대한안과학회지 2017 년제 58 권제 5 호 J Korean Ophthalmol Soc 2017;58(5):539-545 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2017.58.5.539 Original Article 성공적인펨토초레이저백내장수술을위한수술중합병증위험인자분석 Possible Risk Factors Affecting Successful Femtosecond Laser-assisted Cataract Surgery 양헌 한상엽 이경헌 Heon Yang, MD, Sang Youp Han, MD, Kyung Heon Lee, MD 성모안과병원 Sungmo Eye Hospital, Busan, Korea Purpose: To determine the risk factors of intraoperative complications in femtosecond laser-assisted cataract surgery. Methods: This study included 598 eyes of 337 patients who underwent femtosecond laser-assisted cataract surgery (FLACS) between July, 2012 and January, 2017. All eyes had corneal incisions, anterior capsulotomy, nuclear fragmentation, and limbal relaxing incisions (if required). Intraoperative complications were analyzed by watching videos, and the related factors of each complication were retrospectively reviewed alongside the medical records. Results: The mean age of the patients was 62.1 ± 11.9 years. Among the study group, 18 eyes required manual creation of corneal incisions; because the corneal incisions could not be made due to corneal central opacity, corneal peripheral degeneration, ptreygium, conjunctival chalasis, or idiopathic. The anterior capsulotomy was incomplete in 43 cases and manual capsulorrhexis was required for completion. These cases were associated with various conditions, including hypermature cataract, anterior polar or subcapsular cataract, corneal central opacity, pupillary abnormality, lens subluxation, poor pupil dilation, and idiopathic. Overall, 22 eyes had difficulties with nuclear fragmentation, with either mature cataract, lens subluxation, corneal central opacity, anterior polar or subcapsular cataract, or pupillary abnormality. Using the Laser SoftFit patient interface decreased the incidences of incomplete corneal incision (from 3.56% to 2.24%, p = 0.367), anterior capsulotomy (from 9.31% to 4.03%, p < 0.05), and nuclear fragmentation (from 5.20% to 1.34%, p < 0.05). The incidences of complications in the experienced group was statistically lower compared with the novice group (p < 0.05 for all comparisons). Conclusions: The femtosecond laser platform was effective and safe for cataract surgery. However, in the presence of related factors, use of this platform might need to be re-assessed and should be considered for intraoperative complications. Additionally, with the Laser SoftFit patient interface and improved surgeon experience, better intraoperative results can be expected for FLACS surgery. J Korean Ophthalmol Soc 2017;58(5):539-545 Keywords: Anterior capsulotomy, Corneal incision, Femtosecond cataract surgery, Nuclear fragmentation, Related factors 1970년대백내장수술에레이저가사용된이래로레이저는안과의사에게중요한도구로인식되어왔다. 1 2001년에 Received: 2017. 1. 12. Revised: 2017. 3. 29. Accepted: 2017. 4. 25. Address reprint requests to Sang Youp Han, MD Sungmo Eye Hospital, #409 Haeun-daero, Haeundae-gu, Busan 48064, Korea Tel: 82-51-743-0775, Fax: 82-51-743-0776 E-mail: medicalhan@daum.net 는펨토초레이저가안과영역에소개되어라식수술의절편을만들기위해서사용되었으며, 2,3 2009년에는백내장수술에펨토초레이저가도입되어각막절개와수정체전낭절개, 수정체분할에이용되고있다. 4-7 펨토초레이저를이용한백내장수술의장점은고식적백내장수술보다정확한절개와일정한힘을사용하므로수술의정밀도를높일수있으며, 8-10 수정체핵분할술시수술시간과에너지를감소시킬수있다. 11-13 또한펨토초레이저를이용한수정체전낭절개시술후인공수정체의중심이 c2017 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. 539
- 대한안과학회지 2017 년제 58 권제 5 호 - 탈이적고 14, 고식적백내장수술과비교하여측정된수차값이낮고시력의질이뛰어나며 15, 내피세포의손상과전방의염증반응이적고창상치유가빨라안내염의예방효과도있다고알려져있다. 16-19 2009년이후해외의여러연구에서보고된바에따르면펨토초레이저를이용한백내장수술은안전성이높고고식적백내장수술에비해합병증발생률이비슷하거나적은것으로알려졌으나, 20-23 국내에서는아직이와관련된보고가없다. 이에저자들은본연구에서펨토초레이저를이용한각막절개, 수정체낭원형절개, 수정체분할시의합병증의발생률을조사하였고, 각합병증에관련된위험인자에대한보고가없는점에착안하여그와관련된위험인자가무엇인지의무기록을통해후향적으로분석해보았다. 펨토초레이저백내장수술시사용되는인터페이스는펨토초레이저의기종에따라접촉과비접촉방식이있으며, 본연구에서사용된접촉방식의인터페이스는작은직경을가지고있어적은용적을가진안와에적합한장점이있으나, 안압상승과결막하출혈, 각막주름등의문제가자주발생하는단점이있었다. 24 이러한기존의 direct한인터페이스와비교하여흡착시각막에압박을최소화시켜안압상승을줄이고시술중합병증을감소시키는것으로알려진 24 SoftFit TM 인터페이스 (Fig. 1) 의합병증발생률에대해서는국내에서보고된바가없어 SoftFit TM 인터페이스전후의합병증발생률을비교해보았으며, 시술하는술자의숙련도가수술결과에영향을미칠것으로생각되어펨토초레이저시행초기 200안과후기 398안을두그룹으로나누어각그룹간의합병증발생률을비교하였다. 대상과방법 2012년 7월부터 2017년 1월까지 1명의술자에의해펨토초레이저를이용하여백내장수술을시행받은 337명 598 안을대상으로하였다. 펨토초레이저를이용한백내장수술은 LenSx (Alcon LenSx, Fort Worth, TX, USA) 를이용하였으며투명각막절개, 수정체전낭절개, 수정체분할단계에서사용되었고수정체분할패턴은격자방식을채택하였으며, 필요시윤부이완절개술을추가하였다. 투명각막절개창길이는 2.2 mm, 수정체전낭절개직경은 5.0 mm, 수정체분할시직경길이는 5.2 mm로설정하였다. 모든수술은 0.5% proparacaine hydrochlorid로점안마취후시행하였다. 펨토초레이저시술시환자인터페이스를각막에흡착시킨다음시행하였고, 공기방울의존재로인한흡착실패시인터페이스를완전히분리한후재시도하여시행하였다. 수정체전낭절개는산동된동공중심으로설정하였다. 펨토초레이저를이용하여투명각막절개, 수정체전낭절개, 수정체분할이이루어진이후절개부위를 blunt spatula 로확인하였고, 불완전한각막절개시각막절개도를이용하여추가시술하였으며, 불완전한수정체전낭절개의경우낭집게를이용하여수정체낭의방사상파열없이전낭절개가불완전한부분을조심스럽게제거하였다. 수정체분할이불완전한경우 prechopper를이용하여재분할하였다. 수정체유화술과잔여수정체피질의흡인은 Infinity (Alcon Laboratories Inc., Fort Worth, TX, USA) 를이용하여시행하였으며, 점탄물질로전방을채우고인공수정체를삽입한다음관류흡인으로점탄물질을제거하고기질수화로창상을폐쇄하였다. 술후 2개월간항생제, 스테로이드제제, 비스테로이드성항염증제제를점안하였다수술중발생한합병증은녹화된영상을단일관찰자를통 Figure 1. Advantages of SoftFit TM patient interface. In contrast to solid direct patient interface, the design of the new hydrogel SoftFit interface (white arrow) has an extended suction ring skirt that allows the natural curvature of the cornea and delivers a gentle, secure fit with minimal corneal distortion. With the soft contact lens in place, the intraocular pressure remains much lower during the procedure and corneal compression and corneal folds are minimized. 540
- 양헌외 : 펨토초레이저백내장합병증의위험인자 - 해확인하였으며, 합병증에해당하는환자들의의무기록을후향적으로확인하여관련인자를분석하였다. 위의연구는성모안과병원기관윤리심의위원회의승인 (2017-BM-01-1) 후진행되었다. 2014년 4월에도입된 SoftFit 인터페이스사용전후의각합병증의발생률을비교하고유의한차이가있는지검정을통해비교하였다. 비교를위하여 Pearson Chi-square test 를시행하였고, 통계적인분석은 SPSS v22.0 for Windows (SPSS Inc., Chicago, IL, USA) 를사용하였다. p값이 0.05 미만일경우통계적으로유의한차이가있다고분석하였다. 결 과 총 337명중남자가 151명, 여자가 186명이었고평균나이는 62.1 ± 11.9세였으며, 수술받은 598안중우안이 317 Table 1. Baseline demographic characteristics of all patients Characteristic Value Number of eyes (patients) 598 (337) Age (years) 62.1 ± 11.9 (24 83) Sex (male:female) 151:186 Eyes (right:left) 317:281 SoftFit interface (pre:post) 365:233 Values are presented as mean ± SD (range) or n (%) unless otherwise indicated. Table 2. List of intraoperative complications encountered in femtosecond laser cataract surgery cases (N = 598) Intraoperative complication Number of eyes Incomplete corneal incision 18 (3.01) Incomplete capsulotomy 43 (7.19) Incomplete nucleus fragmentation 22 (3.67) Values are presented as n (%). Iris hemorrhage, endothelial incision, posterior capsule rupture, nucleus dislocation were not observed. 안, 좌안이 281안, SoftFit 인터페이스사용전이 365안, 사용후가 233안이었다 (Table 1). 녹화된비디오를확인한결과펨토초레이저수술시불완전한투명각막절개가 18안 (3.01%), 수정체전낭절개가 43안 (7.19%), 수정체분할이 22 안 (3.67%) 으로나타났다 (Table 2). 수술중합병증이일어난환자의의무기록에서관련인자를후향적으로조사한결과불완전한투명각막절개의경우전체 18안중선천적원인또는과거감염, 외상등으로인한각막중심부혼탁이 7안, 노인환이나테리엔각막가장자리변성, 잘쯔만결절변성등의각막주변부변성이 3안, 익상편이 2안, 결막이완이 1안, 특별한원인이없는특발성이 5안있었다. 불완전한수정체전낭절개의경우전체 43안중관련인자로팽대백내장이나모르가니백내장등의과숙백내장이 17안, 전극혹은전낭하백내장이 7안, 각막중심부혼탁이 5안, 동공막잔존이나동공편위등의동공형태비정상이 3안, 섬모체소대약화로인한수정체떨림이나수정체탈구가 3안, 당뇨나거짓비늘증후군으로인한산동불량이 1안, 특별한원인이없는경우가 7안있었다. 불완전한수정체분할의경우전체 22안중관련인자로과숙백내장이 13안, 수정체떨림이나수정체이탈이 3안, 각막중심부혼탁이 3안, 전극혹은전낭하백내장이 2안, 비정상적인동공이 1안있었다. 모든합병증과관련된위험인자를발생빈도순으로정리해보면과숙백내장이 30안, 중심성각막혼탁이 15안, 특발성이 12안, 전극혹은전낭하백내장이 9안, 수정체탈구가 6안, 동공형태비정상이 4안, 각막주변부변성이 3안, 익상편이 2안, 결막이완과산동불량이각각 1안있었다 (Table 3). 펨토초레이저시술시홍채의출혈, 불필요한각막절개및후낭파열이나수정체이탈은발생하지않았다. SoftFit 인터페이스사용전후의합병증발생률을비교해보면, 사용전 365안과사용후 233안을대상으로조 Table 3. Risk factors of intraoperative complications (n = 598) Risk factor Incomplete corneal Incomplete Incomplete nucleus incision capsulotomy fragmentation Total Corneal central opacity 7 (1.17) 5 (0.84) 3 (0.50) 15 (2.51) Corneal peripehreal degeneration 3 (0.50) 0 (0) 0 (0) 3 (0.50) Pterygium 2 (0.33) 0 (0) 0 (0) 2 (0.33) Conjunctival chalasis 1 (0.17) 0 (0) 0 (0) 1 (0.17) Mature cataract 0 (0) 17 (2.84) 13 (2.17) 30 (5.01) Anterior polar or subcapsular cataract 0 (0) 7 (1.17) 2 (0.33) 9 (1.50) Pupillary abnormality 0 (0) 3 (0.50) 1 (0.17) 4 (0.67) Lens subluxation 0 (0) 3 (0.50) 3 (0.50) 6 (1.00) Poor pupil dilation 0 (0) 1 (0.17) 0 (0) 1 (0.17) Idiopathic 5 (0.84) 7 (1.17) 0 (0) 12 (2.01) Total 18 (3.01) 43 (7.19) 22 (3.67) 83 (13.87) Values are presented as n (%). 541
- 대한안과학회지 2017 년제 58 권제 5 호 - Table 4. Intraoperative complications rate before and after SoftFit interface Intraoperative complication Pre-SoftFit interface Post-SoftFit interface (n = 365) (n = 223) p-value Incomplete corneal incision 13 (3.56) 5 (2.24) 0.367 Incomplete capsulotomy 34 (9.31) 9 (4.03) 0.017 * Incomplete nucleus fragmentation 19 (5.20) 3 (1.34) 0.017 * Values are presented as n (%) unless otherwise indicated. * p-value < 0.05 between groups using Pearson Chi-square test. Table 5. Comparison of intraoperative complications between novice group (200 cases) and experienced group (398 cases) Intraoperative complication Novice group (n = 200) Experienced group (n = 398) p-value Incomplete corneal incision 11 (5.50) 7 (1.75) 0.012 * Incomplete capsulotomy 25 (12.50) 18 (4.52) <0.001 * Incomplete nucleus fragmentation 16 (8.00) 6 (1.50) <0.001 * Values are presented as n (%) unless otherwise indicated. * p-value < 0.05 between groups using Pearson Chi-square test. 사한결과불완전한투명각막절개의경우사용전 13안 (3.56%) 에서사용후 5안 (2.24%), 불완전한수정체전낭절개의경우사용전 34안 (9.31%) 에서사용후 9안 (4.03%), 불완전한수정체분할의경우사용전 19안 (5.20%) 에서사용후 3안 (1.34%) 으로 SoftFit 인터페이스사용후모든합병증의발생률이감소한것을알수있었다 (Table 4). 술자의숙련도에따른수술의결과를비교하기위하여펨토초레이저수술초기 200안과후기 398안에서발생한합병증을살펴보면, 불완전한투명각막절개는초기 11안 (5.50%) 에서후기 7안 (1.75%), 불완전한수정체전낭절개는초기 25안 (12.50%) 에서후기 18안 (4.52%), 불완전한수정체분할은초기 16안 (8.00%) 에서후기 6안 (1.50%) 으로술자의경험이증가할수록합병증이감소하는것을확인하였다 (Table 5). 고찰 2009년부터백내장수술에도입된펨토초레이저백내장수술은고식적백내장수술법에비하여시술의결과와안전성이우수하다고알려져있다. 20-23 수술중발생한합병증발생률에대한보고는 Roberts et al 21 이 1,500안을대상으로조사한불완전한투명각막절개가 51안 (3.40%), Chee et al 25 이 1,105안을대상으로조사한불완전한수정체전낭절개 97안 (8.78%) 및불완전한수정체분할 52안 (4.71%) 이보고되었으며, 발생빈도는불완전한수정체전낭절개가가장많고불완전한수정체분할, 투명각막절개순으로나타났다. 국내의경우 2012년부터펨토초레이저백내장수술이백내장수술에도입되어사용되고있으나, 아직까지국내에서펨토초레이저백내장수술중발생한합병증에대하여보고된바는없었다. 본연구에서 1,129안을대상으로조사한 결과는불완전한수정체전낭절개 85안 (7.53%), 불완전한수정체분할 36안 (3.19%), 불완전한투명각막절개가 33안 (2.92%) 으로이전연구에서보고한수술중합병증과발생빈도순이일치하나, 각각의발생률은 Roberts et al 21 이나 Chee et al 25 이보고한합병증의비율보다감소되어있는것으로나타났다. 합병증의비율이감소한이유는기존의연구에서사용하지않았던 SoftFit 인터페이스를본연구에서 2014년 4월부터도입하여시술하였기때문으로생각된다. SoftFit 인터페이스는기존의단단한고체형태의 direct 인터페이스에비하여상대적으로부드러운하이드로젤소재를사용하고흡착고리의주변부길이를연장하여보다자연스럽게각막흡착을가능하게하며, 각막표면의압박을최소화시켜안구내안압의상승을낮추고각막의주름을줄임으로써펨토초레이저가목표점에보다정확히도달하게하는효과를가지고있다. 24 Asena and Kaskaloglu 24 가 100안을대상으로발표한보고에따르면 SoftFit 인터페이스사용전 50안과사용후 50안의합병증발생률은불완전한각막절개의경우사용전 10% 에서사용후 2%, 불완전한수정체전낭절개의경우사용전 12% 에서사용후 0%, 불완전한수정체분할의경우사용전 10% 에서사용후 4% 로모두감소하였다. 본연구에서도발생률의차이는있으나불완전한투명각막절개, 불완전한수정체전낭절개, 불완전한수정체분할등모든시술에서 SoftFit 인터페이스사용후합병증이감소한결과를보였으며, 불완전한수정체전낭절개와불완전한수정체분할의발생률은 SoftFit 인터페이스사용전후군간에유의한차이가있음을알수있었다 (Table 4, Fig. 2). 반면불완전한각막절개발생률은유의미한감소를보이지않았는데이는 Asena and Kaskaloglu 24 가분석한바와같이인터페이스를이용하여각막흡착시나타나는각막후면의주름은각막절개에필요한펨토초레 542
- 양헌외 : 펨토초레이저백내장합병증의위험인자 - Figure 2. Rates of intraoperative complications before and after SoftFit TM interface. Comparison (%) of incomplete corneal incision, incomplete capsulotomy, incomplete nucleus fragmentation between femtosecond laser refractive cataract surgery with a direct contact interface (Pre-SoftFit ) and SoftFit interface (Post-SoftFit ). * p-value<0.05 between groups using Pearson Chi-square test. Figure 3. Rates of intraoperative complications between novice group and experienced group. Comparison (%) of incomplete corneal incision, incomplete capsulotomy, incomplete nucleus fragmentation between novice group (200 cases) and experienced group (398 cases). * p-value < 0.05 between groups using Pearson Chi-square test. 이저의에너지가각막기질에도달하는데영향을주지않으며, 따라서기존인터페이스보다각막후면주름이적게발생하는 SoftFit 인터페이스를사용하여도두군간의불완전한각막절개의발생에는차이가없을것으로추정된다. 또한펨토초레이저시술시술자의숙련도와합병증의연관성을확인하기위하여수술초기 200안과후기 398안으로나누어합병증발생률을비교한결과, 불완전한투명각막절개, 불완전한수정체전낭절개, 불완전한수정체분할모두초기보다후기 398안의합병증발생률이유의하게낮음을확인할수있었다 (Table 5, Fig. 3). 따라서 Bali et al 26 이보고한바와같이술자의숙련도가증가할수록수술중합병증발생은감소할것으로생각된다. 수술중발생한합병증의위험인자를발생빈도가높은순으로살펴보면불완전한투명각막절개의경우각막중심부혼탁 (1.17%), 특발성 (0.84%), 각막주변부변성 (0.50%), 익상편 (0.33%), 결막이완 (0.17%) 순이었다. 특발성을제외하고는각막혼탁이나각막주변부의변성과관련된각막병변 (1.67%) 이불완전한투명각막절개와가장많은연관성이있음을알수있었으며, 이는투명각막절개시펨토초레이저가전달되는과정에서각막의병변으로인하여조직에도달하는에너지에상실이일어났기때문인것으로추측된다. 익상편과결막이완이있는경우는인터페이스를이용하여흡입하는과정에서계측값과의오차가발생할수있을것으로보인다. 불완전한수정체전낭절개의경우관련인자는과숙백내장 (2.84%), 특발성 (1.17%), 전극혹은전낭하백내장 (1.17%), 각막중심부혼탁 (0.84%), 동공형태비정상 (0.50%), 수정체탈구 (0.50%), 당뇨나거짓비늘증후군으로인한산동불량 (0.17%) 순이었으며, 불완전한수정체분할의경우과숙백내장 (2.17%), 각막중심부혼탁 (0.50%), 수정체이탈 (0.50%), 전극혹은전낭하백내장 (0.33%), 비정상적인동공 (0.17%) 순으로나타났다. 과숙백내장이나전극혹은전낭하백내장의경우수정체전낭절개나수정체분할시펨토초레이저의에너지가일반백내장시술보다더많은에너지가필요했을가능성이있으며, 동공형태의비정상이나산동불량, 수정체의탈구등은수정체전낭절개나수정체분할시해당시술부위를동공중심으로판단하므로펨토초레이저의정확성이낮을가능성이있다. 각막중심부에혼탁이있는경우는시술부위에도달하는에너지가부족했을것으로판단된다. 전체적으로수술중합병증과관련된위험인자는과숙백내장 (5.01%), 중심성각막혼탁 (2.51%), 특발성 (2.01%), 전극혹은전낭하백내장 (1.50%), 수정체탈구 (1.00%), 동공형태의비정상 (0.67%), 각막주변부변성 (0.50%), 익상편 (0.33%), 결막이완 (0.17%) 과산동불량 (0.17%) 순으로조사되었다 (Table 3). 이는펨토초레이저를이용한백내장수술시술전검사에서해당위험인자가관찰되는경우관련된불완전한시술의가능성을인지하고조심스럽게접근해야하며, 특별한원인을찾을수없는특발성인경우도세번째로많은비율을차지하고있으므로술전검사시관련위험인자가없고펨토초레이저시술시수술시야상에서합병증이관찰되지않더라도수동적투명각막절개및연속곡선수정체낭원형절개, 수정체분할등추가적인시술의필요성을염두에두고수술에임해야할것으로사료된다. 543
- 대한안과학회지 2017 년제 58 권제 5 호 - 결론적으로저자들은펨토초레이저를이용한백내장수술이기존의고식적백내장수술에서발생하는수술중합병증을완벽히해결해주지는않으나, 술전검사에서합병증과관련된인자가관찰된경우에해당합병증에유의하여시술한다면백내장수술의성공률을향상시킬수있는안전하고효율적인백내장수술법이라고생각하며, 각막흡착시기존의 direct한인터페이스보다 SoftFit 인터페이스를사용하고, 술자의숙련도가높아질수록펨토초레이저백내장수술중합병증의발생을더욱감소시킬수있을것으로기대하는바이다. REFERENCES 1) Krasnov MM. Laser-phakopuncture in the treatment of soft cataracts. Br J Ophthalmol 1975;59:96-8. 2) Ratkay-Traub I, Juhasz T, Horvath C, et al. Ultra-short pulse (femtosecond) laser surgery: initial use in LASIK flap creation. Ophthalmol Clin North Am 2001;14:347-55. viii-ix. 3) Sugar A. Ultrafast (femtosecond) laser refractive surgery. Curr Opin Ophthalmol 2002;13:246-9. 4) Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009;25:1053-60. 5) Masket S, Sarayba M, Ignacio T, Fram N. Femtosecond laser-assisted cataract incisions: architectural stability and reproducibility. J Cataract Refract Surg 2010;36:1048-9. 6) Chang JS, Chen IN, Chan WM, et al. Initial evaluation of a femtosecond laser system in cataract surgery. J Cataract Refract Surg 2014;40:29-36. 7) Park JH, Lee KH, Lee DJ. Comparison of continuous curvilinear capsulorhexis parameters between femtosecond laser and conventional cataract surgery. J Korean Ophthalmol Soc 2014;55:1800-7. 8) Kránitz K, Takacs A, Miháltz K, et al. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg 2011;27:558-63. 9) Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011;37:1189-98. 10) Auffarth GU, Reddy KP, Ritter R, et al. Comparison of the maximum applicable stretch force after femtosecond laser-assisted and manual anterior capsulotomy. J Cataract Refract Surg 2013;39:105-9. 11) Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Effect of femtosecond laser fragmentation on effective phacoemulsification time in cataract surgery. J Refract Surg 2012;28:879-83. 12) Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Effect of femtosecond laser fragmentation of the nucleus with different softening grid sizes on effective phaco time in cataract surgery. J Cataract Refract Surg 2012;38:1888-94. 13) Abell RG, Kerr NM, Vote BJ. Toward zero effective phacoemulsification time using femtosecond laser pretreatment. Ophthalmology 2013;120:942-8. 14) Kránitz K, Miháltz K, Sándor GL, et al. Intraocular lens tilt and decentration measured by Scheimpflug camera following manual or femtosecond laser-created continuous circular capsulotomy. J Refract Surg 2014;28:259-63. 15) Miháltz K, Knorz MC, Alió JL, et al. Internal aberrations and optical quality after femtosecond laser anterior capsulotomy in cataract surgery. J Refract Surg 2012;27:711-6. 16) Takács AI, Kovács I, Miháltz K, et al. Central corneal volume and endothelial cell count following femtosecond laser-assisted refractive cataract surgery compared to conventional phacoemulsification. J Refract Surg 2012;28:387-91. 17) Conrad-Hengerer I, Al Juburi M, Schultz T, et al. Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser-assisted cataract surgery: three-month follow-up. J Cataract Refract Surg 2013;39:1307-13. 18) Abell RG, Allen PL, Vote BJ. Anterior chamber flare after femtosecond laser-assisted cataract surgery. J Cataract Refract Surg 2013;39:1321-6. 19) Chen M. A review of femtosecond laser assisted cataract surgery for Hawaii. Hawaii J Med Public Health 2013;72:152-5. 20) Filkorn T, Kovács I, Takács A, et al. Comparison of IOL power calculation and refractive outcome after laser refractive cataract surgery with a femtosecond laser versus conventional phacoemulsification. J Refract Surg 2012;28:540-4. 21) Roberts TV, Lawless M, Bali SJ, et al. Surgical outcomes and safety of femtosecond laser cataract surgery: a prospective study of 1500 consecutive cases. Ophthalmology 2013;120:227-33. 22) Abell RG, Darian-Smith E, Kan JB, et al. Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: outcomes and safety in more than 4000 cases at a single center. J Cataract Refract Surg 2015;41:47-52. 23) Chen M, Swinney C, Chen M. Comparing the intraoperative complication rate of femtosecond laser-assisted cataract surgery to traditional phacoemulsification. Int J Ophthalmol 2015;8:201-3. 24) Asena BS, Kaskaloglu M. Laser-assisted cataract surgery: soft lens assisted interface (SoftFit) versus direct contact interface. Eur J Ophthalmol 2016;26:242-7. 25) Chee SP, Yang Y, Ti SE. Clinical outcomes in the first two years of femtosecond laser-assisted cataract surgery. Am J Ophthalmol 2015;159:714-9. 26) Bali SJ, Hodge C, Lawless M, et al. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012;119:891-9. 544
- 양헌외 : 펨토초레이저백내장합병증의위험인자 - = 국문초록 = 성공적인펨토초레이저백내장수술을위한수술중합병증위험인자분석 목적 : 펨토초레이저백내장수술시발생하는합병증의위험인자를알아보고자하였다. 대상과방법 : 2012년 7월부터 2017년 1월까지본원에서펨토초레이저백내장수술을시행한 337명 598안을대상으로연구를실시하였다. 모든안에투명각막절개, 수정체전낭절개, 수정체분할을시행하였으며, 필요시윤부이완절개술을추가하였다. 수술중합병증은녹화된영상을이용하여결과를확인하였고, 합병증관련위험인자는의무기록을후향적으로분석하였다. 결과 : 대상환자군의나이는평균 62.1 ± 11.9세였으며, 불완전한투명각막절개 18안중위험인자는각막중심혼탁, 각막주변부변성, 익상편, 결막이완이있었고, 불완전한수정체전낭절개 43안중위험인자는과숙백내장, 전극백내장, 각막중심혼탁, 비정상동공, 수정체탈구, 산동불량이있었으며, 불완전한수정체분할 22안중위험인자는과숙백내장, 수정체이탈, 각막중심혼탁, 전극백내장, 비정상동공이있었다. SoftFit 인터페이스사용후합병증발생률은투명각막절개 (3.56% 에서 2.24%, p=0.367), 수정체전낭절개 (9.31% 에서 4.03%, p<0.05), 수정체분할 (5.20% 에서 1.34%, p<0.05) 모두감소하였으며, 초기사례와후기사례의합병증발생률비교시투명각막절개, 수정체전낭절개, 수정체분할모두초기보다후기에발생률이유의하게감소하였다 (p<0.05). 결론 : 펨토초레이저는백내장수술을안전하고효과적으로할수있는장점이있다. 그러나관련된위험인자가존재하는경우합병증의가능성을고려하여접근해야할것으로보이며, SoftFit 인터페이스를사용하고, 술자의숙련도가높을수록합병증발생을감소시킬수있을것으로생각된다. < 대한안과학회지 2017;58(5):539-545> 545