유리체강내 항혈관내피세포성장인자주입술이 불필요한 말기 삼출황반변성의 해부학적 특징
Anatomical Characteristics of End-stage Exudative Age-related Macular Degeneration Refractory to Intravitreal Anti-vascular Endothelial Growth Factor Injection
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목적: 삼출성 나이관련황반변성으로 인해 법적 실명(20/1,000 이하)에 도달한 환자들의 빛간섭단층촬영에서 나타나는 소견을 조사하여 유리체강내 항혈관내피세포성장인자 치료가 불필요한 말기에 관찰되는 해부학적 특징을 알아보고자 하였다. 대상과 방법: 삼출성 나이관련황반변성을 진단받은 환자 중 유리체강내 항혈관내피세포성장인자주입술을 시행하여 최종내원일에 2줄 이상의 시력 호전을 보이거나 빛간섭단층촬영상 호전된 결과를 보인 환자 103명 120안(활동형 군)과 치료 받았음에도 반응이 없거나 첫 진단 시부터 반흔이 존재하여 최종 시력이 법적 실명에 도달한 환자 54명, 55안(말기형 군)의 의무 기록을 후향적으로 분석하였다. 연구 기간 중 최종내원일의 스펙트럼영역 빛간섭단층촬영을 통하여 활동형 군과 말기형 군의 망막 구조 변화를 비교분석하였다. 결과: 활동형 군에 비해 말기형 군의 평균 연령이 약 5세 정도 높게 나타났고, 경과관찰 중 망막내 출혈 및 망막하 출혈과 망막상피세포 파열의 발생 빈도가 말기형 군에서 유의하게 높았다(p<0.05). 빛간섭단층촬영에서 관찰되는 망막하액이나 망막내낭포액은 활동형 군에서 높은 빈도로 나타났고, 말기형 군 모두에서 망막하 고반사물질의 축적, 섬유혈관성 망막색소상피박리, 범위가 큰 광수용체내외절경계선의 파열이 관찰되었다. 활동형 군에 비해 말기형 군에서 망막색소상피박리의 크기와 두께, 황반중점두께, 황반중심두께, 망막하 고반사물질 두께가 유의하게 더 컸고(p<0.05), 말기형 군 대부분에서 최종적으로 원반반흔을 형성하였다. 결론: 말기 삼출성 나이관련황반변성 환자에서 경과관찰 중 망막 출혈이나 망막상피세포 파열이 발생하거나 원반반흔, 두꺼운 망막하고반사물질, 섬유혈관성 망막색소상피박리 및 범위가 큰 황반 부위의 광수용체내외절경계선 소실이 관찰된다면 유리체강내 항혈관내피성장인자의 낮은 치료 효과를 예상할 수 있고, 이는 향후 치료 종결 시점을 결정하는 데 참고가 될 것으로 보인다.
Abstract
Purpose: To analyze the anatomical characteristics on spectral-domain optical coherence tomography (SD-OCT) of patients who are legally blind (less than 20/1,000) due to end-stage exudative age-related macular degeneration (AMD) that does not require intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection. Methods: After anti-VEGF injections (active group), 120 eyes of 103 exudative AMD patients experienced visual acuity improved by at least 2 lines or improvement on SD-OCT. In addition, 55 eyes of 54 end-stage exudative AMD patients who did not respond to treatment or who were legally blind due to foveal scar at the first visit (end-stage group) were evaluated retrospectively. Changes in retinal structures of the 2 groups were analyzed by SD-OCT at the last visit. Results: The mean age of the end-stage group was about 5 years older than the active group. During the follow-up period, subretinal hemorrhage, intraretinal hemorrhage and retinal pigment epithelium tear occurred more frequently in the end-stage group than in the active group (p < 0.05). Intra-retinal fluids and subretinal fluids were more frequently administered in the active group than in the end-stage group, and thick subretinal hyper-reflective materials (SRHRM), fibrovascular pigment epithelial detachment (PED) and extensive inner segment/outer segment (IS/OS) line disruption were observed in all eyes of the end-stage group. The size and thickness of PED, foveal thickness and SRHRM thickness were significantly larger in the end-stage group than in the active group (p < 0.05). Disciform retinal scars were eventually formed in most of the end-stage group. Conclusions: In end-stage exudative AMD, the presence of retinal hemorrhage and retinal pigment epithelium tear during follow- up, or the findings of thick SRHRM, fibrovascular PED, and extensive IS/OS line disruption on SD-OCT suggest weak expected effect of intravitreal anti-VEGF injection, which can act as a reference for determining the timing of treatment termination.
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