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원저 ISSN 2093-9272 일산병원학술지 2018;17(2):59-63 특발성망막앞막환자에서유리체절제술과백내장병합수술후굴절력예측 연세대학교의과대학안과학교실시기능개발연구소 1, 국민건강보험일산병원안과 김주연 1,2, 한승수 2, 정은지 2 2 Accuracy of Intraocular Lens Power Estimation in Eyes Undergoing Phacovitrectomy for Idiopathic Epiretinal Membrane Joo Yeon Kim 1,2, John Seungsoo Han 2, Eun Jee Chung 2 1 Department of Ophthalmology,Institute of Vision Research, Severance Hospital, Yonsei University, College of Medicine, Seoul, Korea 2 Department of Ophthalmology, National Health Insurance Service Ilsan Hospital, Goyang, Korea Background: To evaluate the accuracy of intraocular lens (IOL) power estimation and factors associated with outcomes in eyes undergoing combined phacovitrectomy for idiopathic epiretinal membrane. Method: We performed a retrospective case review of 33 eyes that underwent phacovitrectomy for idiopathic epiretinal membrane. Axial lengths were measured using ultrasound (A-scan) or optical biometry (IOL Master) or both. Achieved and predicted refractions were compared to calculate mean postoperative refractive prediction error (ME) and mean absolute prediction error (MAE). Systemic conditions of patients and several pre-operative and post-operative factors related to post-operative refraction were analyzed. Result: Mean prediction errors (ME) of 33 eyes measured by A-scan and IOL master were -0.46±0.47 diopters (D) and -0.36 ± 0.44 D after 3 months, respectively. A statistically significant myopic shift was identified with A-scan measurement(p=0.045). Mean absolute prediction errors (MAE) measured by A-san and IOL master were 0.53±0.38 D and 0.31±0.31 D after 3 months, respectively with no statistical significant differences between results (p = 0.197). The amount of decrease in central macular thickness after surgery was significantly associated with greater myopic shift in IOL master measurements(p=0.037). Conclusion: Combined phacovitrectomy for idiopathic epiretinal membrane showed small biometric errors within the tolerable range in most cases. Both optical biometry and ultrasound should be used to estimate axial lengths for improving the accuracy of IOL power calculations. Key Words: Epiretinal membrane, Intraocular lens power estimation, Phacovitrectomy 서론 유리체절제술과백내장병합수술은유리체망막질환환자에있 어서백내장이같이동반되어있을경우흔하게시행되는수술이 책임저자 : 정은지 10444 경기도고양시일산동구일산로 100 국민건강보험일산병원안과전화: (031)900-0590, 팩스: 0303-3448-7107 E-mail : eunjee95@nhimc.or.kr * 본연구는국민건강보험일산병원의연구비지원으로이루어졌음 (NHIMC 2017CR038). 다. 유리체절제술만을단독으로시행했을시백내장으로인해망 막의관찰이어려울수있으며, 2년내에백내장이진행할수있 다는단점이있다. 1 또한선행연구에의하면유리체절제술과백 내장병합수술은순차적인수술과비교하여망막질환과백내장을 동시에치료할수있는안전하고효과적인방법이며추가수술을 피할수있어경제적으로도비용절감에도움이되고, 안구의해 부학적회복또한만족할만하다. 2-5 따라서특히특발성망막앞 막처럼수술후기대되는시력호전의정도가클수록, 정확한인 공수정체도수예측력이중요하다고할수있겠다. 본연구에서는특발성망막앞막환자에서 master 로 A-scan 과 IOL 측정한유리체절제술과백내장병합수술전목표굴절 Volume 17 Number 2 December 2018 59

JY Kim et al. IOL power estimation 력과수술후실제굴절력사이에어떤차이가있는지분석하고, 굴절력에영향을미치는요소에대해알아보고자한다. 대상및방법 2011년 11월부터 2015 년 12월까지국민건강보험일산병원 에서숙련된두명의술자에게망막앞막과백내장진단하유리체 절제술과백내장병합수술을시행받고 6개월이상경과관찰이가 능하여현성굴절검사를시행한 33 명, 33안환자들의의무기록 을후향적으로분석하였다. 포도막염, 외상, 망막혈관질환, 망막 박리수술등에의한이차성망막앞막, 유리체황반견인증후군이 나황반원공이동반되어있거나이전의안내수술을받은수술력 이있는환자는대상에서제외하였다. 본연구는기관생명윤리위 원회의승인을받아(2017-04-022-002) 진행하였다. 안축장의길이는 A-scan(EchoScan US-1800, Nidek, Gamagori, Japan) 과 IOL master (IOL Master, Ziess, Jena, Germany) 를모두이용하여측정하였다. 모든검사는숙 련된한명의검사자에의해시행되었으며, 10회이상측정한결 과중가장신뢰할만한결과값을택하였다. 인공수정체의도수결정과이에따른예상굴절력은 SRK-T 공 식을이용했으며, 두가지방법모두내장된소프트웨어를이용해 계산하였다. 술전목표한굴절력과술후현성굴절검사를통한구면렌즈대 응굴절력을비교하였다. 굴절예측이상값은술후구면렌즈대응 굴절력과술전목표굴절력의차이를평균예측오차 (mean prediction error, ME) 으로계산하여음의값인경우술전목표보다 근시화된것으로양의값인경우원시화된것으로평가하였고, 두 굴절력차의절대값을평균절대예측오차 (mean absolute pre- diction error, MAE) 으로정의하여결과측정치로확인하였다. 대상환자들의수술전과수술후 3, 6 개월에최대교정시력, 안압, 굴절값을조사하였다. 최대교정시력은스넬렌 (Snellen) 시력표를이용하여측정하였으며, LogMAR(Logarithm of minimum angle of resolution) 로변환하였다. 굴절값은현성굴절 검사를이용하여측정하고구면대응치 (Spherical equivalent) 로환산하였다. 수술전후의중심망막두께는빛간섭단층촬영 (Spectral domain optical coherence tomography, Cirrus OCT, Carl Zeiss meditec, Inc., Dublin, CA, USA) 을이용하여측정하였다. 수술방법은전신마취혹은구후마취하에각막윤부에서 3.5mm 후방의하이측에공막천자후상부투명각막절개를가 하고, 이측또는비측에보조각막절개를하였다. 동시에시행된 백내장수술은유리체절제술에앞서먼저시행하였다. 26 gauge 주사침을이용하여전낭원형절개를시행하고, 수력분리술, 수정 체초음파유화술을시행한후점탄물질로전낭을확보한뒤 10-0 Nylon 으로각막절개창을일시적으로봉합하였다. 이후각막윤 부에서 3.5mm 후방의상비측, 상이측에 23 혹은 25 gauge 공 막천자후유리체내액체유입기, 유리체절제기와눈속조명을 이용하여유리체절제술을시행하였다. 망막앞막을제거하였으며, Indocyanine green 을이용한내경계막제거는일부환자에서 시행하였다. 유리체절제이후일시적으로봉합해놓은각막절개 창을열어인공수정체 (Acrysof IQ [SN60WF; Alcon, Fort Worth, TX, USA], Akreos Adapt[Bausch & Lomb, Rochester, NY, USA], Rayner Superflex 620H[Rayner Intraocular Lenses Limited, Hove, East Sussex, UK], Sensar AR40e [Pharamacia and Upjohn LLC, North Peapack, NJ, USA], CLARE[Cristalens, Lannion, FR], TECNIS ZCB00 [Abbott Medical Optics, Santa Ana, CA, USA]) 를낭내에삽입하였다. 통계프로그램은 SPSS 18.0 (SPSS Inc., Chicago, IL, USA) 을사용하였다. 각각의환자의술후굴절예측이상값에대하여 paired -test t 를이용하여분석하였다. p-value 가 0.05 미만인 경우를통계적으로유의한것으로하였다. 결과 전체연구대상은총 33 명(33 안) 이었고남자는 17 명(51.5%), 여자는 16 명(48.5%) 이었다. 평균연령은 66.33 ± 7.86 세 ( 범위: 52-79 세) 이었다. 33명중당뇨환자는 22 명 (81.8%) 이었으며, 고혈압환자는 11 명 (33.3%) 이었다. 수술전평균최대교정시 력은 logmar 0.57 ± 0.23 였으며, 수술후 3개월째평균최대 교정시력은 logmar 0.08 ± 0.07로통계학적으로유의한시력 호전을보였다 (p <0.001) (Table 1). IOL master 로측정한안축장의길이는 A-scan 으로측정한 안축장의길이보다더길게측정되었다 (23.77 ± 0.95 mm vs 23.58 ± 0.95 mm, p <0.001). A-scan 에의한평균목표굴절 값은 -0.03 ± 0.50D, IOL master 에의한평균목표굴절값은 0.13 ± 0.41D 이었고, 수술후 3개월째현성굴절검사를통해 측정한실제평균굴절값은 -0.49 ± 0.58 D 이었다. 술전중심망막두께는 474.79 ± 53.32 μm였고, 술후 3개월 째에는 379.94 ± 58.17 μm 로유의한황반부두께감소를보였 다 (p <0.001). 술후 3개월째굴절값의평균예측오차는 A-scan 을이용한경우에는 -0.46 ± 0.47D 이며 IOL master 를이용한 경우에는 -0.36 ± 0.44D 으로나타나, A-scan 으로측정한것이 60 Korean Journal of National Health Insurance Service Ilsan Hospital

김주연외. 망막앞막환자백내장병합수술후굴절력예측 유의하게더근시편위를보였다 (p=0.045). 술후 3개월째굴절값 의평균절대예측오차는 A-scan 을이용한경우는 0.53 ± 0.39D, IOL Master 를이용한경우에는 0.47 ± 0.32D 로두검사간유 의한차이는나타나지않았다 (p =0.197) (Table 2). 당뇨혹은고혈압의기왕력은황반부두께감소와유의한상관 관계를보이지않았다 ( 각 p =0.777, 0.334). 전체 33안중 9안 에서 Acrysof IQ, 11안에서 Akreos Adapt, 2안에서 Rayner Superflex 620H, 2안에서 Sensar AR40e, 7안에서 CLARE, 2 안에서 Tecnis ZCB00 렌즈를삽입하였으며, 황반부두께감소 는렌즈종류에따라유의한차이가없었다 (p=0.692). 술후중심망막두께의변화량과굴절값의평균예측오차는 A-scan 의경우에는유의하지는않지만음의상관관계 (r=-0.33; p=0.060) 를나타냈고, IOL master 을이용한경우에는유의한 음의상관관계 (r=-0.36; p=0.037) 를나타냈다 (Fig. 1, Fig. 2). 고찰 본연구에서는특발성망막앞막환자에서유리체절제술과백 내장병합수술을시행하였을때에목표굴절값에비해근시편위 를나타냈으나, IOL master 가 A-scan 보다더적은근시편위가 Table 1. Baseline characteristics of Patients Characteristics Total number of eyes Gender Results 33 eyes (33 patients) Male 17 eyes (51.5%) Female 16 eyes (48.5%) Age 66.38 ± 8.27 Associated systemic disease Diabetes mellitus Hypertension BCVA (logmar) 27 of 33 patients (81.8%) 11 of 33 patients (33.3%) Baseline 0.57 ± 0.23 3 months after surgery 0.08 ± 0.07 Mean axial length measure by A-scan 23.58 ± 0.95 Mean axial length measure by IOL master 23.77 ± 0.95 Mean pre op central macular thickness 474.79 ± 53.32 Mean post op central macular thickness 379.94 ± 58.17 BCVA = best-corrected visual acuity; IOL = intraocular lens. Fig. 1. Correlation between change in central macular thickness and predictive refraction error measured by A-scan. (r=-0.33; p=0.060) Table 2. Mean prediction error (ME) and mean absolute prediction error (MAE). Group ME MAE A-scan After 3 months -0.46 ± 0.47 0.53 ± 0.39 IOL master After 3 months -0.36 ± 0.44 0.47 ± 0.32 P value 0.045 0.197 Values are presented as mean ± SD. IOL = intraocular lens. Fig. 2. Correlation between change in central macular thickness and predictive refraction error measured by IOL master. (r=-0.36; p=0.037) Volume 17 Number 2 December 2018 61

JY Kim et al. IOL power estimation Table 3. Comparison of measurements between A-scan and IOL master A-scan IOL master P Value Axial length, mm 23.58 ± 0.95 23.77 ± 0.95 <0.001 Intended SE, D -0.03 ± 0.50-0.13 ± 0.41 0.045 Mean prediction error(me), D -0.46 ± 0.47-0.36 ± 0.44 0.045 Mean absolute prediction error(mae), D 0.53 ± 0.39 0.47 ± 0.32 0.197 SE = spherical equivalent. 나타나더정확한예측력을나타냈다는점을밝혔다. 또한, IOL master 검사에서술후중심망막두께가더많이감소할수록근시 편위가더심하게나타나는것을확인할수있었다. 최근백내장수술과유리체절제술의수술기구와술기가발전 함에따라여러유리체망막질환에서두수술을동시에시행하는 비율이높아지고있다. 6-8 백내장수술을하는경우에는환자들의 시력향상에대한기대치가높기때문에정확한인공수정체의도 수예측력이중요하다고할수있다. 유리체절제술과백내장병합 수술후에는수술후전방깊이의변화, 안축장길이의변화, 유효 렌즈위치의변화, 유리체의방수로의치환으로인한매질변화 등여러원인에의해예측굴절력의오차가발생하는것으로알려 져있다. 정확한안축장측정이인공수정체도수계산에서중요함은잘 알려져있다. 9,10 A-scan 은각막표면과내경계막사이의길이를 측정하는데반해, IOL master 의경우망막색소상피까지의길이 를측정한다. 따라서만일망막두께를증가시킬수있는망막앞 막및당뇨성황반부종등의황반질환에서는 A-scan 으로측정한 경우안축장이실제보다짧게측정될수있다. 또한, 비접촉식인 IOL master 와는달리 A-scan 에서는접촉에의한각막함입이발 생하여안축장이더짧게측정될수있다. 이전연구에서안축장이 IOL master 에비해 A-scan 으로측정한경우에약 0.1-0.5 mm 짧게측정된다고보고하였다. 11-13 본연구에서도 A-scan 에의한 안축장측정값이 IOL master 에비하여 0.19 mm 더짧게측정 되었다 (p<0.001). Attas-Fox 등 14 은 IOL master 와 A-scan 으 로정상안 23 안, 당뇨성황반부종이있는 23안의안축장을측정 하여비교하였는데, 정상안에서는두기기의측정값간에유의한 차이가없었으나, 황반부종이있는안에서는안축장이 A-scan 에 서는 23.02 ± 0.97 mm (range, 21.53-24.81) IOL master 에서는 23.27 ± 0.924 mm (range, 21.9-25.13) 로측정되어, A-scan 에서안축장이더짧게측정되었다 (p<0.001). 하지만, 망 막두께와두검사기기간의안축장차이간의상관관계는없으며 추후연구가더필요할것이라고말하였다. Ková cs 등 5 은수술 전황반부종이있을때 A-scan 으로측정시짧게측정된안축장 으로인해술후굴절값이목표굴절값에비해근시편위되어나타 난다고하였다. 본연구에서특발성망막앞막에의해발생한황반 부종으로인해술전평균중심망막두께가 474.79 ± 53.32 μm 로두꺼웠으며, 술후굴절값의평균예측오차는 A-scan 과 IOL master 를이용한경우둘다근시편위가나타났고, A-scan 을이 용했을때더유의하게근시편위가많이나타났다 (-0.46 ± 0.47D vs -0.36 ± 0.44D, p=0.045). 이는중심망막두께가두꺼울수록 A-scan 으로측정한실제안축장이측정값에비해길어서, 수술 후인공수정체에의한굴절교정이부족교정되어근시편위가나 타나기에, IOL master 과비교하여더유의하게근시편위가많이 나타났다고설명할수있다. 본연구의제한점으로후향적연구로서적은환자수를대상으 로하였다는점과짧은경과관찰기간을들수있다. 따라서향후 전향적으로보다대규모의연구를통해유리체절제술과백내장병 합수술에서의굴절력이상에대한확인이필요할것이다. 또한본 연구에서는인공수정체도수계산공식으로 SRK-T 만을사용하 였지만, Holladay 나 Hoffer-Q 등의다른공식을사용했을때에 는평균예측오차에다른영향을주었을가능성도있으며, 추후방 수치환으로인한유리체절제술후의매질변화를고려한공식에 대한연구도필요할것이다. 요약하면, 특발성망막앞막환자에서유리체절제술과백내장 병합수술은허용할만한수준의굴절력오차범위내의결과를보 였으며, A-scan 이 IOL master 에비하여근시편위정도가더크 게나타났으며, 술후황반부부종의감소정도가클수록근시편위 가증가하였다. 따라서특발성망막앞막환자의유체절제술과백 내장병합수술에서목표굴절값설정시이러한점을고려하여인 공수정체도수를결정하는것이좋겠다. REFERENCES 1. Melberg NS, Thomas MA. Nuclear sclerotic cataract after vitrectomy in patients younger than 50 years of age. Ophthalmology 1995;102:1466-71. 2. Dugas B, Ouled-Moussa R, Lafontaine PO, Guillaubey A, 62 Korean Journal of National Health Insurance Service Ilsan Hospital

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