두주위망막신경섬유층두께를측정하였고, 시야검사를시행하였다. 결과 : 황반망막 (p<0.05) 및시신경유두주위망막신경섬유층 (p<0.001) 두께는개방각녹내장안에서유의하게감소된소견을보였다. 연구대상인 190 안전체에서 mean deviation (MD) 는모든영역의시신경유두주위망막신경섬유층두께 (p<0.001), 중심소와및중심원을제외한모든영역의황반망막두께 (p<0.01) 와유의한양의상관관계가있었다. 결론 : 황반망막및시신경유두주위망막신경섬유층두께는개방각녹내장안에서유의하게감소되었고, 시야변화와도유의한관련성을보였다. < 대한안과학회지 2009;50(2):227-234> 녹내장에서의근본적인병리과정은망막신경절세포와축삭의소실이다. 1-5 망막신경절세포와축삭은후극부에도존재하고, 주로황반부위에집중해서분포해있으며, 황반부위망막두께의 30~35% 를차지한다고알려져있다. 6-8 이는시기능과도관련되어서망막의중심 30도내에망막신경절세포의 20% 소실은자동시야검사상 5데시벨 (db) 의민감도상실과관련있고, 40% 의소실은 10dB의민감도상실과관련있다고주장하는이도있다. 4 따라서, 황반망막두께에대한면밀한관찰은녹내장성손상을감지하는실마리가될수있다. 빛간섭단층촬영 (Optical coherence tomography, OCT) 은자외선에가까운빛파장을이용하여동공을통해비침습적으로안구내조직을고해상도로관찰할수있게해주는방법이다. 9-15 빛간섭단층촬영을이용한시신경유두주위망막신경섬유층및시신경유두부에대한구조적변화와녹내장과의관련성에대해서는많은연구를통하여이미잘알려져있으나, 16-19 녹내장과황반망막의관련성에대해서 접수일 : 2008 년 6 월 30 일 심사통과일 : 2008 년 11 월 24 일 통신저자 : 이주화서울시노원구상계 7 동 761-1 인제대학교상계백병원안과 Tel: 02-950-1096, Fax: 02-935-6904 E-mail: joohlee@paik.ac.kr * 본논문의요지는 2007 년대한안과학회제 97 회춘계학술대회에서구연으로발표되었음. * 본논문은 2007 년도인제대학교학술연구조성비보조에의한것임. 는잘알려져있지않다. 본연구는개방각녹내장안에서빛간섭단층촬영 (Stratus OCT TM model 3000, Carl Zeiss Meditec) 을이용하여황반망막및시신경유두주위망막신경섬유층두께를측정하고, 자동시야검사상의시야변화를정상안과각각비교함으로써, 녹내장성변화에서구조와기능과의관계를조사해보기위함이다. 대상과방법 50세이상의 116명을특이한안과질환이없는정상군 24명 40안, 고안압증군 15명 30안, 시야결손전녹내장군 18명 30안, 개방각녹내장군 59명 90안으로분류하여후향적연구를진행하였다. 개방각녹내장군의경우에는시야결손의정도에따라초기시야결손군 (early defect) 18명 30 안, 중등도시야결손군 (moderate defect) 19명 30안, 심한시야결손군 (severe defect) 22명 30안의 3개군으로분류하였다. 모든대상자는시력, 굴절력, 골드만압평안압계로측정한안압, 간접검안경및세극등현미경을이용한산동상태의안저검사등기본적인안과적검사를시행받았다. 모든대상자는최대교정시력이 0.5 이상, 굴절이상이 3.0D (Diopter) 에서 +3.0D 사이였고, 망막질환, 망막레이저시술병력, 망막수술병력, 신경학적질환, 당뇨병등이있는경우연구에서제외되었다. 개방각녹내장군은원발개방각녹내장또는정상안압녹내 227
- 대한안과학회지 2009 년제 50 권제 2 호 - 장인경우로정의하였다. 원발개방각녹내장군은안압이 21 mmhg 이상으로상승되어있고, 특징적인녹내장성시야결손과시신경손상이있으며, 전방각은정상해부학적구조를갖고개방되어있으며, 안압상승의원인이될만한뚜렷한안과적혹은전신적이상이없는상태를가진경우로정의하였다. 정상안압녹내장은특징적인녹내장성시신경유두함몰과시야결손은있지만, 안압이 21 mmhg 이하이고, 전방각은개방되어있으며시야결손의원인이될만한안질환이나전신질환이없는상태로정의하였다. 시신경유두에녹내장성변화는있으나, 시야검사상녹내장성시야변화가없는군을시야결손전녹내장, 안압이 21 mmhg 이상이면서정상시신경유두와정상시야를갖고안압상승의원인이되는안소견이나전신적인이상이없는상태를고안압증으로정의하였다. 시신경유두의녹내장성변화는시신경유두에서수직유두함몰비의증가 (0.5 이상 ), 시신경유두테의패임, 시신경유두소와, 유두함몰의균일한동심성증가, 시신경유두출혈, 비정상적시신경유두위축, 코쪽유두함몰증가, 귀쪽시신경유두테의완만한낮아짐, 함몰이없는국소창백등으로정의하였다. 시야검사는굴절률및나이를보정하여 Humphrey 자동시야검사 (Zeiss-Humphrey, San Leandro, CA, USA) 의 central 30-2, SITA-Standard strategy로검사하였고, 표준지표 (global indices) 인 mean deviation (MD) 와 pattern standard deviation (PSD) 값을구하였다. 시야검사결과중에서주시상실도 (fixation loss) 가 20% 이상, 위양성율이 33% 이상, 위음성율이 33% 이상중에하나라도해당된경우에는분석대상에서제외하였다. 시야검사상 MD가 6dB 미만이며, pattern deviation plot에서 5% 보다작은점이 25% 이하이고, 1% 보다작은점이 10개이하이며, 중심 5도이내에 6dB 미만의점이없는경우를초기시야결손으로정의하였다. MD가 12dB 미만이며, pattern deviation plot에서 5% 보다작은점이 50% 이하이고, 1% 보다작은점이 20개이하이며, 중심 5도이내에 15dB 미만의점이한쪽 hemifield에국한된경우를중등도시야결손으로정의하였다. MD가 12dB 이상이거나, pattern deviation plot에서 5% 보다작은점이 50% 이상이거나, 1% 보다작은점이 20개이상이든지, 중심 5도이내에 15dB 미만의점이양쪽 hemifield에국한된경우를심한시야결손으로정의하였다. 20 빛간섭단층촬영은먼저피검자의눈에 1% tropicamide 와 2.5% phenylephirine hydrochloride를점안하여산동시킨후, OCT (Stratus OCT TM model 3000, Carl Zeiss Meditec) 의 fast RNFL thickness 3.4 scan으로유두주위 360도를 30도 (12 clock-hours) 로나누어서 12구역 (sector) 각각의시신경유두주위망막신경섬유층두께를구하였다 ( 우안의경우, 12시방향이상측, 3시방향이비측, 6시방향이하측, 9시방향이이측에해당됨 ). 1.92 초동안중심와를중심으로 6 mm 직경의방사상주사를하는 fast macular thickness map 을이용하여황반망막두께를측정하였고, 내경계막과망막색소상피사이의거리로서황반망막두께를정의하였다. 중심와가중심인 6 mm 직경의원에서중심 1 mm 이내를중심원 (central ring) 으로하고, 3 mm 직경원에서중심원을제외한주변을안쪽원 (inner ring) 으로정의하였으며, 그외곽을바깥쪽원 (outer ring) 으로나누었다. 그리고안쪽원과바깥쪽원은다시상측, 하측, 이측, 비측 4개의분획으로나누어서중심원과함께총 9개분획의황반부두께의평균치를 retinal thickness analysis system 을이용하여분석하였다. 황반망막의평균두께는 9개분획의황반망막두께의총합을 9로나눈것으로정의하였다. 통계분석은 PC/SPSS (Version 10.0; Chicago, IL., U.S.A.) 프로그램을이용하여 ANOVA, Pearson 상관계수로분석하였고, p-value 가 0.05 미만인경우를통계학적으로유의한것으로판정하였다. 결과 평균나이는정상군 58.7±7.2세, 고안압증군 58.9±7.8 세, 시야결손전녹내장군 59.4±8.5세, 초기시야결손군 61.4±6.6세, 중등도시야결손군 61.1±9.0세, 심한시야결손군 60.5±8.0세였다. 굴절력은정상군 -0.18±1.69 Dsph, 고안압증군 0.33±1.15 Dsph, 시야결손전녹내장군 0.15±1.19 Dsph, 초기시야결손군 0.29±1.06 Dsph, 중등도시야결손군 0.35±1.08 Dsph, 심한시야결손군 0.21± 1.26 Dsph 였다. 여섯집단사이에서나이, 굴절력, 성별등은유의한차이를보이지않았다. Humphrey 자동시야검사의 MD는고안압증군, 시야결손전녹내장군에서정상군과비교하였을때유의한차이를보이지않았으며, 개방각녹내장군에서는정상군과비교하여통계적으로유의한차이를보였다 (p<0.001). PSD도고안압증군, 시야결손전녹내장군을제외한개방각녹내장군에서정상군에비해유의한차이를보였다 (p<0.001)(table 1). 시신경유두주위망막신경섬유층평균두께는정상군 94.5 ±12.4 μm, 고안압증군 90.4±11.2 μm, 시야결손전녹내장군 77.1±19.1 μm, 초기시야결손군 74.6±9.2 μm, 중등도시야결손군 70.1±9.5 μm, 심한시야결손군 59.3±11.6 μm으로, 여섯군간에유의한차이를보였고 (p<0.001), 사 228
- 정원도외 : 황반망막두께와녹내장성시야변화 - Table 1. Clinical characteristics of the subjects Normal (n=40 eyes) OHT П Pre-perimetric Early defect Moderate defect Severe defect Age (yrs) (mean±sd) 58.7±7.2 58.9±7.8 59.4±8.5 61.4±6.6 61.1±9.0 60.5±8.0 0.282 Sex (M:F) 23:17 14:16 17:13 16:14 18:12 18:12 0.571 MD (mean±sd) PSD (mean±sd) -1.21±1.49-0.90±0.91 p=0.458-0.99±1.07 p=0.607-3.61±1.75 p<0.001-9.25±1.67 p<0.001-19.32±4.89 1.87±1.13 2.28±1.34 p=0.301 2.52±1.36 p=0.106 4.51±1.69 p<0.001 9.25±3.28 p<0.001 12.1±1.95 * p=anova; Analysis of variance with post-hoc Tukey test; normal vs. each group; MD=mean deviation; PSD=pattern standard deviation; П OHT=ocular hypertension. Table 2. The peripapillary retinal nerve fiber layer thickness of the study populations Peri- papillary RNFL thickness Normal (n=40 eyes) OHT Pre-perimetric Early defect Moderate defect Severe defect Superior (µm) 114.6±20.9 110.5±15.7 105.6±15.5 86.9±15.6 82.3±12.6 76.4±19.3 p=0.245 p=0.153 p<0.001 p<0.001 Inferior (µm) 124.2±18.8 119.8±14.8 99.6±12.2 91.8±20.4 71.5±19.9 61.5±20.8 p=0.352 p<0.001 p<0.001 p<0.001 Nasal (µm) 69.1±14.1 67.9±10.5 57.9±13.6 60.6±10.7 70.8±12.5 50.1±9.1 p=0.456 p<0.001 p=0.028 p<0.001 Temporal (µm) 70.1±7.4 67.4±9.3 61.9±12.4 57.9±13.6 52.2±11.9 48.1±14.1 p=0.273 p=0.011 p<0.001 p=0.035 Mean (µm) 94.5±12.4 90.4±11.2 77.1±19.1 74.6±9.2 70.1±9.5 59.3±11.6 p=0.237 p=0.001 p<0.001 p<0.001 * p=anova; Analysis of variance with post-hoc Tukey test; normal vs. each group; RNFL=retinal nerve fiber layer; OHT =ocular hypertension. p * p * 분원으로나눈구역별시신경유두주위망막신경섬유층의두께에대한비교시, 4개의사분원모두여섯군간에통계적으로유의한차이를보였다 (p<0.001). 그러나, 정상군과의비교에서고안압증군은유의한차이를보이지않았고, 시야결손전녹내장군은위쪽사분원을제외한 3구역에서시신경유두주위망막신경섬유층두께가유의하게감소되었으며 (p<0.05), 개방각녹내장군은모든사분원에서유의하게감소되었다 (p<0.05)(table 2). 여섯군간에황반망막두께는중심소와를제외한중심원, 안쪽원, 바깥쪽원모두에서유의한차이를보였고 (p<0.01), 황반망막의평균두께도유의한차이를보였다 (p<0.001). 정상군과의비교에서고안압증군은 9개영역모두에서유의한차이를보이지않았고, 시야결손전녹내장군은중심소와, 중심원, 안쪽원이측을제외한나머지영역 (p<0.05), 초기시야결손군, 중등도시야결손군, 심한시야결손군을포함한개방각녹내장군은중심소와를제외한모든영역에서정상군에비해황반망막두께가유의하게감소되었다 (p<0.05)(table 3). 190안에서자동시야검사의 MD값은중심소와, 중심원을제외한황반망막두께의모든영역과유의한양의상관관계를보였고 (p<0.01), PSD값도중심소와, 중심원을제외한황반망막두께의모든영역과유의한음의상관관계를보였다 (p<0.01)(table 4). 즉, 시야결손이클수록황반망막의중심소와, 중심원을제외한모든영역의두께가감소하였다. MD값은시신경유두주위망막신경섬유층두께의모든사분원과유의한양의상관관계를보였고 (p<0.001), PSD값도시신경유두주위망막신경섬유층두께의모든사분원과유의한음의상관관계를보였다 (p<0.01)(table 5). MD값은시신경유두주위망막신경섬유층의평균두께 (Pearson 상관계수 0.554, p<0.001) 뿐만아니라황반망막의평균두께 (Pearson 상관계수 0.513, p<0.001) 와도유의한양의상관관계를보였다 (Fig. 1A). 또한, PSD값도황반망막의평균두께 (Pearson 상관계수 -0.596, p<0.001) 뿐만아니라시신경유두주위망막신경섬유층의평균두께 (Pearson 상관계수 -0.492, p<0.001) 와유의한음의상관관계를보였다. 229
- 대한안과학회지 2009 년제 50 권제 2 호 - Table 3. The macular thickness in normal, OHT, pre-perimetric glaucoma, open angle glaucoma (early, moderate, severe defect) groups Macular thickness (MT)(µm) Normal (n=40 eyes) OHT Pre-perimetric Early defect Moderate defect Severe defect fovea (µm) 157.5±19.7 152.1±14.2 156.5±23.1 152.7±18.9 154.9±16.1 151.0±17.9 p=0.436 p=0.881 p=0.221 p=0.472 p=0.278 0.597 1 mm (µm) 192.1±19.5 182.7±15.2 187.9±16.7 176.9±14.2 178.4±13.2 177.6±13.7 p=0.181 p=0.485 p=0.005 p=0.014 p=0.011 0.006 Superior (3 mm)(µm) Inferior (3 mm)(µm) Nasal (3 mm)(µm) Temporal (3 mm)(µm) Superior (6 mm)(µm) Inferior (6 mm)(µm) Nasal (6 mm)(µm) Temporal (6 mm)(µm) 268.2±11.9 263.6±12.2 p=0.250 259.8±10.3 p=0.027 245.9±15.6 p<0.001 256.1±16.1 p=0.006 235.9±34.2 268.2±12.1 263.8±18.1 p=0.292 250.9±10.3 p<0.001 247.5±19.3 p<0.001 245.4±12.5 p<0.001 224.0±17.3 272.4±12.5 265.9±11.4 p=0.143 258.1±12.3 p=0.001 250.0±17.9 p<0.001 259.8±14.1 p<0.001 243.6±26.9 258.4±12.4 254.4±16.7 p=0.349 252.3±11.1 p=0.126 241.5±15.1 p<0.001 236.5±14.5 p<0.001 224.6±14.5 235.9±14.0 237.8±12.0 p=0.736 225.1±14.8 p=0.023 218.5±15.5 p<0.001 216.4±14.0 p<0.001 207.8±8.8 220.9±11.8 222.0±18.1 p=0.785 202.4±16.1 p=0.023 200.3±14.3 p<0.001 197.5±11.5 p<0.001 185.9±14.2 250.0±13.8 248.5±11.4 p=0.763 233.5±15.7 p=0.001 231.1±19.4 p<0.001 230.1±13.5 p<0.001 205.7±26.2 219.5±12.6 217.7±14.1 p=0.785 207.7±12.2 p=0.005 204.0±10.1 p<0.001 201.3±10.1 p<0.001 186.8±11.5 Mean MT (µm) 242.8±10.1 238.6±11.3 p=0.349 230.9±10.9 p=0.001 224.0±14.1 p<0.001 224.6±9.8 p<0.001 210.2±15.1 * p=anova; p<0.05, Analysis of variance with post-hoc Tukey test; normal vs. each group; p>0.05, Analysis of variance with post-hoc Tukey test; normal vs. each group; OHT=ocular hypertension. Table 4. Correlation between MD, PSD and macular thickness in 190 eyes Macular thickness Pearson correlation coefficient (MD ) Pearson correlation coefficient (PSD ) fovea 0.048 (p=0.635 * ) -0.010 (p=0.917 * ) 1 mm 0.009 (p=0.933 * ) -0.050 (p=0.610 * ) Superior (3 mm) 0.279 (p=0.005 * ) -0.422 (p<0.001 * ) Inferior (3 mm) 0.353 (p<0.001 * ) -0.483 (p<0.001 * ) Nasal (3 mm) 0.270 (p=0.005 * ) -0.322 (p=0.001 * ) Temporal (3 mm) 0.449 (p<0.001 * ) -0.599 (p<0.001 * ) Superior (6 mm) 0.483 (p<0.001 * ) -0.602 (p<0.001 * ) Inferior (6 mm) 0.420 (p<0.001 * ) -0.507 (p<0.001 * ) Nasal (6 mm) 0.363 (p<0.001 * ) -0.492 (p<0.001 * ) Temporal (6 mm) 0.490 (p<0.001 * ) -0.600 (p<0.001 * ) Mean macular thickness 0.513 (p<0.001 * ) -0.596 (p<0.001 * ) * Correlation analysis: Pearson correlation; MD=mean deviation; PSD=pattern standard deviation. p* 시신경유두주위망막신경섬유층의평균두께가얇아질수록, 황반망막의평균두께도유의하게얇아졌으며 (R= 0.495, p<0.001)(fig. 1B), 상측으로만시야결손을보이는개방각녹내장 20안에있어서상측보다하측에서황반 망막의안쪽원 (p=0.026), 바깥쪽원 (p<0.001) 및시신경유두주위망막신경섬유층 (p=0.001) 의두께가유의하게감소되었다 (Table 6). 230
- 정원도외 : 황반망막두께와녹내장성시야변화 - 고 찰 Figure 1. (A) Relationship between the mean deviation (MD) (db) and the mean peripapillary retinal nerve fiber layer (RNFL) thickness (µm), n=190; Pearson correlation coefficient=0.554 (p<0.001), and relationship between the mean deviation (MD) (db) and the mean macular thickness (µm), n=190; Pearson correlation coefficient=0.513 (p<0.001). (B) Relationship between the mean macular thickness (µm) and the mean peripapillary retinal nerve fiber layer (RNFL) thickness (µm), n=190; Pearson correlation coefficient=0.513 (p<0.001); * MD=mean deviation; db=decibel; RNFL=retinal nerve fiber layer. 녹내장이진행할수록시신경유두함몰비가커지고, 시신경유두주위망막신경섬유층의두께가얇아지면서시야결손이증가한다는것은이미잘알려져있다. 1-5 시신경유두와시신경유두주위망막신경섬유층, 황반망막등을관찰할수있는빛간섭단층촬영과같은검사법들이개발되면서시야결손은나타나지않으나미세한시신경유두주위망막신경섬유층의두께의감소가나타나는시야결손전녹내장환자를선별할수있어, 녹내장의조기진단을통해녹내장진행의예방에큰도움을받고있다. 그러나녹내장환자에서의시야결손과황반망막두께가상관성이있는지, 황반망막두께와시신경유두주위망막신경섬유층두께가상관성이있는지등에대해서는아직정확히알려지지않았다. 특히본연구에서는황반망막의각영역별두께와시야결손과의상관성, 황반망막평균두께와시신경유두주위망막신경섬유층평균두께와의상관성을조사하였다는점에서큰의미가있을것이다. 한연구에서녹내장안의시신경유두주위망막신경섬유층두께와후극부의망막신경섬유층두께가유의한상관관계가있다고하였고, 이는중심소와를둘러싼부위에서망막신경절세포의소실을반영한다고하였다. 21 본연구에서도시신경유두주위망막신경섬유층의평균두께가감소할수록황반망막의평균두께도유의하게감소된것을관찰할수있었으나 (Fig. 1B), 영역별로의관련성에대해서는정확히규명할수없었다. 그러나, 상측으로만시야결손을가졌던개방각녹내장 20안에있어서, 시신경유두주위망막신경섬유층의두께가하측이상측보다유의하게감소하였고, 황반망막의두께가안쪽원과바깥쪽원모두에서하측이상측보다유의하게감소된것을관찰해볼때 (Table 6), 이는개방각녹내장이진행할수록시야변화가심해지면서시신경유두주위망막신경섬유층과더불어황반망막두께도같이감소한다는주장을뒷받침할수있다. 그러나정상안의황반망막두께는안쪽원에서상측과하측이비슷하지만, 바깥쪽원에서는하측이상측보다얇은것으로알려져있어본연구에서의한계점중하나로생각된다. 8,22,23 Table 5. Correlation between MD, PSD and RNFL thickness in 190 eyes RNFL thickness Pearson correlation coefficient (MD ) Pearson correlation coefficient (PSD ) Superior 0.579 (p<0.001 * ) -0.524 (p<0.001 * ) Inferior 0.374 (p<0.001 * ) -0.392 (p<0.001 * ) Nasal 0.399 (p<0.001 * ) -0.291 (p<0.001 * ) Lateral 0.485 (p<0.001 * ) -0.485 (p<0.001 * ) Mean RNFL 0.554 (p<0.001 * ) -0.492 (p<0.001 * ) * Correlation analysis: Pearson correlation; MD=mean deviation; PSD=pattern standard deviation; RNFL=retinal nerve fiber layer. 231
- 대한안과학회지 2009 년제 50 권제 2 호 - Table 6. Comparison of superior and inferior inner, outer macular thickness, retinal nerve fiber layer thickness in open angle glaucoma 20 eyes with unilateral (superior only) visual field defect MT superior (3 mm)(µm) MT inferior (3 mm)(µm) p * Superior VF defect(n=20) 245.70±25.26 223.40±14.52 0.026 MT superior (6 mm)(µm) MT inferior (6 mm)(µm) p * Superior VF defect(n=20) 208.30±15.56 179.50±10.45 <0.001 RNFL superior (µm) RNFL inferior (µm) p * Superior VF defect(n=20) 88.90±9.54 65.90±15.95 0.001 * p=anova; MT=macular thickness; VF=visual field. 어떤연구들은국소화된시야결손을가진녹내장안에서시야결손에상응하는황반망막의두께가유의하게감소된다고주장하였다. 22-27 본연구에서도개방각녹내장군인초기, 중등도, 심한시야결손군모두에서중심소와를제외한모든영역의황반망막두께가정상군에비해유의하게감소된것을관찰할수있었고 (Table 3), 시야검사상의 MD 값이황반망막의평균두께와유의한양의상관관계를보였다 (p<0.001)(fig. 1A). 즉, 녹내장안은정상안에비해황반망막의평균두께가얇고, 진행된녹내장일수록황반망막의평균두께가유의한상관관계를가지면서감소한것을알수있었다. 또한, 190안에서 MD의절대값이커질수록중심소와및중심원을제외한황반망막두께의모든영역이유의한상관관계를가지면서감소하였다 (Table 4). 녹내장이진행할수록빛간섭단층촬영으로측정한시신경유두주위망막신경섬유층의두께가감소하고, 시야결손이증가한다는것은이미잘알려져있으며, 본연구에서도이와일치하는결과를보였다 (Table 1, 2, 5)(Fig. 1A). 1-5 이상에서개방각녹내장군은정상군에비해시신경유두주위망막신경섬유층및황반망막두께가감소하였고, 개방각녹내장이진행하여시야결손의정도가커질수록감소의정도가더심한것을관찰할수있었다. 그러나, 황반망막에서중심소와의두께는정상군, 고안압증군, 시야결손전녹내장군, 초기시야결손군, 중등도시야결손군, 심한시야결손군사이에서유의한차이를보이지않아, 황반망막의중심소와두께측정은녹내장을조기진단하는데유용하지않은것으로나타났다. 중심원은정상군에비해개방각녹내장군에서만유의하게감소하였고, 고안압증군및시야결손전녹내장군에서는감소되지않아, 중심원의두께측정역시녹내장의조기진단에도움을주지못하는것으로생각된다. 그리고시야결손전녹내장군에서안쪽원, 바깥쪽원내의일부영역들이정상군에비해황반망막두께가유의하게감소된것으로나타났고, 녹내장의조기진단에있어결정적인단서를제공하기에는부족함이있을것으로사료되지만, 시신경유두주위망막신경섬유층이감소 할수록황반망막두께도감소한다는주장을뒷받침하는데에는도움을줄수있을것으로생각된다 (Table 2, 3). 고안압증군은황반망막두께의모든영역이정상군과유의한차이를보이지않았는데, 이는고안압증군에서시신경유두주위망막신경섬유층두께가정상군에비해유의한차이를보이지않았던것과관련이있을것으로생각된다 (Table 2, 3). 본연구에서개방각을가진경우에한정해서대상자를선정한이유는폐쇄각녹내장이급성기일경우급격한안압변동, 각막부종및급성시신경손상등에의한요인으로시야검사결과에영향을미칠수있고, 황반망막두께에미치는영향이경우에따라달라질수있기때문이다. Murugacz et al 28 은근시가심해질수록중심소와의망막두께가감소한다고주장하였고, 본연구에서는이러한굴절이상에대한영향을최소화하기위해 3.0D에서 +3.0D 사이의굴절이상을가지는경우만대상에포함시켰다. 또한, 동공의크기가빛간섭단층촬영상의결과에영향을줄수있기때문에모든대상자에대하여산동상태로검사를진행하였다. 정상인에서연령에따라황반망막두께의차이가있다는보고가있으며, 29-31 본연구는나이에따른변화요인을최소화하기위해대상연령을 50세이상으로제한하였다. 또한, 개방각을가진경우만을대상으로하였기때문에폐쇄각녹내장환자에서녹내장의진행정도와황반망막두께의관련성을이해하는데는무리가있으나, 시신경및시야변화에미치는영향은큰차이가없을것으로생각되며어느정도의결과에대한추정은가능할것이다. 그리고안압의절대값, 고안압이지속된기간등은본연구에서반영되지않았기때문에, 안압이황반망막에미치는영향에대해서는앞으로보완해서연구해야할점으로생각된다. 또한, 황반망막과시신경유두주위망막신경섬유층, 그리고시야변화등의관련성에대하여더많은환자들을대상으로하는추가적인연구가필요할것으로생각된다. 본연구에서황반망막도시신경유두주위망막신경섬유 232
- 정원도외 : 황반망막두께와녹내장성시야변화 - 층과같이개방각녹내장이진행함에따라두께가유의하게감소되는것을관찰할수있었다. 황반망막두께의변화는개방각녹내장의조기진단에일부기여할수있을것으로생각되며, 무엇보다녹내장의진행정도에따른시기능손상정도를반영하는지표로서의역할을할것이다. 그리고고안압증및시야결손전녹내장군에서시신경유두주위망막신경섬유층의두께와함께비교분석함으로써앞으로의경과를관찰하는데도움을주고, 개방각녹내장환자의상태를좀더종합적으로이해하는데도움을줄것으로기대한다. 참고문헌 1) Quigley HA, Addicks EM, Green WR. Optic nerve damage in human glaucoma. III. Q uantitative correlation of nerve fiber loss and visual field defect in glaucoma, ischemic neuropathy, papilledema, and toxic neuropathy. Arch Ophthalmol 1982;100:135-46. 2) Quigley HA, Miller NR, George T. Clinical evaluation of nerve fiber layer atrophy as an indicator of glaucomatous optic nerve damage. Arch Ophthalmol 1980;98:1564-71. 3) Sommer A, Miller NR, Pollack I, et al. The nerve fiber layer in the diagnosis of glaucoma. Arch Ophthalmol 1977;95: 2149-56. 4) Quigley HA, Dunkelberger GR, Green WR. Retinal ganglion cell atrophy correlated with automated perimetry in human eyes with glaucoma. 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- 대한안과학회지 2009 년제 50 권제 2 호 - 1999;106:269-73. 30) Kanai K, Abe T, Murayama K. Retinal thickness and changes with age. Nippon Ganka Gakkai Zasshi 2002;106:162-5. 31) Panda-Jonas S, Jonas JB, Jakobczyk-Zmija M. Retinal photoreceptor density decreases with age. Ophthalmology 1995;102: 1853-9. =ABSTRACT= Correlation Between Macular, Retinal Nerve Fiber Layer Thickness, and Visual Field in Open Angle Glaucoma Won-Do Jeong, MD 1, Dongeun Lee, MD 2, Joo-Hwa Lee, MD 1, Joon-Woo Shin, MD 1 Department of Ophthalmology, Inje University College of Medicine, Sanggye Paik Hospital 1, Seoul, Korea Department of Ophthalmology, Inje University College of Medicine, Seoul Paik Hospital 2, Seoul, Korea Purpose: This study was performed to evaluate the macular and peripapillary retinal nerve fiber layer (RNFL) thickness and to evaluate their association with glaucomatous visual field change. Methods: Forty normal eyes of 24 subjects, 30 ocular hypertension eyes of 15 patients, 30 pre-perimetric glaucoma eyes of 18 patients and 90 open angle glaucoma eyes of 59 patients. The macularand peripapillary RNFL thickness were measured by the optical coherence tomography (Stratus OCT TM model 3000, Carl Zeiss Meditec) and visual field tests were performed by the Humphrey's automated perimetry. Results: There was a significant decrease of both the macular (p<0.05) and peripapillary RNFL thickness (p<0.001) in the open angle glaucoma group compared with the normal group. In 190 eyes, statistically significant positive relationship was demonstrated between mean deviation (MD) and all areas of peripapillary RNFL thickness (p<0.001) as well as between MD and all areas of macular thickness except the fovea, central ring (p<0.01). Conclusions: The macular and peripapillary RNFL thickness were significantly decreased and the findings indicated a significant association with the visual field change in open angle glaucoma eyes. J Korean Ophthalmol Soc 2009;50(2):227-234 Key Words: Macular thickness, Optical coherence tomography, Retinal nerve fiber layer, Visual field defect Address reprint requests to Joo-Hwa Lee, MD Department of Ophthalmology, Inje University Sanggye Paik Hospital #761-1 Sanggye 7 dong, Nowon-gu, Seoul 139-707, Korea Tel: 82-2-950-1096, Fax: 82-2-935-6904, E-mail: joohlee@paik.ac.kr 234