대한안과학회지 2019 년제 60 권제 10 호 J Korean Ophthalmol Soc 2019;60(10):959-965 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2019.60.10.959 Original Article 유리체절제술과백내장병합수술시동시시행한후낭절개술후앞방깊이와굴절력변화 The Changes of Anterior Chamber Depth and Refractive Errors after Phacovitrectomy with Posterior Capsulotomy 유웅선 1,2,3 서진석 1,2 정지성 1,2 신민호 4 김성재 1,2,3 정인영 1,2,3 Woong-Sun Yoo, MD 1,2,3, Jin-Seok Seo, MD 1,2, Ji-Sung Jeong, MD 1,2, Min-Ho Shin, MD 4, Seong-Jae Kim, MD, PhD 1,2,3, In Young Chung, MD, PhD 1,2,3 경상대학교의과대학안과학교실 1, 경상대학교병원안과 2, 경상대학교건강과학연구원 3, 조선대학교의과대학안과학교실 4 Department of Ophthalmology, Gyeongsang National University College of Medicine 1, Jinju, Korea Department of Ophthalmology, Gyeongsang National University Hospital 2, Jinju, Korea Health Science Institute, Gyeongsang National University 3, Jinju, Korea Department of Ophthalmology, Chosun University College of Medicine 4, Gwangju, Korea Purpose: To evaluate the changes in anterior chamber depth (ACD) and refractive error after combined phacovitrectomy with posterior capsulotomy using a vitrectomy probe. Methods: In 20 eyes of 20 patients who underwent combined phacovitrectomy with posterior capsulotomy using a vitrectomy probe, the ACD was measured with Scheimpflug imaging (Pentacam, OCULUS Optikgeräte GmbH, Wetzlar, Germany) preoperatively and postoperatively. We compared the preoperative desired refraction and postoperative refraction using an autokeratorefractometor. Results: The preoperative ACD was 2.58 ± 0.248 mm; the ACD significantly increased in 1 month postoperatively to 3.65 ± 0.475 mm (p < 0.001), and it was maintained as 3.70 ± 0.452 mm (p = 0.213) at 3 months postoperatively. The preoperative target spherical equivalent was -0.60 ± 0.809 diopters (D). Myopic shifting was noticed at 1 month postoperatively as -1.45 ± 1.252 D, and it changed between 1 month and 3 months postoperatively (-1.48 ± 1.235 D at 3 months postoperatively was not statistically significant). There was no increased intraocular pressure or intraocular lens-related complication. Conclusions: Phacovitrectomy with posterior capsulotomy using a vitrectomy probe might be a useful way to stabilize the axial position of an intraocular lens without constriction of the capsular bag. However, using this procedure, the surgeon must consider the possibility of myopic shifting in the postoperative refractive error. J Korean Ophthalmol Soc 2019;60(10):959-965 Keywords: Anterior chamber, Posterior capsulotomy, Refractive error, Vitrectomy Received: 2019. 1. 3. Revised: 2019. 2. 24. Accepted: 2019. 9. 24. Address reprint requests to In Young Chung, MD, PhD Department of Ophthalmology, Gyeongsang National University Hospital, #79 Gangnam-ro, Jinju 52727, Korea Tel: 82-55-750-8171, Fax: 82-55-758-4158 E-mail: in0chung@hanmail.net * Conflicts of Interest: The authors have no conflicts to disclose. 유수정체안에서망막질환을치료하는데있어서유리체절제술과백내장병합수술이최근많이사용되고있으며유리체절제술후에백내장수술을따로한경우에비해경제적, 시간적이점을가지고있으며한번의수술로빠른시력회복을가져오는이점도있다. 1,2 두단계로나누어유리체절제술과백내장수술을따로하는경우에비해병합수술이이점을가지고있지만, 병합수술시행시술중혹은술 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. 959
- 대한안과학회지 2019 년제 60 권제 10 호 - 후합병증발생위험도가증가함을보고하기도한다. 1 수술시간이길어짐에따른합병증뿐만아니라홍채후유착, 근시이행, 후낭혼탁등이잘생긴다고보고되고있다. 3-5 특히야그후낭절개술이필요한후낭혼탁은병합수술환자에서 10% 에서 51% 까지발생한다고보고되고있으며유리체절제술이후낭혼탁의위험인자라고알려져있다. 6-11 또한후낭혼탁의진행은수정체낭의수축을유발시키고이로인한인공수정체의위치변화를일으켜예측한굴절력과다른결과를낳기도하며인공수정체의기울어짐이나위치이상을일으키기도한다. 12,13 이러한합병증을예방하기위해백내장수술과동시에후낭절개술을시행하기도하며, 후낭절개술유무에따른비교연구에서후낭절개술을동시에시행한경우, 하지않은경우에비해인공수정체의앞방이동이적음을보고하기도하였다. 14 이에본연구에서는유리체절제술과백내장병합수술시유리체절단침을이용하여후낭절개술을동시에시행한경우수술후앞방깊이및굴절력변화를확인하고자한다. 대상과방법 4.0 mm 크기의원형의후낭절개술을시행하였다. 모든환자들에게시력, 세극등현미경, 안압, 자동각막굴절계, 안저검사와함께샤임플러그사진기 (Pentacam, OCULUS Optikgeräte GmbH, Wetzlar, Germany) 를이용하여앞방깊이술전, 술후 1개월, 3개월째에측정하였으며스펙트럼영역빛간섭단층촬영기 (HRA Spectralis+OCT, Heidelberg Engineering, Heidelberg, Germany) 를이용하여술전, 술후 1개월, 3개월의황반부단층촬영을시행하였다. 또한 IOL master (Carl Zeiss Meditec AG, Jena, Germany) 를이용하여안구길이측정을술전및술후 3개월째에시행하였다. 검사의조건은산동상태로동일하게하였으며, 검사및측정모두동일한검사자가시행하였다. 인공수정체의도수결정은 SRK-T 공식을이용하였고, 굴절력은 spherical equivalent 로계산하였다. 질환군별측정치비교는 analysis of variance test를이용하였으며, 수술전후의측정치비교는 paired samples t-test를이용하였다. 모든통계분석은 SPSS (version 21.0, software for windows; IBM Corp., Armonk, NY, USA) 를이용하였으며, p값이 0.05 미만인경우에통계적으로유의하다고판단하였다. 2018년 1월에서 2018년 7월까지본원에서유리체절제술과백내장병합수술을시행받은환자중 3개월이상추적관찰이가능했던환자를대상으로의무기록을통한후향적연구를진행하였다. 본연구는헬싱키선언 (Declaration of Helsinki) 을준수하였으며, 경상대학교병원임상연구윤리위원회 (institutional review board, IRB) 의승인하에진행되었다 (GNUH 2018-11-016). 유리체절제술및백내장병합수술을시행하면서유리체절단침을이용한후낭절개술을받은 20명 20안을대상으로하였다. 이전에안내수술을받은경험이있는경우, 과거에유리체절제술을시행받은경우, 녹내장의병력이있는경우, 과거에포도막염이나안내염증을앓았던경우, 외상의병력이있는경우는연구대상에서제외하였고, 술중유리체강내실리콘기름주입을시행한경우, 술중후낭파열이일어난경우, 수정체소대의이상이발견된경우및인공수정체를섬모체고랑에삽입한경우또한연구에포함시키지않았다. 모든수술은한명의술자 (I.Y.C.) 에의해표준화된방법으로시행하였다. 유리체절제술은전신마취혹은구후부마취하에 3개의공막천자를통한섬모체평면부를통해시행하였고, 백내장적출술은투명각막절개를통해수정체유화술을시행하였다. 모든환자에서인공수정체는동일한 1-piece 비구면아크릴인공수정체를사용하였으며 (ZCB00 TECNIS, Abbott Medical Optics Inc., Santa Ana, CA, USA), 인공수정체삽입후공막천자부위를통해유리체절단침을이용하여후낭에약 결 과 남자가 6안, 여자가 14안이었으며, 평균나이는 61.0 ± 7.49세였다. 유리체절제술및백내장병합수술의원인질환으로망막전막 6안, 증식성당뇨망막병증에의한합병증 5안, 황반원공 2안, 유리체혼탁 5안, 기타 2안이었다 (Table 1). 원인질환에따라나누어비교하였을때연령은질환에따른차이가없었으며술전, 술후 3개월째중심황반부두께와앞방깊이, 안축장길이및굴절력은질환에따른유의한차 Table 1. Baseline characteristic of patients Characteristic Baseline demographic (n = 20) Age (years) 61.0 ± 7.49 Sex Male 6 (30) Female 14 (70) Laterality Right 7 (35) Left 13 (65) Disease Epiretinal membrane 6 (30) PDR 5 (25) Macular hole 2 (10) Vitreous opacity 5 (25) Other 2 (10) Values are presented as mean ± standard deviation or number (%). PDR = proliferative diabetic retinopathy. 960
- 유웅선외 : 병합수술과동시시행한후낭절개술후변화 - 이를보이지않았다 (Table 2). 술전최대교정시력은 logmar 0.67 ± 0.619였으며술후 1개월에 logmar 0.24 ± 0.217로유의하게증가하였으며 (p=0.003), 술후 3개월에 logmar 0.20 ± 0.223으로술후 1개월에비해통계적으로유의한증가를보였다 (p=0.01) (Table 3, Fig. 1). 술전안압은 14.6 ± 2.06 mmhg였으며술후 1개월, 3개월째각각 15.0 ± 1.96, 14.6 ± 1.82 mmhg였으며유의한안압의상승이나타나지않았다 (p=0.548, p=0.467) (Table 3, Fig. 2). 수술전후의앞방깊이의변화를살펴보면수술전앞방깊이는 2.58 ± 0.248 mm였으며술후 1개월에 3.65 ± 0.475 mm로유의한증가가나타났으며 (p<0.001), 술후 3개월에 3.70 ± 0.452 mm로앞방깊이의감소없이유지되는양상이었다 (p=0.213) (Table 3, Fig. 3). 술후안구길이의변화를비교해보면술전안구길이는 23.35 ± 0.189 mm였으며수술후 3개월째안구길이는 23.36 ± 0.193 mm로유의한변화를보이지않았다 (p=0.953) (Table 3, Fig. 4). 술 Figure 1. Changes of best corrected visual acuity (BCVA) logarithm of minimal angle of resolution in postoperative 1 month and 3 months. BCVA increased statistically significant in postoperative 1 month, and it maintained in postoperative 3 months. LogMAR = logarithm of minimal angle of resolution. Table 2. Comparison of CST, ACD, axial length and SE in preoperative and postoperative 3 months between diagnoses Characteristic ERM (n = 6) PDR (n = 5) Macular hole Vitreous opacity (n = 2) (n = 5) Others (n = 2) p-value * Age (years) 66.7 ± 7.17 54.2 ± 8.67 62.0 ± 1.41 62.4 ± 2.19 56.0 ± 1.41 0.46 CST (μm) Preoperative 442.8 ± 99.73 348.0 ± 39.60 452.0 ± 55.15 303.2 ± 19.18 265.5 ± 19.09 0.06 3 Months postoperative 325.2 ± 51.89 310.6 ± 92.65 328.0 ± 94.75 305.6 ± 34.22 267.0 ± 14.14 0.84 ACD (mm) Preoperative 2.67 ± 0.210 2.66 ± 0.238 2.51 ± 0.106 2.34 ± 0.212 2.78 ± 0.261 0.09 3 Months postoperative 3.90 ± 0.540 3.63 ± 0.659 3.61 ± 0.177 3.67 ± 0.264 3.49 ± 0.028 0.81 Axial length (mm) Preoperative 23.65 ± 0.677 23.48 ± 0.759 23.48 ± 0.474 22.63 ± 0.918 23.35 ± 0.845 0.30 3 Months postoperative 23.67 ± 0.756 23.56 ± 0.755 23.50 ± 0.495 22.62 ± 0.925 23.66 ± 1.280 0.30 SE (D) Target SE -0.35 ± 0.204-1.04 ± 1.341-0.33 ± 0.042-0.27 ± 0.181-1.30 ± 1.386 0.36 3 Months postoperative -0.87 ± 0.932-1.95 ± 1.485-0.75 ± 0.353-1.05 ± 0.741-2.10 ± 1.298 0.26 Values are presented as mean ± standard deviation unless otherwise indicated. CST = central subfield thickness; ACD = anterior chamber depth; SE = spherical equivalent; ERM = epiretinal membrane; PDR = proliferative diabetic retinopathy; D = diopter. * p-value was calculated by analysis of variance. Table 3. Changes of BCVA, IOP, ACD, axial length and SE in postoperative 1 month and 3 months Characteristic Preoperative 1 Month postoperative 3 Months postoperative BCVA (logmar) 0.67 ± 0.619 0.24 ± 0.217 0.20 ± 0.223 IOP (mmhg) 14.6 ± 2.06 15.0 ± 1.96 14.6 ± 1.82 ACD (mm) 2.58 ± 0.248 3.65 ± 0.475 3.70 ± 0.452 Axial length (mm) 23.35 ± 0.189 N/A 23.36 ± 0.193 SE (D) -0.60 ± 0.809 * -1.45 ± 1.252-1.48 ± 1.235 Values are presented as mean ± standard deviation. BCVA = best corrected visual acuity; IOP = intraocular pressure; ACD = anterior chamber depth; logmar = logarithm of minimal angle of resolution; SE = spherical equivalent; D = diopter; N/A = not associated. * Target spherical equivalent. 961
- 대한안과학회지 2019 년제 60 권제 10 호 - 후굴절력의변화양상을보면, 술전목표굴절력은 -0.60 ± 0.809D였으며술후 1개월째 -1.45 ± 1.252D로통계적으로유의한근시성이동이관찰되었으며 (p<0.001), 술후 3개월째는 -1.48 ± 1.235D로수술 1개월과비교하였을때변화없이유지됨을알수있었다 (p=0.781) (Table 3, Fig. 5). 술중앞방출혈, 섬모체소대손상, 인공수정체관련이상, 맥락막상강출혈등의합병증은없었으며, 술후 3개월까지인공수정체의위치이상, 고안압증및신생혈관녹내장, 유리체출혈등의합병증은관찰되지않았다. 고찰 유리체절제술및백내장병합수술은황반원공및망막전막등의유리체망막질환에서치료로많은술자들이선호 하고있다. 백내장이경도인경우에도유리체절제술단독수술후백내장진행이빠름을감안하여빠른시력회복을위해단계적수술보다는병합수술이최근증가하고있다. 15 Rogers et al 16 은황반원공과망막전막에서유리체절제술후백내장수술과비교하여백내장병합수술이안전하고효과적이라보고하였다. 본연구에서도단계적수술과직접적비교는어려우나병합수술전후의미있는시력상승을확인하였다. 유리체절제술및백내장병합수술의가장흔한술후합병증으로야그후낭절개술이필요한후낭혼탁으로 10-51% 에서보고되고있으며 6-11 최근망막전막과황반원공에서시행한병합수술의대규모연구에서는 10.6% 의후낭혼탁이발생함을보고하였다. 15 후낭혼탁의진행은수정체낭의수축을유발및인공수정체의위치변화를일으키며인공 Figure 2. Changes of intraocular pressure (IOP) in postoperative 1 month and 3 months. IOP has no significant differences between preoperative and postoperative 1 month and 3 months. Figure 4. Changes of axial length in postoperative 3 months. Axial length showed no changes in postoperative 3 months compared with preoperative. Figure 3. Changes of anterior chamber depth (ACD) in postoperative 1 month and 3 months. ACD showed statistically increased in postoperative 1 month and it maintained until 3 months. Figure 5. Changes of refractory error in postoperative 1 month and 3 months. Postoperative 1 month and 3 months revealed statistically significant myopic shifting compared with preoperative target spherical equivalent. 962
- 유웅선외 : 병합수술과동시시행한후낭절개술후변화 - 수정체의기울어짐등을유발하기도한다. 12,13 또한후낭혼탁이발생된경우시행하게되는야그후낭절개술은환자의비문증을일으켜주관적불편감을흔히나타내며, 기계적인인공수정체의이동이나손상을입히며, 낭포황반부종을일으키거나망막박리와같은심각한합병증을유발하기도한다. 17 따라서 Sato et al 18 은유리체절제술및백내장병합수술에서인공수정체를삽입한후유리체절제침을이용한후낭절개술을처음으로보고하였고효과적이며안전한방법으로소개하였다. 본연구에서도유리체절제침을이용한후낭절개술을병합수술을시행하였을때술중, 술후합병증을보이지않았으며술후에도의미있는시력상승을확인할수있었다. 또한야그후낭절개술후발생할수있는안압상승역시본연구에서는술후 3개월까지나타나지않았다. 다만유리체절제술및백내장수술후후낭절개술을시행하는경우술중에액체공기치환술을하는도중인공수정체의후면에결로가생겨안저관찰이용이하지않은경우가있으나이런경우백내장수술후남은점탄물질을이용하여인공수정체의후면에도포하면쉽게해결할수있었다. Stifter et al 14 은백내장수술중후낭절개술을시행한환자에서앞방의깊이를측정한경우하지않은대조군과비교하였을때수술후 1개월까지안정적으로유지하며대조군에서수정체낭수축으로발생하는인공수정체의앞방이동이술중후낭절개술을시행한군에서의미있게감소함을보고하였다. 저자들의연구에서대조군설정이되어있지않아직접적인비교를할수는없으나이전연구와유사하게환자군에서병합수술시시행한후낭절개술후샤임플러그를이용한앞방깊이측정시술전에비해술후 1개월에의미있게증가하였으며특히증가한앞방의깊이가 3개월까지변화없이잘유지됨을알수있었다. 이는인공수정체의앞방이동등으로인한앞방깊이의변화가없음을보여주며인공수정체의굴절력에안정성을나타내는지표로생각된다. 대조군이설정되어있지않은제한점은있으나이전연구와는다르게유리체절제술을시행한후후낭절개술을시행하였으며유리체에의한후낭지지역할과유리체탈출등으로인한앞방깊이의변화에영향을주지않는점이있어이전연구와차별점이있다. 이전에보고된백내장수술중후낭절개술을시행한연구에서술후 1개월에통계적으로의미는없지만술전에비해술후경한근시성굴절이동을나타냈으며, 14 본연구에서는술전에예측한굴절력에비해의미있는근시성굴절이동이나타났음을알수있었다. 유리체절제술및백내장수술후발생하는근시성굴절이동은유리체와앞방수의굴절계수의차이, 안구길이의변화등의가설이제시되었 으나정확한원인을이전연구에서밝히지는못하였으며, 병합수술중인공수정체를삽입시 0.5디옵터의원시화를하는것이제시되었다. 19 저자들도근시성변화를확인하기위해술전과술후 3개월째안구길이를측정하였으나의미있는차이를보이지않아병합수술후발생한근시성변화의원인에대한추가적연구가필요할것으로생각되며대조군설정을통한후낭절개술에의한근시성이동유무를비교해보아야할것이다. 하지만이전에후낭절개술을시행하지않은병합수술후굴절력근시화의보고에서근시화의정도가 -0.76디옵터로 19 직접적인비교는어려우나저자들의연구에서보인굴절력근시화이동과큰차이를보이지는않아후낭절개술이굴절력근시화에큰영향을미치지않을것으로보인다. 다만유리체절제술및백내장병합수술시인공수정체도수를예측인공수정체도수보다 0.5디옵터원시화하는것이좋을것으로생각된다. 본연구의가장큰제한점으로대조군설정되어있지않은다수환자군분석으로직접적인유리체절제침을이용한후낭절개술후앞방깊이변화비교가어려운점이있으며, 이는추후전향적환자-대조군연구가필요할것으로생각된다. 또한환자군에서앞방깊이와굴절력의변화가술후 3개월까지잘유지되었으나관찰기간이짧아장기적결과를관찰하지않은제한점이있어추후장기간의경과관찰을통한추가연구가필요할것이다. 결론적으로본연구는유리체절제술및백내장병합수술후유리체절제침을이용하여후낭절개술을시행한후샤임플러그를이용한앞방의깊이의변화와굴절력변화를측정한첫연구로유리체절제술및백내장병합수술은빠른시력회복을도모하며안전한수술이며, 병합수술의흔한합병증으로알려진후낭혼탁은병합수술중유리체절제침을이용한후낭절개술을통해방지할수있고이를통해수정체낭의수축으로인한인공수정체의위치변화및굴절력변화를방지할수있는하나의방법으로생각된다. REFERENCES 1) Steel DH. Phacovitrectomy: expanding indications. J Cataract Refract Surg 2007;33:933-6. 2) Muselier A, Dugas B, Burelle X, et al. Macular hole surgery and cataract extraction: combined vs consecutive surgery. Am J Ophthalmol 2010;150:387-91. 3) Manvikar SR, Allen D, Steel DH. Optical biometry in combined phacovitrectomy. J Cataract Refract Surg 2009;35:64-9. 4) Kim YK, Woo SJ, Hyon JY, et al. Refractive outcomes of combined phacovitrectomy and delayed cataract surgery in retinal detachment. Can J Ophthalmol 2015;50:360-6. 5) Pinarci EY, Bayar SA, Sizmaz S, et al. Anterior segment complica- 963
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- 유웅선외 : 병합수술과동시시행한후낭절개술후변화 - = 국문초록 = 유리체절제술과백내장병합수술시동시시행한후낭절개술후앞방깊이와굴절력변화 목적 : 유리체절제술과백내장병합수술시유리체절단침을이용하여후낭절개술을동시에시행한경우수술후앞방깊이및굴절력변화를확인하고자하였다. 대상과방법 : 유리체절제술과백내장병합수술및유리체절단침을이용한후낭절개술을받은 20 명 20 안을대상으로하였다. 술전후의앞방의깊이는샤임플러그사진기 (Pentacam, OCULUS Optikger te GmbH, Wetzlar, Germany) 를이용하여측정했으며, 술후굴절력은자동각막굴절측정기를이용하여예측한굴절력과차이를비교하였다. 결과 : 수술전앞방깊이는 2.58 ± 0.248 mm 였으며, 수술후 1 개월째 3.65 ± 0.475 mm 로유의하게깊어졌으며 (p<0.001), 수술후 3 개월째 3.70 ± 0.452 mm 로 1 개월째와유의한차이를보이지않았다 (p=0.213). 술전예측굴절력은 -0.60 ± 0.809D 였고, 수술후 1 개월째 -1.45 ± 1.252D 로술전예측굴절력에비해의미있는근시성이동이관찰되었으며, 이는 3 개월째 -1.48 ± 1.235D 로술후 1 개월에비해유의한변화를보이지는않았다. 안압상승이나인공수정체관련합병증은관찰되지않았다. 결론 : 유리체절제술과백내장병합수술시유리체절단침을이용한후낭절개술은술후 3 개월까지수정체낭수축등으로인한인공수정체의앞방이동을방지할수있는유용한방법이될수있으나근시화되는점을고려하여인공수정체도수계산을해야할것으로생각된다. < 대한안과학회지 2019;60(10):959-965> 유웅선 / Woong-Sun Yoo 경상대학교의과대학안과학교실 Department of Ophthalmology, Gyeongsang National University College of Medicine 965