http://jsms.sch.ac.kr 147

아메드 밸브 삽입술 후 장치의 노출에 대해 보존 대퇴근막 이식으로 치료한 1예박가희, 하승주

순천향대학교 의과대학 안과학교실

Preserved Fascia Lata Transplantation for Implant Plate Exposure after Ahmed Glaucoma Valve Implant Surgery: One CaseKa Hee Park, Seung Joo Ha

Department of Ophthalmology, Soonchunhyang University College of Medicine, Seoul, Korea

We report one case of implant plate exposure after Ahmed valve implantation, treated with preserved fascia lata transplantation. Exposure of implant occurred in 47-year-old patient with Ahmed glaucoma valve implantation. She was treated with preserved fas-cia lata graft and amniotic membrane transplantation. No recurrent implant plate exposure has been found since then. Intraocular pressure has been maintained well for 3 months of follow-up. In cases of implant plate exposure, additional preserved fascia lata graft and amniotic membrane transplantation can improve surgical success.

Keywords: Ahmed glaucoma valve; Amniotic membrane transplantation; Implant plate exposure; Preserved fascia lata graft

서 론

녹내장의여과수술은일반적으로원발개방각녹내장,색소녹내

장,거짓비늘녹내장의경우에성공률이70-90%에이르나신생혈

관녹내장,포도막염이나외상으로인한이차녹내장,무수정체안또는인공수정체안녹내장,결막에반흔을동반하는경우와이전

에고식적인여과수술에실패한환자에서재수술을시도하는경우등에서는성공률이매우낮은것으로알려져있다.수술예후가나쁜녹내장에서수술의성공률을높이기위해수술시5-Fluoro-uracil,Mitomycin-C와같은항대사제를보조적으로사용하기도하지만,또다른방법으로방수유출장치삽입수술을시행하는빈도가증가하고있으며여러연구에서좋은결과가보고되었다.방수유출장치에대한개념은1906년Rollett와Moreau[1]에의

해처음언급되었으며,이후다양한디자인과재질을가지는여러종류의장치가사용되고있다.이들중현재는각막윤부에삽입하

는관을통해안구전방으로부터방수를안구뒤쪽의테논낭아래

로배출하고,유출된방수가안와혈관조직을통해흡수될때까지저류부위를형성하는방식의방수유출장치인아메드밸브가흔히사용되고있다.이러한방수유출장치에서수술후동반될수있는여러합병증이

보고되고있다.이중삽입장치의노출은3-11.7%정도로흔하게발생하지는않으나[2-4]발생하게될경우치유가힘들고재발하는경우가많아대부분이러한경우에는삽입한장치를제거하게되는것으로알려져있다.이에저자들은아메드밸브삽입술후발생한삽입장치의노출에대해장치를제거하지않고보존대퇴근막과양막의이식을통해치료에성공한1예를처음으로보고하고자한다.

증 례

증식성당뇨병성망막증에의한우안의신생혈관녹내장으로본

Soonchunhyang Medical Science 17(2):147-150, December 2011 pISSN: 2233-4289 I eISSN: 2233-4297

CASE REPORT

Correspondence to:  Seung Joo HaDepartment of Ophthalmology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine,  657 Hannam-dong, Yongsan-gu, Seoul 140-743, KoreaTel: +82-2-709-9354, Fax: +82-2-798-7797, E-mail: sjha@schmc.ac.krReceived:  Sep. 25, 2011 / Accepted after revision:  Dec. 6, 2011

© 2011 Soonchunhyang Medical Research InstituteThis 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/).

Park KH and Ha SJ • Implant Plate Exposure after Ahmed Glaucoma Valve Implant Surgery

Soonchunhyang Medical Science 17(2):147-150148 http://jsms.sch.ac.kr

원안과에내원한47세여자환자에서아메드밸브삽입술을시행

하였다.수술전우안의교정시력은안전수지20cm였고안압은안압하강을위해안약과경구약을투여하였으나58-64mmHg으로적절히조절되지않았다.전안부검사상좌안은특별한이상이발견

되지않았으며안저검사상당뇨성변화는있었으나안정된상태를보이고있었다.우안은각막부종과홍채와전방각경검사상360도변연부에신생혈관이관찰되었고주변홍채앞유착(PAS)이부분적

으로보였으며안저검사에서유리체출혈이관찰되었다.수술후안압은8-16mmHg으로안정적으로조절되었으며수술

부위는특별한이상없이잘유지되었다.이후환자는우안에발생

한유리체출혈과노인성백내장으로유리체절제술과초음파유화

술및인공수정체삽입술을시행받았다.밸브삽입술시행3년후아메드밸브를덮고있는결막의미란과함께장치의노출이관찰되어동종공막편과양막조직의이식을시행하였다.양막조직은바닥면

을윗면으로하여주변결막이잘자라들어올수있게덮어주었다.동종공막이식시행후30일경까지수술부위에주변결막조직이자라들어오는것이관찰되었으나,이후더이상결막조직이자라들어오지않았으며수술후3개월째다시이식부위의미란과함께장치의노출이관찰되었다(Fig.1).초기에는안압이잘유지되고염증소견이없어경과관찰하였으나점차노출부위의크기가증가하

여보존대퇴근막(TutoplastR,TutogenMedical,Erlangen,Ger-many)과양막조직의이식을통해노출된장치를다시덮어주었다.보존대퇴근막이식후3개월이경과하여이식부위에결막조직은잘자라들어오고있으며안압도7-14mmHg으로안정되게유지

되고있다(Fig.2).

고 찰

아메드밸브장치는전방으로부터테논낭하저장소로윤부에위치한도관을통해방수를배출하는장치이다.배출되는방수는테논낭밑에저장되므로결막에손상을주는경우가드물며섬유화

에따른폐쇄를방지할수있다.또한저장공간이넓기때문에많은양의방수를유출할수있어안압의하강효과가좋다.이러한이유

로기존의녹내장여과수술을시행할경우누공과그주변조직간에섬유화와유착으로인해수술의실패가능성이높게예측되는난치성녹내장에서많이사용되고있다.방수유출장치삽입술후의합병증은크게수술중발생하는경

우와술후발생하는경우로나눌수있다.수술중전방으로도관

을삽입할때각막윤부절개창의크기가과다한경우에는과도한방수의유출이있게되고절개창의위치가적절하지못한경우에

Fig. 1. (A) Photograph which was taken 3 years after Ahmed valve implanta-tion shows exposure of the implant through the conjunctiva. (B) Photograph which was taken 1 week after scleral patch graft and amniotic membrane transplantation. (C) Photograph which was taken 3 months after sclera patch graft shows reexposure of the implant through the conjunctiva.

A B

C

아메드 밸브 노출과 보존대퇴근막 이식 • 박가희 ·하승주

Soonchunhyang Medical Science 17(2):147-150 http://jsms.sch.ac.kr 149

는관과각막,홍채혹은수정체가접촉하게됨으로써발생하는손상및관의폐쇄가있을수있다.상공막삽입물주변으로피낭이형성되기전수술후초기에는

방수의과도한유출로인해전방의깊이가감소하거나저안압증,맥락막박리등이생길수있으며수술후염증또한합병증으로나타

날수있다.수술후후기에는상공막삽입물주변의과도한피낭형성,관의폐쇄및이동,상공막삽입물의노출이나관의미란등이발생할수있다.관의폐쇄나관의후방이동으로인한폐쇄또는피낭여과포의기능장애는수술후기에안압의상승을유발하기도한다.방수유출장치삽입물의노출이발생하는과정에대해서는여러의견들이발표되었다.이식편을고정하는봉합사에의한압력

이나결막이작은혈관들을압박하면서국소적허혈과괴사를유발하여삽입장치의노출을유발하는것으로생각되기도하며,완전히고정되지않은삽입장치가덮고있는이식편과결막에마찰을유발하면서손상을일으키는것으로생각되기도한다[3,4].삽입장

치의노출과연관된위험요소들을살펴본연구에서대상의연령,장치의삽입위치,녹내장의종류,당뇨나혈압은요소가되지않으

나수술의시행횟수가깊은연관성이있음이보고되었으며본증례에서도이러한위험요소가작용하였던것으로생각된다[3].수술의경험과기술이발전함에따라삽입장치가노출되는경우

는점차줄고있으나,삽입장치의노출은삽입장치의위치이상과기능장애를초래할수있으며또한2차적인감염으로인해안내염,실명까지이르는경우도있기때문에매우심각한합병증이다.또한장치의노출이발생하게되는경우손상된결막은다시회복되

기어려우며지속적으로재발이생겨이러한삽입장치의노출에대하여아직까지명확한치료방법이확립되지않은상태이다.Byun등[4]은아메드밸브삽입술후삽입장치의노출이발생한경우11명(4.1%)에서7명의환자를대상으로장치의재고정및공막편과양막이식을시행하였을때4명의환자에서장치의재노출이관찰

되었다고보고하였다.도관이노출된경우에는이차적인감염의위험성을줄이기위해

동종공막재이식술을통하여다시덮어주어야하며결막만단순봉합하는것은적절치못하다.미란이계속재발되는경우에는동종공막재이식을반복해볼수도있으며다른조직으로이를대치

하여성공적인결과를보인예도발표되었다.동종공막대신에시행할수있는이식편으로동종경막,대퇴근막,심낭막등이보고되

었으며자가공막층판이식을시행한후15개월간경과관찰하였

을때별다른합병증없이이식부위가잘유지된사례도보고되었

다[5-8].또한국내에서자가구강점막이식을통하여재발되는관미란을치료한사례가보고되었으며심낭막조직을이식하여성공

적인결과를보인경우도보고되었다[9,10].보존대퇴근막은현재전두근걸기술재료로서널리사용되는생

체재료이다.자가대퇴근막은영구적인주변조직과의유착력및인체내안정성,감염의위험이없는장점이있으나이를얻기위한대퇴부위의수술이필요하여수술로인한반흔이남게되는문제

점이있다.보존대퇴근막은동종의대퇴근막을처리하여감염성질환전파의위험성을최소화한조직으로공여부위의수술이필요없고생체적합성을띠면서면역학적으로도안전한장점이있다.Tanji등[6]은녹내장밸브삽입후도관이노출된22안에서보존대퇴근막을이식편으로사용하여19개월간경과관찰하였을때22안모두에서도관의노출이없었음을보고하였고,보존대퇴근막이식후32개월간경과관찰시조직학적인변성과세포침윤없이결막미란을방지하였음을보고한경우도있다[11].보존대퇴근막

이녹내장수술에서새로운이식편으로서효용성이있음이어느정도인정되었고지속적으로연구되고있으나국내에서는아직까

지성공적인사례가보고된적은없었다.또한도관이노출되는경우는노출범위가적고직접적으로방수

유출장치의기능에영향을미치는경우가드문데반해삽입장치

Fig. 2. (A) Photograph which was taken 1 week after preserved fasia lata graft and amniotic membrane transplantation. (B) Postoperative 3 months after preserved fasia lata graft and amniotic membrane transplantation. The graft is well positioned with conjunctival vascularization.

A B

Park KH and Ha SJ • Implant Plate Exposure after Ahmed Glaucoma Valve Implant Surgery

Soonchunhyang Medical Science 17(2):147-150150 http://jsms.sch.ac.kr

자체의노출은노출범위와염증가능성이더크고장치의기능과직접적으로연관되어있기때문에장치를유지하기가더어렵다.그러므로이식편을이용하여장치를유지한예가보고된경우는드물며대부분의경우에서는수술의실패로간주하고장치의제거를선택하는경우가많다.이에본증례에서는방수유출삽입장치의노출에대해다양한

이식편의시도를시행하였고성공적인사례가있어보고하고자하는것이다.아직까지완전한수술방법이라고하기에는대상환자수

가적고수술후경과관찰기간이충분하지않으므로앞으로효과

적인수술로인정받기위해보다많은대상의수와충분한경과관찰기간이필요하겠다.

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3. AyyalaRS,ZurakowskiD,SmithJA,MonshizadehR,NetlandPA,Rich-ardsDW,etal.AclinicalstudyoftheAhmedglaucomavalveimplantinadvancedglaucoma.Ophthalmology1998;105:1968-76.

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