대한안과학회지 2019 년제 60 권제 7 호 J Korean Ophthalmol Soc 2019;60(7):696-700 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2019.60.7.696 Case Report 공막두르기술재수술시기존실리콘밴드공간을이용한수술방법 Utilizing a Previous Silicone Band Track in Recurred Retinal Detachment 김예슬 1 최경식 2 Yeseul Kim, MD 1, Kyung Seek Choi, MD 2 순천향대학교의과대학부천병원안과학교실 1, 순천향대학교의과대학서울병원안과학교실 2 Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine 1, Bucheon, Korea Department of Ophthalmology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine 2, Seoul, Korea Purpose: We report a case of utilizing a previous silicone band track in the reoperation of scleral encircling. Case summary: An 8-year-old male presented with rhegmatogenous retinal detachment in the right eye. Five days after this diagnosis, he received scleral buckling surgery and cryopexy to seal the retinal tear. One month after surgery, a fundus examination showed subretinal fluid at the inferior site of the scleral buckle. He underwent scleral encircling surgery and a cryopexy procedure. The patient has had an uneventful postoperative course, and the retina has remained attached over a follow-up period of 9 months. However, exotropia and hypotropia developed in the right eye. Diagnosis of restrictive strabismus due to tissue adhesion around the silicone band was made. The encircling band was therefore removed and laser photocoagulation was performed 360 o around the retina. Twenty-four hours after surgery, a fundus examination showed subretinal fluid. He received 360 o scleral encircling surgery not using the 360 o conjunctival peritomy. After confirming a previous encircling tract using #0-0 polydioxanone as a guide, #5-0 Nylon was tied to the end of the guide and inserted through the encircling tract with the end sutured with the silicone band. The silicone band was inserted into the encircling tract by pulling the #5-0 Nylon as a guide. Ophthalmoscopy revealed an attached retina with indentation of the scleral buckle at 360. Conclusions: For reoperation in patients who previously underwent scleral encircling surgery, using the previous scleral encircling tract may be effective in cases with conjunctival and tissue adhesion. J Korean Ophthalmol Soc 2019;60(7):696-700 Keywords: Conjunctival peritomy, Reoperation, Retinal detachment Received: 2018. 9. 27. Revised: 2018. 11. 30. Accepted: 2019. 6. 19. Address reprint requests to Kyung Seek Choi, MD Department of Ophthalmology, Soonchunhyang University Seoul Hospital, #59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea Tel: 82-2-709-9354, Fax: 82-2-710-3196 E-mail: ckseek@schmc.ac.kr * This work was supported by the Soonchunhyang University Research Fund. * This study was awarded the research video prize at the 119th Annual Meeting of the Korean Ophthalmological Society 2018. * Conflicts of Interest: The authors have no conflicts to disclose. 공막두르기술 (scleral encircling) 은열공성망막박리에서망막열공을막기위해 360 로공막돌륭을만드는효과적인방법이다. 공막두르기술은 360 결막절개를시행한후 4개의직근을박리한후실리콘밴드를이용하여안구벽을안쪽으로함입시켜망막색소상피증과신경망막층의유착을유도하는것으로망막열공을막고유리체망막견인을완화시킨다. 그러나공막두르기술을시행한후망막박리가재발하여재수술이필요한환자에서결막과조직유착으로인해수술의어려움이발생할수있는데이에대한보고가국내에서는아직없는바, 저자들은공막두르기술재수술시결막절개를최소화하여수술을시행한 1예를보고하고자한다. c2019 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. 696
- 김예슬 최경식 : 공막두르기술재수술시기존공간활용 - 증례보고 8세남자환아로타안과에서우안의열공성망막박리를진단받고본원에내원하였다. 과거력상전신질환및안과적질환은없었다. 나안시력우안 0.16, 좌안 0.8, 안압은우안 18 mmhg, 좌안 20 mmhg였으며세극등검사상특이소견은없었다. 안저검사상우안은 9시방향에서망막열공이관찰되었으며황반을침범하는망막박리가 6시에서 10시범위에서관찰되었고 (Fig. 1A) 좌안은이상소견이없었다. 그리하여전신마취하에 504번실리콘스펀지를사용하여공막돌륭술과망막열공주변으로냉동고정술을병행하였다. 수술후 1개월째, 안저검사에서공막돌륭아래부위에망 막하액이관찰되어망막박리가재발하여전신마취하 360 결막절개를시행하고 4개의직근을박리한후 240번실리콘밴드를이용하여공막두르기술과추가적으로냉동고정술을시행하였다. 수술후 9개월동안망막은유착된상태로유지되었으나우안에외사시와상사시가발생하였다 (Fig. 1B). 실리콘밴드주위로조직이유착되어발생한제한성사시진단하, 전신마취하에실리콘밴드를제거하였으며 360 레이저광응고술을추가하였다. 그러나수술 24시간후시행한안저검사상망막하액및공막과맥락막함입의감소가관찰되었다 (Fig. 1C). 그리하여수술후 4일째, 40번실리콘밴드를이용하여공막두르기술을다시시행하였다. 360 결막절개술은시행하지않고내측결막절개술을시행한후내직근 A B C D Figure 1. Fundus photographs and Hess screening test of the patient. (A) Fundus photograph image at the first visit. Retinal tear at 9 o clock direction and retinal detachment were observed. (B) Postoperative Hess screening test of the patient 9 months after scleral encircling. Exotropia and hypotropia developed in the right eye. (C) Postoperative fundus photograph 1 day after scleral encircling band removal and laser indirect ophthalmoscope photocoagulation showing subretinal fluid, decreased buckle height and laser scar. (D) Postoperative fundus photograph 1 day after re-operation of scleral encircling showing the sufficient buckle height and retinal attachment. 697
- 대한안과학회지 2019 년제 60 권제 7 호 - 을박리한후반대쪽으로고정하였다 (Fig. 2A). 기존의실리콘밴드를넣었던위치를확인한후 0-0 polydioxanone (PDS) 를 encircling tract을따라삽입하였다 (Fig. 2B). 0-0 PDS로는실리콘밴드를봉합할수없기때문에 5-0 Nylon 을 0-0 PDS 말단에연결후 0-0 PDS를가이드로사용하여 encircling track을따라 5-0 Nylon을삽입하였다 (Fig. 2C). 삽입한 5-0 Nylon을 40번실리콘밴드에봉합후 5-0 Nylon 을가이드로사용하여 encircling track 안에실리콘밴드를삽입하였다 (Fig. 2D). 실리콘밴드를외직근아래로위치시켰고 2시방향에클립으로고정하였다 (Fig. 2E). 재수술후 1일째시행한안저검사에서 360 로공막과맥락막의함입을유지하였고망막은잘유착되었으며 (Fig. 1D) 실리콘밴드주변의유착제거후잔존하는사시는없으며정위상태였다. 고찰 열공성망막박리는유리체망막수술의가장흔한적응증 이다. 열공성망막박리의원인으로는근시, 고령, 안외상, 그리고수정체수술과거력이있다. 1 망막박리의근대적수술방법은 Gonin 2 에의해 1930년에처음으로시작되었으며그는망막열공과유리체의변화그리고망막박리의관계를규명하고열소작법을이용하여망막열공을폐쇄하는방법을제시하여망막박리의성공률을높였다. 그후, 안구바깥쪽에서공막표면을변형시켜망막을유착시키는공막돌륭술이의해도입되었고, 이것을 1950년대말에는 Schepens 3 가현대적의미의공막돌륭술로발전시켰으며, 또한그는영구적으로유리체견인력을감소시키는공막두르기법을소개하였다. 3,4 유리체절제술의기술이발전함에따라망막박리치료에서공막돌륭술을유리체절제술과병행하여시행하기도하고일차치료로서유리체절제술의빈도가늘어나고는있으나여전히공막돌륭술의역할은중요한위치를차지하고있다. 5 또한망막박리수술법의발달과더불어공막을눌러주는여러가지모양과크기의인공물질이개발되고있고망막과공막을유착시키기위해열소작법, 냉동요법, 레이저치료등이발달하여최근에는공막돌륭술의 A B C D E Figure 2. Intraoperative photographs from the surgeon s perspective reveal the operative procedure using the previous encircling tract. (A) Medial conjunctival peritomy (black arrows) and medial rectus muscle dissection (blue arrow) were done. (B) After confirming the previous encircling tract, 0-0 polydioxanone (PDS) (black arrow) was inserted through the encircling tract (yellow arrow). (C) The 5-0 Nylon was tied to the end of 0-0 PDS and using 0-0 PDS as a guide, 5-0 Nylon (blue arrow) was inserted to the encircling tract (yellow arrow). (D) The 5-0 Nylon was sutured to the 40 silicone band and using 5-0 Nylon as a guide (blue arrow), silicone band (white arrow) was inserted to the encircling tract (yellow arrow). (E) Silicone band (white arrows) was placed beneath the four rectus muscles and was fixed by the clip. MR = medial rectus. 698
- 김예슬 최경식 : 공막두르기술재수술시기존공간활용 - 성공률이약 80% 이상으로보고되고있다. 6,7 공막돌륭술후발생할수있는합병증으로는외안근손상, 안검하수, 증식성유리체망막병증, 굴절이상, 백내장, 유리체혼탁, 복시, 사시, 녹내장, 맥락막박리및출혈, 돌륭물질의감염또는노출, 전안부허혈등이있다. 8,9 공막돌륭술시행후복시와같은합병증이발생하는경우대부분일시적이나약 4% 에서영구적인것으로보고되었다. 10,11 복시가발생하는원인으로는돌륭물질주위로조직의유착, 외안근허혈, 테논낭과결막의불충분한봉합등이있으며수술후사시가발생하여도망막박리수술로인해얻는이익이더크므로환자가스스로적응하거나프리즘안경을처방하는등다양한치료를시행해볼수있겠다. 12 공막외식편을제거하는적응증으로는외식편의돌출, 이동, 감염, 과도한함입, 안구통, 복시및시각장애가있으며외식편제거후망막박리재발률은 3.2-47% 에이른다. 13 본증례에서도공막두르기술시행후실리콘밴드로조직이유착되어사시가발생하여실리콘밴드를제거하였으나망막박리가재발하였다. Foster and Meyers 14 은공막두르기술을시행한망막박리환자에서망막박리가재발하였을때, 액체가스교환술또는레이저광응고술, 유리체절제술등을시행하였다고보고하였다. 그러나본증례의환자는소아환자로유리체절제술등을시행하기어려우며결막과조직의유착으로인해다시광범위한결막절개술을시행하기에는어려움이있어기존의 encircling track을활용하여공막두르기술을시행하였다. 따라서본증례를통해공막두르기술을받았던환자에서재수술을시행할때, 결막을광범위하게절개하지않고이전에공막두르기술을시행한길을사용하는것이결막과조직의유착이있는경우유용할것으로사료된다. REFERENCES 1) Shunmugam M, Shah AN, Hysi PG, Williamson TH. The pattern and distribution of retinal breaks in eyes with rhegmatogenous retinal detachment. Am J Ophthalmol 2014;157:221-6.e1. 2) Gonin J. The treatment of detached retina by searing the retinal tears. Arch Ophthalmol 1930;4:621-5. 3) Schepens CL. Symposium: present status of retinal detachment surgery. Scleral buckling with circling element. Trans Am Acad Ophthalmol Otolaryngol 1964;68:959-79. 4) Lincoff HA, Baras I, McLean J. Modifications to the custodis procedure for retinal detachment. Arch Ophthalmol 1965;73:160-3. 5) D'Amico DJ. Clinical practice. Primary retinal detachment. N Engl J Med 2008;359:2346-54. 6) Greven CM, Wall AB, Slusher MM. Anatomic and visual results in asymptomatic clinical rhegmatogenous retinal detachment repaired by scleral buckling. Am J Ophthalmol 1999;128:618-20. 7) Yao Y, Jiang L, Wang ZJ, Zhang MN. Scleral buckling procedures for longstanding or chronic rhegmatogenous retinal detachment with subretinal proliferation. Ophthalmology 2006;113:821-5. 8) Tsui I. Scleral buckle removal: indications and outcomes. Surv Ophthalmol 2012;57:253-63. 9) Kreiger AE, Hodgkinson BJ, Frederick AR Jr, Smith TR. The results of retinal detachment surgery. Analysis of 268 operations with a broad scleral buckle. Arch Ophthalmol 1971;86:385-94. 10) Kanski JJ, Elkington AR, Davies MS. Diplopia after retinal detachment surgery. Am J Ophthalmol 1973;76:38-40. 11) Sewell JJ, Knobloch WH, Eifrig DE. Extraocular muscle imbalance after surgical treatment for retinal detachment. Am J Ophthalmol 1974;78:321-3. 12) Wolff SM. Strabismus after retinal detachment surgery. Trans Am Ophthalmol Soc 1983;81:182-92. 13) Saleh TA, Gray RH. New retinal detachment following removal of a scleral explant. Eye (Lond) 2003;17:245-6. 14) Foster RE, Meyers SM. Recurrent retinal detachment more than 1 year after reattachment. Ophthalmology 2002;109:1821-7. 699
- 대한안과학회지 2019 년제 60 권제 7 호 - = 국문초록 = 공막두르기술재수술시기존실리콘밴드공간을이용한수술방법 목적 : 공막두르기술재수술시기존실리콘밴드공간을이용하여수술을시행한 1 예를보고하고자한다. 증례요약 : 8 세남자환아가우안의열공성망막박리를주소로내원하였다. 진단후 5 일째에공막돌륭술과냉동고정술을병행하였다. 수술후 1 개월째, 공막돌륭아래부위에망막하액이관찰되어공막두르기술과냉동고정술을시행하였다. 수술후 9 개월동안망막은유착된상태로유지되었으나우안에외사시와상사시가발생하였다. 실리콘밴드주위로조직이유착되어발생한제한성사시진단하에실리콘밴드제거및레이저광응고술을추가하였다. 그러나수술 24 시간후망막하액이관찰되어공막두르기술을다시시행하였다. 360 결막절개술대신 0-0 polydioxanone 를가이드로사용하여이전에공막두르기술을시행했던길로 5-0 Nylon 을삽입후, 실리콘밴드에봉합하여당겨실리콘밴드가공막두르기술을시행했던길로들어가도록하였다. 안저검사에서 360 로공막과맥락막의함입을유지하였고망막은잘유착되었다. 결론 : 공막두르기술을받았던환자에서재수술을시행할때, 이전에공막두르기술을시행한길을사용하는것이결막과조직이유착이있는경우유용할수있겠다. < 대한안과학회지 2019;60(7):696-700> 김예슬 / Yeseul Kim 순천향대학교의과대학부천병원안과학교실 Department of Ophthalmology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine 700