검안및콘택트렌즈학회지 2018 년제 17 권제 2 호 Ann Optom Contact Lens 2018;17(2):25-32 ISSN 2384-0919 (Print) ISSN 2384-0927 (Online) Original Article 동공괄약근마비가발생한급성폐쇄각녹내장환자의백내장수술후고위수차변화 Higher Order Aberration Changes after Cataract Operation in Acute Angle Closure with Mid-dilated Fixed Pupil 서수연 1 이동현 1 조성호 1 신종훈 1 서제현 2 Su Youn Suh, MD 1, Dong Hyun Lee, MD 1, Seong Ho Jo, MD 1, Jonghoon Shin, MD 1, Je Hyun Seo, MD, PhD 2 부산대학교의학전문대학원양산부산대학교병원안과학교실, 중앙보훈병원보훈의학연구소 Department of Ophthalmology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine 1, Yangsan, Korea Veterans Health Service Medical Center, Veterans Medical Research Institute 2, Seoul, Korea Purpose: To investigate the change of ocular higher-order aberrations (HOA) after cataract surgery in the eyes of acute primary angle closure (PAC) attack with mid-dilated fixed pupil. Methods: This study included eyes of patients with mid-fixed dilated pupil after acute primary angle closure attack. Also, uncomplicated cataract patients were enrolled as control. All the eyes had been underwent cataract surgery with phacoemulsification. Best-corrected visual acuity (BCVA, in logmar) and HOA (i-trace, Tracey technologies, Houston, TX) were evaluated preoperatively and postoperatively at 1 month. Paired t-test were used to compare preoperative and postoperative HOA values, and independent t-test for comparison of postoperative HOA in PAC and control groups. Results: BCVA were significantly increased in PAC group (0.64 ± 0.51 vs. 0.43 ± 0.45, p=0.042, respectively), and in control group (0.51 ± 0.25 vs. 0.18 ± 0.15, p<0.001, respectively). Intraocular pressure were significantly decreased in both groups. In control group, coma-like, spherical-like, and high order total (HOT) aberrations were significantly changed (p=0.006, 0.008, 0.006, respectively) in internal optics aberrations. However, HOA values did not show significant changes in PAC group. HOT aberrations of entire eye after cataract surgery in PAC group were higher than those in control group (1.21 ± 1.13 vs. 0.41 ± 0.48, p=0.001). Conclusions: This result suggests that HOAs change after cataract surgery were less profound in the eyes with mid-fixed dilated pupil after acute primary angle closure attack than uncomplicated cataract group. Ann Optom Contact Lens 2018;17(2):25-32 Key Words: Phacoemulsification; Glaucoma; Corneal wavefront aberration; Glaucoma angle-closure Received: 2018. 1. 22. Revised: 2018. 4. 12. Accepted: 2018. 5. 3. Address reprint requests to Je Hyun Seo, MD, PhD Veterans Medical Research Institute, Veterans Health Service Medical Center, #53 Jinhwangdo-ro 61-gil, Gangdong-gu, Seoul 05368, Korea Tel: 82-2-2225-1265, Fax: 82-2-2225-1433 E-mail: jazmin2@naver.com * This study was supported by a 2017 research grant from Pusan National University Yangsan Hospital. 서론 원발폐쇄각은주변홍채앞유착, 안압상승, 홍채이상, 녹내장수정체혼탁, 전방각색소침착등의소견은있으나, 시신경이상은없는경우를말하며, 폐쇄각녹내장은원발폐쇄각에추가적으로녹내장성시신경손상이관찰되는것을말한다. 1,2 폐쇄각녹내장의시력예후는개방각녹내장보다나쁘다고알려져있으며, 전세계적으로녹내장으로실명되는 Copyright 2018, The Korean Optometry Society The Korean Contact Lens Study Society Annals of Optometry and Contact Lens is an Open Access Journal. All articles are 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. 25
- 검안및콘택트렌즈학회지 2018 년제 17 권제 2 호 - 것의반정도를차지한다고알려져있다. 1 급성폐쇄각녹내장의발병에는동공차단, 고원홍채, 수정체전방이동등의원인으로발생된다고알려져있으며, 급성폐쇄각녹내장발작의주요기전인동공차단은안압을상승시키고, 레이저홍채절개술로폐쇄각기전을해결해서안압을조절한다. 3 그러나모든환자가레이저치료로해결되는것은아니며백내장수술이나백내장과녹내장의병합수술등이필요한경우도있다. 3-6 또한수정체가폐쇄각유발과관련있기때문에장기적으로만성폐쇄각녹내장으로의이행을예방하기위해서는백내장수술이도움이된다. 7 최근에각막지형도및웨이브프론트분석기술의발달로, 안과수술전후의고위수차분석이가능해졌고이에따라시력의질적변화에대한추정이가능해지면서백내장수술, 익상편절제술, 각막이식술, 공막돌륭술등의여러안과수술에서고위수차의변화를분석하여안과수술이시력의질에어떤영향을주는지에대한많은연구와보고들이이루어지고있다. 8,9 녹내장치료와관련되어서고위수차연구는거의이루어지지는않았지만, 최근에 Fukuoka et al 10 이섬유주절제술후고위수차가섬유주절제술후 1개월에증가했다가 3개월째에술전으로변화한다고보고한바가있으며국내에서도 Kim et al 11 이펜타캠에의한결막편절개방법에따른섬유주절제술전후의고위수차변화에대한보고한바가있다. 일반적으로동공은폐쇄각이발생할때산대되어있어서안압을떨어뜨린후필로카르핀으로축동시켜서레이저홍채절개술을시행하는데안압상승과관련된동공근의마비가발생하면필로카르핀점안에도불구하고동공의크기가줄지않는경우가드물지않게발생한다. 이런경우레이저홍채절개술이실패하는경우가있어서아르곤레이저주변홍채성형술 (argon laser peripheral iridoplasty, ALPI) 을시행하게되는데효과가지속되지않는경우가있다. 12 이런경우백내장수술을시행하게되는데그이유는우선적으로안압을조절하기위함인데, 저자들의경험상동공마비가동반된폐쇄각녹내장환자들은백내장수술후에시력의질이술자와환자의기대만큼호전되지않아불편함을호소하는경우가드물지않게있다. 전방각이얕거나섬모체소대의위치가다소달라서기존에 SRK-T/II 공식에따른 intraocular lens (IOL) 값에굴절력예측치가다른경우도하나의원인이될수있으나안경으로교정해도해결이안되는경우가있어동공산대와관련된고위수차의문제일수있다는가설을상정해보고구체적인비교를해보고자한다. 본연구에서는 i-trace (Tracey Technologies, Houston, TX, USA) 를이용하여동공이마비된급성폐쇄각녹내장에서장기적인안압조절을위하여백내장수술을받은환자및일 반적인백내장수술을받은대조군의수술전후의최대교정시력및안압, 구면렌즈대응치, 안구전체와각막및수정체를각각구분한고위수차의변화를비교하여알아보고자한다. 대상과방법 본연구는 2013년 2월부터 2016년 9월까지양산부산대학교병원에서급성폐쇄각녹내장으로레이저치료로안압은하강하였으나합병증으로동공괄약근마비가지속적으로관찰되는환자중백내장수술을받은환자 31명 31안, 대조군으로기저안질환없이동일기간에백내장수술을받은환자중무작위로선정한 31명 31안을대상으로의무기록을토대로시행한후향적비교연구로양산부산대학교병원연구윤리심의위원회의승인을받았다 (IRB No.05-2016-027). 급성폐쇄각녹내장의정의는 International Society for Geographical and Epidemiological Opthalmology 분류에의해안구통, 두통, 구토, 오심, 시력저하등의임상증상과동공산대, 각막부종, 결막충혈, 얕은전방깊이등의임상소견이동반된환자에서폐쇄된전방각, 급격한안압상승, 동공괄약근이상, 녹내장수정체혼탁 (glaukomflecken), 전방각색소침착등이관찰되는경우로하였다. 1 본연구에서는이중지속적으로동공괄약근마비가관찰되는급성폐쇄각녹내장환자를대상으로하였다. 대조군으로는같은기간동일술자에게백내장수술을받았으며백내장이외에다른안과질환이없는사람을무작위로선정하였고이환자들은 Lens opacities classification system III 3등급의백내장이있으면서백내장에의한시력저하가느껴질때수술을시행하였다. 두군모두에서이전에안수술의병력이있거나안과적질환이있는경우그리고시야에이상을유발할수있는신경학적질환이있는경우연구대상에서제외하였다. 또한백내장수술중수정체해리, 후낭파열이발생하여삼체형인공수정체를섬모체고랑에넣거나유리체절제술시행을받은경우와인공수정체지지에장애가있을것으로예상되어공막고정술을시행한경우에는본연구에서제외하였다. 이외에도 +5.0디옵터이상의원시이거나 -6.0디옵터이하의근시, +3.0디옵터이상의난시에해당하는환자는제외하였다. 동공마비급성폐쇄각녹내장군에서는급성발작이왔을때고삼투압제를정맥주사로투여하여안압이하강하면 2% 필로카르핀을 3회점안하여동공을축동시켜주변부홍채를최대한얇아지도록하였고, 축동이안되는경우는추가적인점안없이레이저홍채절개술을시행하였다. 레이저홍채절개술은 0.5% proparacaine (Alcon Inc, Fort Worth, TX, 26
- 서수연외 : 폐쇄각녹내장에서백내장술후고위수차 - USA) 으로점안마취후파스칼레이저를사용하여상비측이나상이측홍채에분화구를만든후 Neodymium-doped yttrium aluminum garnet 레이저를이용하여홍채를절개하였다. 홍채마비로동공이축동되지않아레이저홍채절개술이실패할경우에는아르곤레이저주변홍채성형술을 15회정도시행하여전방각이넓어지는것을유도하였다. 이후레이저시술후염증조절목적으로 1% prednisolone acetate (Predforte, Allergan Inc., Irvine, CA, USA) 를하루에 4회 1주일간점안하였다. 이후에안압이다소높고전방각이얕아서급성폐쇄각이재발하거나만성폐쇄각녹내장으로이완이높을것으로예상되는경우수정체유화술에의한백내장수술을시행하였다. 유리체압력을낮추기위하여백내장수술 2시간전에 mannitol 20% 100 ml를정맥주사하였으며 0.5% proparacaine으로점안마취후수술을시행하였다. 각막상측에 2.75 mm 크기로미세절개하여투명각막절개부위로점탄물질을전낭에주입하고 25게이지바늘및집게를이용하여수정체낭원형절개를시행하였다. 수력분리술시행후수정체초음파유화술및관류흡입술을순서대로시행하였고점탄물질을주입하여전방과수정체낭의공간을확보한다음인공수정체를수정체낭내에삽입하였다. 이후점탄물질을제거하고인공수정체가수정체낭내에정위치된것을확인하고 10-0 나일론비흡수성봉합사로각막절개부위를봉합후수술을종료하였다. 인공수정체도수는 IOL Master (Carl Zeiss Meditec, Dublin, CA, USA) 로각막곡률, 안축장, 전방깊이를측정후 SRK-T/II 공식을이용하여결정하였고인공수정체는두군에서모두 Tecnis ZCB00 (Abbott Laboratories Inc., Abbott Park, IL, USA) 의같은종류를사용하였다. 백내장수술을받은환자는수술전, 수술후 1주, 2주, 4주, 3달에최대교정시력, 안압, 굴절검사, 세극등현미경검사, 각막난시를측정하였으며, 수술전과수술후 1개월째 i-trace (Tracey technologies) 를이용하여각막지형도및고위수차를측정하였다. 고위수차측정은동공마비가동반되는급성폐쇄각녹내장군과대조군모두수술전, 수술후 1개월암실에서 i-trace (Tracey Technologies, Houston, TX, USA) 를이용하여각막중심으로부터 4 mm의안구수차값을측정하여분석하였다. 고위수차는제르니케다항식 (zernike polynomials) 으로 6차수차까지분석하였다. 전체고위수차및코마, 세조각, 구면수차와 4-6차의측정된고위수차제곱근평균제곱 (root mean square, RMS) 값을계산하였으며임상적으로유용한동경차수가 3차수차인코마수차와 4차수차인구면수차를제르니케다항식으로분석하였다. 3차제르니케다항식의계수에해당하는 (C -3 3, C -1 3, C 1 3, C 3 3 ) 제곱근평 균제곱값은코마유사수차로, 4차제르니케다항식의계수에해당하는 (C -4 4, C -2 4, C 0 4, C 2 4, C 4 4 ) 제곱근평균제곱값은구면수차유사수차로계산하였다. 모든고위수차값은전체안구에서측정되는고위수차를비롯하여각막고위수차및수정체고위수차로세분화된값도각각구하여분석하였다. 통계적분석은 SPSS 18.0 for Windows (SPSS Inc., Chicago, IL, USA) 를이용하였고최대교정시력, 안압, 구면렌즈대응치및고위수차의수술전후변화는 paired t-test를사용하였으며동공마비급성폐쇄각녹내장환자에서시행한백내장수술과기저안과질환이없는백내장수술두군간의비교는 independent t-test를사용하였다. p값이 0.05 미만인경우를통계적으로유의하다고판정하였다. 결과 본연구의대상환자는동공괄약근마비를동반한급성폐쇄각녹내장환자중에서백내장수술을받은 31명 31안, 백내장이외에기저안과질환없이백내장수술을받은 31명 31안을대상으로하였다. 동공괄약근마비를동반한급성폐쇄각녹내장대상군과대조군인단순백내장수술군에서의수술시나이는통계적으로차이가없었다 (66.71 ± 8.33 vs. 65.13 ± 9.88, p=0.535) (Table 1). 술전최대교정시력은동공마비가동반된폐쇄각녹내장환자군과대조군에서유의한차이가없었다 (logmar 0.64 ± 0.51 vs. logmar 0.51 ± 0.25, p=0.212). 구면렌즈대응치는두군간에차이는없었다 (-0.05 ± 2.28 D vs. -0.17 ± 3.28 D, p=0.969). 그리고수술전안압은급성폐쇄각녹내장환자군에서다소높았지만, 일부에서안압하강제에서사용중인상태여서대조군에비하여두군간의통계적으로유의한차이는관찰하지못하였다 (18.47 ± 13.1 mmhg vs. 14.52 ± 2.83 mmhg, p=0.106). 동공괄약근마비를동반한급성폐쇄각녹내장대상군에서술후 4주째최대교정시력은 logmar 0.43 ± 0.45로시력이호전되었으나 (p=0.042) (Table 2), 구면렌즈대응치는 -0.63 ± 1.09로증가하는경향을보였으나통계학적으로유의한변화는아니었다 (p=0.189). 안압은수술후 4주째 12.71 ± 4.75 mmhg 로수술전 18.47 ± 13.1 mmhg 에비하여유의하게감소하였다 (p=0.021). 한편, 단순백내장수술군에서술후 4주째최대교정시력은 logmar 0.18 ± 0.15로시력이호전되었고 (p<0.001), 안압역시수술전에비하여 12.97 ± 3.06 mmhg로유의하게감소하였다 (p=0.006). 구면렌즈대응치는 -0.30 ± 0.74로증가하였으나통계학적으로유의한변화는아니었다 (p=0.546). 수술후 3달째두군모두에서술전에비해최대교정시력은호전되고안압은감소하는유의한변화가확인되었다 (Fig. 1). 27
- 검안및콘택트렌즈학회지 2018 년제 17 권제 2 호 - 고위수차비교 1) 안구전체고위수차동공괄약근마비를동반한급성폐쇄각녹내장대상군에서코마수차와구면수차는수술전보다수술후 4주째에감소소견이관찰되었으나통계적유의성은없었으며, 전체고위수차는증가하였지만역시통계적차이가없었다 (Table 3). 그러나, 대조군인단순백내장수술군에서는코마수차 (p=0.005), 구면수차 (p=0.005), 전체고위수차 (p=0.005) 모두유의하게감소하였다. 두군간의고위수차비교에서는수술전의코마수차 (p=0.007), 구면수차 (p=0.002), 전체고위수차 (p=0.030) 모두동공괄약근마비를동반한급성폐쇄각녹내장대상군에서 단순백내장수술군보다유의하게낮게측정되었다 (Table 3). 수술후 4주째에는전체고위수차에서동공괄약근마비를동반한급성폐쇄각녹내장대상군이단순백내장수술군에비해유의하게높게관찰되었으나 (p=0.001), 나머지고위수차에서는유의한차이가관찰되지않았다. 2) 각막고위수차동공괄약근마비를동반한급성폐쇄각녹내장대상군에서수술전과수술후 4주째에코마수차만유의하게감소하였고단순백내장수술군에서는코마수차, 구면수차, 전체고위수차각각수술전과수술후 4주째유의한각막고위수차변화는관찰되지않았다 (Table 3). 두군간의고위수차비교에서수술전과수술후 4주째코마수차와구면수 Table 1. Demographic and baseline characterics of subjects Group A * (n = 31) Group B (n = 31) p-value Age (years) 66.71 ± 8.33 65.13 ± 9.88 0.535 BCVA (logmar) 0.64 ± 0.51 0.51 ± 0.25 0.212 IOP (mmhg) 18.47 ± 13.1 14.52 ± 2.83 0.106 Spherical equivalents -0.05 ± 2.28-0.17 ± 3.28 0.969 DM history 10 (32.3) 6 (19.4) 0.253 HTN history 6 (19.4) 13 (41.9) 0.055 Visual field (MD, db) -11.58 ± 10.67 N/A Visual field (PSD, db) 5.18 ± 2.94 N/A Values are presented as number (%). BCVA = best corrected visual acuity; IOP = intraocular pressure; DM = diabetes mellitus; HTN = hypertension; MD = mean deviation; db = decibels; PSD = pattern standard deviation. * Group A = phacoemulsification in acute angle closure with mid-dilated fixed pupil; Group B = phacoemulsification in control group; p-value by independent t-test between Group A and B for variables, in case of numeric, Chi-square test applied. Table 2. Changes of best corrected visual acuity (BCVA), spherical equivalents (SE) and intraocular pressure (IOP) between Group A (phacoemulsification in acute angle closure with mid-dilated fixed pupil) and Group B (phacoemulsification in control group) Group A * Group B p-value (n = 31) (n = 31) BCVA, logmar Baseline 0.64 ± 0.51 0.51 ± 0.25 0.212 Post 4 weeks 0.43 ± 0.45 0.18 ± 0.15 0.004 p-value 0.042 0.000 SE Baseline -0.05 ± 2.28-0.17 ± 3.28 0.969 Post 4 weeks -0.63 ± 1.09-0.30 ± 0.74 0.680 p-value 0.189 0.546 IOP, (mmhg) Baseline 18.47 ± 13.1 14.52 ± 2.83 0.106 Post 4 weeks 12.71 ± 4.75 12.97 ± 3.06 0.801 p-value 0.021 0.006 BCVA = best corrected visual acuity; SE = spherical equivalents; IOP = intraocular pressure. * Group A = phacoemulsification in acute angle closure with mid-dilated fixed pupil; Group B = phacoemulsification in control group; p-value by independent t-test between Group A and B for variables.; p-value by paired t-test between baseline value and postoperative 4 weeks for each groups 28
- 서수연외 : 폐쇄각녹내장에서백내장술후고위수차 - A B Figure 1. Changes of (A) best corrected visual activity (BCVA) and (B) intraocular pressure (IOP) between Group A (Phacoemulsification in acute angle closure with mid-dilated fixed pupil) and Group B (Phacoemulsification in control). * p-value was less than 0.05, showing significance by paired t-test, when compared with baseline value. p-value was less than 0.05, showing significance by independent t-test, when compared between group A and B. Table 3. Comparison of changes in higher order aberrations between Group A and Group B Comalike Entire eye Baseline 0.48 ± 0.43 (μm, RMS) 4 weeks 0.47 ± 0.46 Group A * (n = 31) Spherical -like HOT Comalike 0.09 ± 0.23-0.01 ± 0.38 0.88 ± 0.83 1.21 ± 1.13 2.03 ± 3.01 0.37 ± 0.41 Group B (n= 31) Spherical -like 1.07 ± 1.63 0.16 ± 0.27 HOT 2.30 ± 3.42 0.41 ± 0.48 p-value 0.954 0.372 0.142 0.005 0.005 0.005 Cornea Baseline 0.18 ± 0.13 (μm, RMS) 4 weeks 0.11 ± 0.08 Internal -optics 0.08 ± 0.08 0.05 ± 0.05 0.32 ± 0.28 0.31 ± 0.20 0.24 ± 0.24 0.23 ± 0.32 0.14 ± 0.15 0.11 ± 0.30 0.29 ± 0.27 0.26 ± 0.43 p-value 0.021 0.095 0.651 0.883 0.689 0.778 Baseline 0.45 ± 0.41 (μm, RMS) 4 weeks 0.49 ± 0.48 0.00 ± 0.24-0.05 ± 0.39 0.89 ± 0.84 1.18 ± 1.20 0.87 ± 0.78 0.41 ± 0.62 0.58 ± 0.70 0.22 ± 0.40 1.06 ± 1.03 0.47 ± 0.74 p-value Π 0.007 0.002 0.030 0.338 0.051 0.001 0.138 0.100 0.857 0.054 0.269 0.617 0.01 0.000 0.456 0.621 0.006 0.004 p-value # 0.906 0.544 0.245 0.006 0.008 0.006 HOT = higher order total : magnitude of the third to sixth-orders; RMS = root mean square; HOA = higer order aberrations. * Group A = phacoemulsification in acute angle closure with mid-dilated fixed pupil; Group B = phacoemulsification in control group; Coma-like : the third-order Zernike coefficients(c -3 3, C -1 3, C 1 3, C 3 3 ); Spherical-like : the fourth-order Zernike coefficients (C -4 4, C -2 4, C 0 4, C 2 4, C 4 4 ); Π p-value by independent t-test of HOAs between Group A and B (Coma-like, Spherical-like, Higher order total); # p-value by paired t-test between baseline value and postoperative 2 weeks for each groups (Coma-like, Spherical-like, Higher order total). 차, 전체고위수차모두두군간에유의한차이가없었다 (Table 3). 3) 수정체고위수차동공괄약근마비를동반한급성폐쇄각녹내장대상군에서코마수차와구면수차, 전체고위수차값은수술전과수술 4주째에유의한변화는관찰되지않았으나 (Table 3). 단 순백내장수술군에서는수술전에비하여수술후 4주째코마수차 (p=0.006), 구면수차 (p=0.008) 및전체고위수차 (p=0.006) 모두유의하게감소하였다. 두군간의고위수차비교에서는대조군보다동공괄약근마비를동반한급성폐쇄각녹내장대상군에서수술전코마수차 (p=0.01) 와구면수차 (p<0.001) 가유의하게더높게측정되었으나전체고위수차는의미있는차이가관찰되지 29
- 검안및콘택트렌즈학회지 2018 년제 17 권제 2 호 - 않았다. 수술후 4주째에는동공괄약근마비를동반한급성폐쇄각녹내장대상군에서단순백내장수술군보다구면수차는유의하게낮았고 (p=0.006) 전체고위수차는유의하게높았다 (1.18 ± 1.20 vs. 0.47 ± 0.74, p=0.004). 고찰 폐쇄각녹내장환자에서흔히발생하는합병증중하나인지속적인동공산대는근거리및원거리시력저하, 눈부심등의증상을유발하고이는지속적인안압하강제사용, 홍채무력증, 홍채위축등에의한것이라는보고가있었다. 13 또한 de Castro et al 14 은시력의질에직접적인영향을주는고위수차가나이, 각막곡률, 근시, 동공크기등에의해영향을받으며특히동공크기의증가가고위수차의증가와강한상관관계가있다고보고한바가있다. 이외에도 Hiraoka et al 15 은약시치료를위해지속적으로조절마비제를사용한눈에서원시굴절률과고도수차가증가하여실제로환자가느끼는시력의질뿐만아니라최대교정시력이저하된다고보고한바있다. 급성폐쇄각녹내장으로인한동공괄약근마비가관찰된환자중백내장수술을받은환자군에게수술에앞서수술의목적은안압조절과녹내장치료라고설명하여도백내장수술후시력의질적저하를호소하고수술결과에실망하는경우가가끔있었으며굴절력을이용하여도시력이충분히교정되지않아서고위수차의차이를그원인중하나로추정하였다. 최근웨이브프론트방식의고위수차가개발되어안과수술전후의고위수차변화및이에따른시력의질변화를예측할수있게되어술후고위수차를줄이기위해노력하고있다. 16,17 이에본연구에서는동공마비가동반된폐쇄각녹내장환자군과기저안질환없이단순백내장수술을받은환자군을나누어동공산대와관련된고위수차의변화가술후시력의질에어떤영향을미치는지알아보고, 고위수차를각막고위수차, 수정체고위수차를구분하여수술로인해시력의변화에더크게영향을미치는요소를알아보고자하였다. Lai et al 18 은폐쇄각녹내장환자에서수술전안압이 19.7 mmhg에서백내장수술을시행한후 20.7개월에평균 4.2 mmhg의안압하강효과를나타냈으며 47.6% 에서시력호전효과를보였다는보고를하였다. 본연구에서도급성폐쇄각녹내장으로인해동공괄약근마비가관찰된환자에서백내장수술을시행한군에서의미있는시력의호전및안압하강이관찰되었으나고위수차의경우각막의코마수치외에는의미있는변화를확인할수없었다. 이에반해단순백내장수술환자군은의미있는시력의변화및안압하강 은물론수술후고위수차의감소로시력의질이향상됨을확인하였으며, 특히수정체고위수차의뚜렷한감소에의한안구전체고위수차의감소로환자가느끼는시력에개선이나타남을확인할수있었다 (Fig. 2). 수술전두군의고위수차를비교해보면단순백내장수술환자군이급성폐쇄각녹내장으로인해동공괄약근마비가관찰된환자에서백내장수술을시행한군보다수정체의코마수차와구면수차및안구전체고위수차에서의미있게높게관찰된다. 이에대해생각해볼수있는가설로는급성폐쇄각녹내장환자가장기적인안압을조절하기위하여백내장수술한경우와시력교정을위하여백내장수술한경우를비교했을때환자의백내장중등도의차이가다소날수있을것이며폐쇄각녹내장환자들은동공괄약근마비로인해동공크기가단순백내장수술환자군보다크기때문에고위수차의차이를유발과관련이있을수도있으나, 고위수차검사는암실에서암순응을하고측정하기때문에오히려동공이고정되어동공이어느정도이상커지지않았기때문으로생각한다. 폐쇄각녹내장군의경우대조군에비해전방의깊이가얕지만 de Castro et al 14 은전방의깊이가고 A B Figure 2. Comparison of wave front between Group A (Phacoemulsification in Acute Angle Closure with Mid-dilated Fixed Pupil) and Group B (Phacoemulsification in control group). High-order aberrations in Group A were increased after 4 weeks (A, from 0.549 μm to 1.515 μm), and those in Group B were decreased after 4 weeks (B, from 1.059 μm to 0.233 μm). 30
- 서수연외 : 폐쇄각녹내장에서백내장술후고위수차 - 위수차에영향을주지않는다고서술한바있다. Wang et al 19 은동공의크기가클수록구면수차, 코마수차가증가한다고하였고코마수차보다구면수차의변화가더크다고보고한바가있다. 본연구에서안구전체고위수차는급성폐쇄각녹내장으로인해동공괄약근마비가관찰된환자에서코마수차및구면수차는통계적차이가없었으나전체고위수차는유의하게더컸다. 동공크기와관련된기존에알려진구면수차와코마수차의차이가없다면동공크기이외에인자에대해서생각해보아야한다. 앞에서술한굴절력도하나의원인일수도있고, 14 폐쇄각녹내장환자의경우얕은전방각깊이를제외하더라도수정체낭및섬모체구조의해부학적이상을동반할수있기때문에기존의인공수정체공식과인공수정체디자인의오차가있을수도있다고생각된다. 일반적으로백내장수술을할경우고위수차가감소하여 0에가까이되는고위수차의호전이관찰된다. 20 본연구에서도기저안질환없이단순백내장수술을받은환자군에서술전후의고위수차비교시각막고위수차의경우의미있는변화가없었으나수정체및안구전체의코마수차및구면수차, 전체고위수차에서의미있는감소를확인할수있었다. 그러나동공마비가동반된폐쇄각녹내장환자군에서는그렇지못했다. 술후고위수차만을비교하면폐쇄각녹내장환자가단순백내장수술을받은대조군에비해높았다. 이의원인으로생각할수있는변수로폐쇄각녹내장환자에서전방각깊이나수정체낭의위치가정상인과차이가있을수있어 SRK-T 공식이다소부정확할수있고수술후에인공수정체의위치가변하는것을하나의원인으로생각할수있으며, 이외에도급성폐쇄각녹내장환자는백내장수술전에안압이높아녹내장안약을쓰거나전방각의염증이동반되는등임상적상황이대조군과차이가있다. 본연구의제한점은첫째로, 후향적의무기록지분석연구여서대상군개개인의백내장정도에대한정확한평가가어려운단점이있으며, 대조군역시대상군을연구할때무작위로추출된환자이기에정보의한계가있을수도있다. 둘째로, 대상군의녹내장치료상황, 각막부종의상황, 전방각의깊이, 동공크기, 나이, 환자의협조등이영향을미칠수있다. 폐쇄각녹내장의초기치료로레이저홍채절개술이성공하여녹내장안약으로안압이조절되는환자를대상으로하여서녹내장안약자체가연구에영향을미칠수도있겠다. 셋째로, 저자들이예상했던것보다동공마비에대한고위수차의영향이적었는데이는기본적으로고위수차가암실에시행하여동공크기가 4 mm 이상일때정확하므로, 실제로환자가느끼는시각의질보다더좋게나 올수도있겠다. 시력질의더명확한비교를위해서는눈부심검사처럼밝은빛에서검사를하면실제로동공마비가동반된폐쇄각녹내장환자에서백내장수술후시력의질을알수있겠다. 넷째로, 고위수차를각항목별로분석하지않았는데이는관련자료를제시하기에는일관적이지않은면이있어, 그렇지만이는경과관찰에중요한사항이므로향후이에대한후향적조사를통해추가적인연구가필요하다. 다섯째, 대상군이 31명으로다소적었는데급성폐쇄각녹내장환자들이치료를위해일찍내원할경우동공괄약근의허혈이비교적적어동공마비없이폐쇄각녹내장을치료하는경우가많아서단일센터내에서동공괄약근마비까지동반된급성폐쇄각녹내장환자를모으는것이다소어려웠다. 결론적으로급성폐쇄각녹내장발작시에발생한동공마비가있는백내장환자에서폐쇄각녹내장의이환을줄이기위하여백내장수술을하게되는데백내장수술을할경우안압하강효과는관찰되나술후고위수차가높아서일반적인백내장수술에서보다는시력개선의효과를얻기어려울것으로생각된다. 이에대상군의환자들에게는백내장수술을시행하기전에술후시력의예후및질적개선정도, 수술의목적에대하여충분한설명이이루어져야할것으로사료된다. REFERENCES 1) Foster PJ, Buhrmann R, Quigley HA, Johnson GJ. The definition and classification of glaucoma in prevalence surveys. Br J Ophthalmol 2002;86:238-42. 2) Distelhorst JS, Hughes GM. Open-angle glaucoma. Am Fam Physician 2003;67:1937-44. 3) Choong YF, Irfan S, Menage MJ. Acute angle closure glaucoma: an evaluation of a protocol for acute treatment. Eye (Lond) 1999;13 (Pt 5):613-6. 4) Tello C, Tran HV, Liebmann J, Ritch R. Angle closure: classification, concepts, and the role of ultrasound biomicroscopy in diagnosis and treatment. Semin Ophthalmol 2002;17:69-78. 5) Quigley HA. Long-term follow-up of laser iridotomy. Ophthalmology 1981;88:218-24. 6) Aung T, Ang LP, Chan SP, Chew PT. Acute primary angle-closure:long-term intraocular pressure outcome in Asian eyes. Am J Ophthalmol 2001;131:7-12. 7) See J. Phacoemulsification in angle closure glaucoma. J Curr Glaucoma Pract 2009;3:28-35. 8) Ye H, Zhang K, Yang J, Lu Y. Changes of corneal higher-order aberrations after cataract surgery. Optom Vis Sci 2014;91:1244-50. 9) Pesudovs K, Figueiredo FC. Corneal first surface wavefront aberrations before and after pterygium surgery. J Refract Surg 2006;22:921-5. 10) Fukuoka S, Amano S, Honda N, et al. Effect of trabeculectomy on ocular and corneal higher order aberrations. Jpn J Ophthalmol 31
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