대한안과학회지 2015 년제 56 권제 5 호 J Korean Ophthalmol Soc 2015;56(5):672-679 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) http://dx.doi.org/10.3341/jkos.2015.56.5.672 Original Article 국내공여각막과해외공여각막의전층각막이식술후임상결과비교 Comparative Analysis of Clinical Outcome in Penetrating Keratoplasty Using Domestic or Imported Cornea 김동현 1,2 이자영 3 오주연 1,2 최혁진 1,2 김미금 1,2 위원량 1,2 Dong Hyun Kim, MD 1,2, Ja Young Lee, MD 3, Joo Yeon Oh, MD, PhD 1,2, Hyuk Jin Choi, MD, PhD 1,2, Mee Kum Kim, MD, PhD 1,2, Won Ryang Wee, MD, PhD 1,2 서울대학교의과대학안과학교실 1, 서울대학교병원의생명연구원인공안구센터안면역각막재생연구실 2, 순천향대학교의과대학구미병원안과학교실 3 Department of Ophthalmology, Seoul National University College of Medicine 1, Seoul, Korea Laboratory of Ocular Regenerative Medicine and Immunology, Seoul Artificial Eye Center, Seoul National University Hospital Biomedical Research Institute 2, Seoul, Korea Department of Ophthalmology, Soonchunhyang University Gumi Hospital, Soonchunhyang University College of Medicine 3, Gumi, Korea Purpose: To compare the survival of corneal grafts and the changes in endothelial cell density in penetrating keratoplasty using domestic or imported corneas. Methods: Medical records of 236 eyes of 211 patients who underwent penetrating keratoplasty from November 2004 to August 2011 in Seoul National University Hospital and were followedup at least 1 year were retrospectively reviewed. After excluding the patients who received the combined surgeries with other surgeries except cataract surgery, the eyes were divided into 2 groups depending on the origin of donor tissue resulting in a domestic cornea group (108 eyes) and an imported cornea group (128 eyes). Recipient demographics, preoperative diagnosis, donor age, death-to-preservation time, death-to-operation time and pre-and postoperative visual acuities were compared between the 2 groups. Kaplan-Meier survival and changes in endothelial cell density were analyzed at 3, 6 and 12 months and then every year. Results: The most common preoperative diagnoses were regraft and corneal opacity in the domestic and imported cornea groups, respectively, without statistical difference. Death-to-preservation time was 8.9 hours and 8.0 hours in the domestic and imported cornea groups, respectively, without statistical difference. However, death-to-operation time was longer in the imported cornea group (4.98 days) than in the domestic cornea group (2.18 days). There were no differences in pre- and postoperative visual acuities, decrease in annual changes in endothelial densities and survival up to 3 years between the 2 groups. In addition, the survival and decreased annual changes in endothelial densities were not different from each other in penetrating keratoplasty combined with cataract surgery or in penetrating keratoplasty for a corneal edema. Conclusions: Our study results suggest that clinical outcomes of the penetrating keratoplasty using imported corneas are comparable in efficacy when compared with the clinical outcomes using domestic corneas. J Korean Ophthalmol Soc 2015;56(5):672-679 Key Words: Domestic cornea, Endothelial cell density, Imported cornea, Penetrating keratoplasty, Survival Received: 2014. 7. 25. Revised: 2014. 10. 20. Accepted: 2015. 4. 20. Address reprint requests to Mee Kum Kim, MD, PhD Department of Ophthalmology, Seoul National University Hospital, #101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea Tel: 82-2-2072-2665, Fax: 82-2-741-3187 E-mail: kmk9@snu.ac.kr 각막이식은약물로호전되지않는각막혼탁또는내피세포병증으로인한각막부종에표준치료이나, 미국과호주등과는달리한국을포함한아시아권은기증문화의부족으로기증자가적어각막이식대기자가많다. 1 보존액의발달로다른장기와달리각막은단기보존이가능하고, 이에따라 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. 672
- 김동현외 : 국내및해외공여각막전층이식술비교 - 장거리지역운송후에도이식이가능하다. 서울대학교병원안과에서는 1981년각막이식을시행한이래, 국내기증상황에따라각막이식수술건수의증감폭이매우컸는데, 2003년 Northwest Lions Eye Bank ( 현. SightLife) 와 Organ Sharing 의인도적차원에서협약을맺고, 해외공여각막을기증받게되면서이후각막이식수술이매우활발하게되었고 (Supplementary Fig. 1, 2), 이런해외공여각막을이용한각막이식수술의증가는전체국내변화추세와도비슷하였다. 2 해외공여각막은얼음팩을동봉하여냉장상태에서운반하지만항공운송및통관과정에따른다양한주변환경에노출될수있는어려움이있고, 결정적으로기증자사망부터수여자이식까지의시간이지연될수밖에없다. 다양한상업적보존제에공여각막을단기보존할경우 6일까지내피세포의변화는큰차이가없는것으로알려졌으며, 3 최근의대규모연구에의하면해외공여각막은국내공여각막과임상결과에차이가없다는보고도있고, 4 대부분의질환은차이가없었지만각막부종질환이식의생존율에는차이가있다는보고도있어 5 해외공여각막과국내공여각막의유효성이동등한지는아직의견이정립되어있지않다. 국내에서도이를걱정하는연구진에의해해외공여각막의유효성에대한일부연구가진행되었으나 6 연구규모가작아추가연구가필요한상태이다. 본연구진은실제임상에서해외공여각막의유효성을의심하는환자와상담시, 국내자료분석을통한학문적근거를제시할필요를느꼈기에국내공여각막과해외공여각막의전층각막이식술후임상결과비교연구를통해해외공여각막의국내공여각막대비유효성을확인하고자하였다. 대상과방법 본연구는 2004년 11월부터 2011년 8월까지서울대학교병원안과에서전층각막이식술을시행받은환자중 1년이상추적관찰이된환자의의무기록을후향분석하였다. 각막이식을받은환자중해외기증각막의정보가유실되어없거나주기적인내피세포의분석이시행되지않은환자는제외되었고, 각막이식중에후낭파열또는맥락막상강출혈, 유리체강내출혈등의합병증이발생하였거나, 계획적으로녹내장수술, 유리체절제술, 윤부이식술을각막이식과병행한경우의환자는모두제외되었다. 총 211명의환자의 236안이분석대상이되었고, 이중국내공여각막을받은군은 104명 108안이었으며 ( 국내공여각막군 ), 해외공여각막을받은군은 122명 128안이었다 ( 해외공여각막군 ) (Table 1). 각군별성별, 나이, 술전녹내장수술병력, 및수술전후수정체상태는 Table 1에기술하였으며각군간변수별통계적으로유의한차이는없었다. 해외공여각막은 Seattle에위치한 Northwest Lions Eye Bank ( 현. SightLife) 에서기증받았고, 최소내피세포밀도 2,400 cell/mm 2 이상, 기증자사망부터수여자수술시까지의시간 6일이내, 기증자연령 70세이하인조건의각막만공여받았다. 공여각막의상태를각군간비교하였는데, 공여자연령, 기증자사망부터각막채취까지의시간, 기증자사망부터수여자각막이식까지의시간을비교하였다. 내피세포의밀도는국내공여각막의경우초기정보가없어서비교하지않았다. 국내공여각막군과해외공여각막군의각군별각막이식수술전진단과시력, 수술후시력및시간에따른생존율과내피세포의밀도변화를비교하였다. 추가적으로백내장수술동반여부에따른각군간내피세포의밀도변화 Table 1. Demographics of the patients of penetrating keratoplasty using domestic or imported cornea Domestic cornea Imported cornea No. of eyes (patients) 108 (104) 128 (122) Mean age (years, range) 55.7 (17-87) 53.4 (11-84) Sex (M:F) 55:53 78:50 Laterality (R:L) 57:51 58:70 Prior glaucoma surgery (no. of eyes, %) 15 (13.9) 15 (11.7) Preoperative lens status (no. of eyes, %) Phakic 56 (51.8) 82 (64.1) Pseudophakic 38 (35.2) 36 (28.1) Aphakic 14 (13.0) 10 (7.8) Postoperative lens status (no. of eyes, %) Phakic 29 (26.9) 34 (26.6) Pseudophakic 66 (61.1) 81 (63.3) Aphakic 13 (12.0) 13 (10.1) No statistical significance at all variables. R = right eye; L = left eye. 673
- 대한안과학회지 2015 년제 56 권제 5 호 - 및생존율을분석하였고, 각막부종질환군 ( 수포성각막병증 ) 만따로분리하여국내공여각막군과해외공여각막군의내피세포밀도변화및생존율을추가분석하였다. 술후추적관찰기간중발생하는각막이식의생존실패는원인에상관없이치료에도불구하고이식편이비가역적으로혼탁해지는것으로정의하였다. 이식편거부반응은상피혹은내피의이식거부선이나타나거나이전에투명하던각막에부종이생기면서전방염증이나타날때로정의하였으며, 3개월이상의면역억제치료후에도비가역적인경우는생존실패로정의하였다. 카플란마이어생존함수를이용한생존분석을시행함에있어이식편의생존기간은이식술을시행한날부터마지막내원일까지로계산하였고, 생존실패한이식편에대해서는이식한날부터실패의징후가나타난날까지로계산하여각군별생존율을알아보았다. 내피세포의밀도변화는경면내피세포현미경 (Noncon ROBO CA, Konan medical Inc., Hyogo, Japan) 으로측정하였고, 각막이식후 3개월시점부터각군에서 6개월, 1년까 지비교하고, 1년이후에는 1년단위로비교하였다. 통계는 SPSS Statistics version 17.0 (SPSS Inc., Chicago, IL, USA) 을이용하여 independent t-test, chi-square test, Kaplan-Meier survival analysis 및 log rank test 등을시행하였다. 결과 술전진단의빈도를분석하였을때, 국내공여각막군에서는재이식이가장많았고, 다음으로각막혼탁, 각막수포병증순이었으며, 해외공여각막군에서는각막혼탁이가장많았고, 다음으로재이식, 각막수포병증순이었다. 질환의분포는각군간유의한차이가없었다 (Table 2). 공여각막의특성을각군별로분석하여보았을때 (Table 3), 기증자연령은국내공여각막군에서평균연령 46.8세로해외공여각막군의 55.5세에비해유의하게낮았고 (p<0.05, independent t-test), 기증자사망부터각막채취까지의시간은 Table 2. Preoperative diagnosis in the patients of penetrating keratoplasty using domestic or imported cornea Preoperative diagnosis Domestic cornea (no. of eyes, %) Imported cornea (no. of eyes, %) Regrafts 29 (26.9) 26 (20.3) Corneal opacity/scar 25 (23.1) 35 (27.3) Pseudophakic bullous keratopathy 23 (21.3) 25 (19.5) Keratoconus 7 (6.5) 7 (5.5) Herpes simplex keratitis 6 (5.6) 17 (13.3) Others 18 (16.7) 18 (14.1) Total 108 128 No statistical significance at all items. Table 3. Characteristics of the donor cornea Domestic cornea Imported cornea Donor age (years, range) * 46.8 ± 14.9 (13-74) 55.5 ± 11.1 (12-71) Death to preservation time (hours) 8.9 ± 7.7 8.0 ± 3.9 Death to transplant time (hours) * 52.3 ± 24.0 (mean 2.18 days) 119.6 ± 17.6 (mean 4.98 days) Optisol-GS (no. of eyes, %) 108 (100) 128 (100) Moist chamber (no. of eyes, %) 0 (0) 0 (0) Values are presented as mean ± SD unless otherwise indicated. * p < 0.05 by independent t-test. Table 4. Clinical outcome of penetrating keratoplasty using domestic or imported cornea Domestic cornea Imported cornea Preoperative BCVA (log MAR) 1.67 ± 0.33 1.67 ± 0.38 Postoperative BCVA (log MAR) 0.70 ± 0.55 0.67 ± 0.55 Graft failures (no. of eyes, %) Graft rejection 25 (23.1) 29 (22.7) Late endothelial failure 10 (9.3) 3 (2.3) F/U periods (months) * 33.71 ± 18.54 42.30 ± 23.83 Values are presented as mean ± SD unless otherwise indicated. BCVA = best corrected visual acuity; F/U = follow-up. p < 0.05 by independent t-test. 674
- 김동현외 : 국내및해외공여각막전층이식술비교 - Table 5. The percentages of combined cataract surgery in penetrating keratoplasty using domestic or imported cornea Surgeries Domestic cornea (no. of eyes, %) Imported cornea (no. of eyes, %) PKP without combined cataract surgery 71 (65.7) 67 (52.4) PKP with combined cataract surgery 27 (25) 47 (36.7) PKP with stepwise cataract surgery 10 (9.3) 14 (10.9) Total 108 128 No statistical differences between the groups by chi-square test. PKP = penetrating keratoplasty. Log rank test (p = 0.1246) Figure 1. Kaplan-Meier survival in penetrating keratoplasty using domestic cornea (black) or imported cornea (gray). Log rank test (p = 0.2208) Figure 2. Kaplan-Meier survival in penetrating keratoplasty combined with cataract surgery using domestic cornea (black) or imported cornea(gray). 국내공여각막 8.9시간, 해외공여각막 8.0시간으로차이가없었다. 기증자사망부터수여자이식까지의시간은국내공여각막군이평균 2.18일로해외공여각막군의평균 4.98 일에비해유의하게짧았다 (p<0.05, independent t-test). 양군모두 Optisol-GS (Chiron Intraoptics, Irvine, CA, USA) 에보존하였다. 임상성적을비교하여보았을때 (Table 4), 국내공여각막및해외공여각막양군간에술전시력은차이가없었고 (logmar 1.67 ± 0.33 vs. 1.67 ± 0.38), 최종추적관찰시술후양군모두에서시력호전이있었으나군간차이는없었다 (logmar 0.70 ± 0.55 vs. 0.67 ± 0.55). 이식실패는국내공여각막및해외공여각막군에서각각 32.4% 와 25.0% 였고, 거부반응으로인한실패가각각 23.1% 와 22.7%, 말기내피세포부전이각각 9.3% 와 2.3% 였는데, 두군간유의한차이는없었다. 추적관찰기간은국내공여각막군의평균 33.71개월에비해해외공여각막군이평균 42.3개월로유의하게길었다 (p<0.05, independent t-test). 카플란마이어생존함수를이용한생존분석에서전층각막이식후생존율은국내공여각막군 ( 평균생존시간 [mean survival time]; 54.1 ± 3.9개월 ) 과해외공여각막군 ( 평균생존시간 61.5 ± 3.0개월 ) 은통계적인차이가없었다 (p=0.125, log rank test, Fig. 1). 백내장수술은공여편내피세포밀도에영향을줄수있으므로, 양군에서백내장수술을병행한경우와추후백내장수술을추가한경우의분포를살펴보았는데 (Table 5), 백내장수술을병행한경우는국내공여각막군과해외공여각막군이각각 25% 와 36.7%, 각막이식술후백내장수술을추가시행한경우는각각 9.3%, 10.9% 로두군간통계적유의성은없었다. 백내장수술을병행또는추후시행한군을따로분리하여국내공여각막군과해외공여각막군의생존율을비교하였을때, 생존율은국내공여각막군 ( 평균생존시간 58.9 ± 6.3개월 ) 과해외공여각막군 ( 평균생존시간 71.7 ± 4.2개월 ) 이통계적인차이가없었다 (p=0.221,log rank test, Fig. 2). 또한내피세포의밀도변화를각군에서시간별로비교하여보았는데, 전체전층각막이식군과전층각막이식및백내장수술을병행 / 추후시술한아군 (Subgroup) 모두에서국내공여각막군과해외공여각막군사이에통계적인차이는없었다 (Fig. 3). 최근각막부종환자에서해외기증각막의생존율이낮다는일부보고가있어, 각막부종환자군만분리하여추가분석하여보았다. 생존율은국내공여각막군과해외공여각막군은통계적인차이가없었고 (p=0.900, log rank test, Fig. 4A), 연간내피세포의밀도변화도두군간에차이가없 675
- 대한안과학회지 2015 년제 56 권제 5 호 - A B Figure 3. Annual changes of endothelial cell density in total cases of penetrating keratoplasty (A) and in penetrating keratoplasty combined with cataract surgery (B) using domestic cornea (black) or imported cornea (gray). There is no statistical difference between those in all periods. ECD =endothelial cell density. A B Log rank test (p = 0.9003) Figure 4. Kaplan-Meier survival table (A) and annual endothelial cell changes (B) in penetrating keratoplasty for a bullous keratopathy using domestic cornea (black) or imported cornea (gray). There is no statistical difference between those in all periods. ECD =endothelial cell density. 었다 (Fig. 4B). 고찰 본연구로저자들은전층각막이식에서해외공여각막이기증자연령이높고, 기증자사망부터수여자이식까지의시간이많음에도불구하고, 국내공여각막과동등한임상적유효성을보임을확인하였다. 호주의대규모연구 (10,952 cases) 를통한전층각막이식수술후생존율은 1년째 86%, 5년째 73%, 10년에 62% 로최근보고되었고, 7 2001년에보고된국내 275예의연구를통한전층각막이식수술후생존율은 1년째 78%, 5년째 62% 를보고하였다. 8 본교실의전층각막이식수술후생존율은국내공여각막과해외공여각막모두 1년째에는 93% 이나, 5년째에는 48%, 60% 로두군이통계적으로유의하지는않으나, 국내공여각막의생존율이기타보고와차이를보이고있다. 국내공여각막의생존율이더낮게나온것은 술자의경험도차이일가능성이있는데, 해외공여각막군은대부분숙련된각막전문의에의해시행된반면, 국내공여각막군은비숙련된전문의에의해행해진수술이일부포함되면서영향을미쳤을가능성이있다. 술자에의한요소를제거하기위해, 숙련된한명의술자 (K.M.K) 에의해시행된수술만분리하여비교하였을때 (Supplementary Fig. 3), 1년생존율은앞의결과와비슷했고, 5년생존율은국내공여각막 65%, 해외공여각막 60% 로차이가없었고, 기존의보고와도유사함을확인하였다. 호주의보고와 5년생존율이약간의차이를보이고있는데, 술전질환의분포에차이가있을가능성이있다. 호주의보고는술전질환의분포를제시하지않았다. 본연구의환자들의분포는두군모두에서 20-25% 의환자가재이식이었기때문에다시거부반응이발생할만한고위험군이많이포함되어있어 5년생존율에영향을미쳤을가능성이있다. 해외공여각막을기증받게될경우에일반적으로유효성, 안전성에대해모두우려할수있다. 대부분의안은행이준 676
- 김동현외 : 국내및해외공여각막전층이식술비교 - 수하고있는유럽안은행연합 (European Eye Bank Association) 가이드라인에서조사한바에의하면, 공여각막의보관은안은행마다, 보관용액의종류에따라약간의차이가있으나상업화된보존액을사용하는경우는평균적으로 5.7일 (2.6-12일 ) 보관해사용하고있으며, 9 상업적보존제에공여각막을단기보존할경우 6일까지내피세포의변화는큰차이가없다는것이일반적이다. 3 이에근거해본교실은 6 일이내해외공여각막만기증을받았다. 보존기간뿐아니라보존환경도중요한데, 일부동물실험결과는일정한진동에노출되면내피세포가손상됨을보고하였다. 10 해외공여각막은이러한진동에의한손상을줄이기위해, 팩키지를콤팩트하게해서운송이되고있다. 그럼에도불구하고운송과정중의움직임에의한손상가능성을포함하여, 시간지연에따른변화를우려한국내연구진이시행한미국에서운송된해외공여각막내피세포의밀도변화를보면, 실제안은행에서운송전에검수한세포밀도보다국내에도착하였을때에는 9.18% 감소되어있다고보고하였다 ( 평균 2,828.00 cells/mm 2 vs. 2,569.06 cells/mm 2 ). 11 그러나감소된내피세포밀도도실제로는이식가능한기준안에포함되는수치이기때문에, 임상적으로는큰문제가되지않는다고판단되며, 이는본연구의임상결과가잘뒷받침하고있다고생각한다. 또한본교실의해외공여각막안은행에서제공된평균내피세포밀도는 3,004 ± 331 cells/mm 2 로약 9% 감소한다고고려해도임상적으로공여각막으로사용가능한범위내에있음을알수있다. 또다른연구인 Pre-cut 해외공여각막에서내피세포밀도의변화는사망부터수술까지의시간이평균 5.64일인조직에서약 5.68% 를보였다. 12 따라서내피세포의소실이 6-9% 에서발생한다는전제하에, 해외공여각막안은행측정내피세포밀도를선별하여선정하면사망부터수술까지의시간이 6일이내에서는임상적으로문제가없다고판단된다. 또한안전성에대한우려로국내연구진이해외공여각막에서미생물학적검사를시행하여낮은빈도이지만오염가능성을보고하였다. 13 본교실에서각막이식직후안내염이발생한사례가 2예있었는데 (unpublished data), 모두국내공여각막을기증받은환자에서만발생하였다. 따라서해외공여각막은임상적으로감염가능성이높지않다고판단하였다. 초창기에는해외공여각막이이송전에비해이송후유의한내피세포밀도감소가있다고보고되었다. 14 최근보존기술의발달로상황은개선되었고, 대규모로해외공여각막의임상적유효성을연구한아시아권논문이두편있는데, 일본에서나온연구는해외공여각막과국내공여각막의생존율이차이가없었으며, 4 이는본결과와일치한다. 이연구는공여각막의보존부터수술까지의시간이 139시 간 (5.79일) 으로본연구와유사하였다. 이에반해, 사우디아라비아에서발표된연구는다른질환은생존율이차이가없었으나, 각막부종질환의경우 5년생존율이 39% 로다른질환에비해생존율저하를보였는데, 이연구는공여각막의보존부터수술까지의시간이 213 시간 (8.87일) 으로길었고, 국내공여각막과의비교연구는아니었다. 본연구에서는각막부종질환에서의해외공여각막과국내공여각막의생존율은차이가없었으나, 전체생존율보다는낮은경향을보였고, 이는기존의보고와비슷하다. 15 따라서해외공여각막에의한요인보다는수여자질환자체에따른, 주변부내피세포의상태도건강하지못한경우각막부종질환의생존율자체에더중요한것으로파악된다. 본연구에서국내공여각막군 ( 평균 46.8세 ) 과해외공여각막군 ( 평균 55.5세 ) 의기증자연령차이가있었는데, 이는전체생존율에영향을미치지않았다. 연령이일반적으로는시간에따른내피세포의밀도변화또는생존율에영향을미친다고알려져있으나, 60세이전은차이가없고 60세이후가차이를보이는것으로알려져있다. 5,15 한편, 국내연구진에의한해외공여각막의연령분포와내피세포밀도변화의상관관계에서는차이가없는것으로나타났고, 16 최근대규모연구에서기증자연령 65세전후의 10년전층각막이식생존율을분석한결과차이가없는것으로알려져서 (31-65세: 77%, 66-75세 : 71%) 17 이결과를종합하여볼때, 70세이하의기증자연령해외각막을공여받는것은사망-수술까지의시간이 7일이내에서는임상적으로문제가없다고생각된다. 결론적으로, 저자들은기증자사망부터수여자수술까지 6 일이내, 공급안은행측정내피세포밀도가 2,400 cell/mm 2 이상의해외공여각막이전층각막이식에사용될경우국내공여각막과동등한임상적유효성을보임을확인하였다. REFERENCES 1) Hara H, Cooper DK. Xenotransplantation-the future of corneal transplantation? Cornea 2011;30:371-8. 2) Cho EY, Kim MS. Penetrating keratoplasty before and after establishment of Korean network for organ sharing. J Korean Ophthalmol Soc 2006;47:525-30. 3) Halberstadt M, Athmann S, Winter R, Hagenah M. Impact of transportation on short-term preserved corneas preserved in Optisol-GS, Likorol, Likorol-DX, and MK-medium. Cornea 2000;19:788-91. 4) Shimazaki J, Shinozaki N, Shimmura S, et al. Efficacy and safety of international donor sharing: a single-center, case-controlled study on corneal transplantation. Transplantation 2004;78:216-20. 5) Wagoner MD, Gonnah el-s, Al-Towerki AE; King Khaled Eye Specialist Hospital Cornea Transplant Study Group. Outcome of primary adult optical penetrating keratoplasty with imported donor 677
- 대한안과학회지 2015 년제 56 권제 5 호 - corneas. Int Ophthalmol 2010;30:127-36. 6) Park SH, Kim JH, Joo CK. The clinical evaluations of the penetrating keratoplasty with imported donor corneas. J Korean Ophthalmol Soc 2005;46:28-34. 7) Williams KA, Esterman AJ, Bartlett C, et al. How effective is penetrating corneal transplantation? Factors influencing long-term outcome in multivariate analysis. Transplantation 2006;81:896-901. 8) Ha D, Kim CK, Lee SE, et al. Penetrating keratoplasty results in 275 cases. J Korean Ophthalmol Soc 2001;42:20-9. 9) European Eye Bank Association. Technical guidelines for ocular tissue. 2013. Available at: http://www.europeaneyebanks.org/files/ Technical_Guidelines_Rev6_Feb2013.pdf. 10) Wang IJ, Hu FR. Effect of shaking of corneal endothelial preservation. Curr Eye Res 1997;16:1111-8. 11) Lee K, Hwang KY, Kim MS. Influence of endothelial cell loss during preservation on graft survival in imported donor cornea. J Korean Ophthalmol Soc 2013;54:862-8. 12) Yamazoe K, Yamazoe K, Shinozaki N, Shimazaki J. Influence of the precutting and overseas transportation of corneal grafts for Descemet stripping automated endothelial keratoplasty on donor endothelial cell loss. Cornea 2013;32:741-4. 13) Na YS, Woo SW, Kang JH, Joo MJ. Microbiologic study of imported donor corneas and preserved solutions. J Korean Ophthalmol Soc 2005;46:1974-7. 14) Hu FR, Tsai AC, Wang IJ, Chang SW. Outcomes of penetrating keratoplasty with imported donor corneas. Cornea 1999;18:182-7. 15) Armitage WJ, Jones MN, Zambrano I, et al. The suitability of corneas stored by organ culture for penetrating keratoplasty and influence of donor and recipient factors on 5-year graft survival. Invest Ophthalmol Vis Sci 2014;55:784-91. 16) Kong SJ, Cho K, Kim MS. Analysis of factors affecting the decrease of endothelial cell density in imported donor corneas. J Korean Ophthalmol Soc 2012;53:20-6. 17) Writing Committee for the Cornea Donor Study Research Group, Mannis MJ, Holland EJ, et al. The effect of donor age on penetrating keratoplasty for endothelial disease: graft survival after 10 years in the Cornea Donor Study. Ophthalmology 2013;120:2419-27. Supplementary Figure 1. Annual report of the keratoplasty in Department of Ophthalmology in Seoul National University Hospital from 1981 to 2011. Supplementary Figure 2. Annual report of the keratoplasty using domestic or imported cornea in department of Ophthalmology in Seoul National University Hospital from 2003 to 2011. A B Log rank test (p = 0.7536) Supplementary Figure 3. Kaplan-Meier survival table (A) and annual endothelial cell changes (B) in penetrating keratoplasty performed by one experienced surgeon (K.M.K) using domestic cornea (black) or imported cornea (gray). There is no statistical difference between those in all periods. ECD = endothelial cell density. 678
- 김동현외 : 국내및해외공여각막전층이식술비교 - = 국문초록 = 국내공여각막과해외공여각막의전층각막이식술후임상결과비교 목적 : 국내공여각막과해외공여각막을이용한전층각막이식술후생존율및각막내피세포밀도변화를비교해보고자하였다. 대상과방법 : 서울대학교병원에서 2004 년 11 월부터 2011 년 8 월까지전층각막이식술을시행받은환자중백내장제거술이외의다른수술이병행된경우를제외하고최소 1 년간경과관찰이가능하였던 211 명 236 안을대상으로국내공여각막군 (108 안 ) 과해외공여각막군 (128 안 ) 으로나누어의무기록을후향적으로분석하였다. 각그룹간나이, 성별, 수술전진단명, 기증자연령, 공여자사망부터각막이식편보존시간과공여자사망부터이식시간, 수술전후교정시력, 수술후 3, 6, 12 개월째, 이후 1 년단위마다각막내피세포밀도감소율및생존율등을비교분석하였다. 결과 : 수술전진단명으로국내각막군에서는재이식, 수입각막군에서는각막혼탁이가장많았으나통계적차이는없었다. 각막이식편보존까지는국내각막군에서 8.9 시간, 수입각막군에서 8.0 시간으로유의한차이가없었으나, 이식까지는국내각막군에서 2.18 일, 수입각막군에서 4.98 일로통계적으로유의하게수입각막군에서길었다. 수술전후교정시력과, 각막내피세포감소율은 3 년까지모든시간대에서두군간유의한차이가없었으며, 생존율도백내장수술동반유무또는각막부종질환과는상관없이유의한차이가없었다. 결론 : 본결과는해외공여각막을이용한전층각막이식술후임상결과가국내공여각막을이용한전층각막이식술과동등한유효성을보임을시사한다. < 대한안과학회지 2015;56(5):672-679>. 679