당뇨황반부종의 형태학적 분류에 따른 유리체강 내 라니비주맙 초기치료 후의 장기 임상결과
Long-term Outcomes of Diabetic Macular Edema Following Initial Intravitreal Ranibizumab Injection Based on Morphologic Pattern
0
조회
0
다운로드
3
인용
0
참고문헌
키워드
초록
목적: 당뇨황반부종 환자에서 초기 유리체강 내 라니비주맙 주입술 후 시력 및 해부학적 구조 변화를 빛간섭단층촬영의 형태학적분류에 따라 살펴보았다. 대상과 방법: 당뇨황반부종을 진단 받은 32명의 총 32안을 대상으로 빛간섭단층촬영의 형태학적 특징에 따라, 1군은 미만성으로 망막이 두꺼워진 황반부종, 2군은 낭포황반부종, 3군은 장액성 망막박리가 동반된 황반부종으로 분류하였다. 모든 환자는 첫 3달 동안 유리체강 내 0.5 mg 라니비주맙 주입술을 한 달 간격으로 3회 시행 받은 후 기준에 따라 라니비주맙 또는 덱사메타존 임플란트 주입술을 추가로 시행 받았다. 모든 환자는 36개월 이상의 경과관찰을 통해 유리체강 내 주입술 횟수, 최대교정시력, 중심와두께 및 황반부 부피의 변화를 분석하였다. 결과: 대상은 1군 16안(50%), 2군 6안(18.8%), 3군 10안(31.2%)으로 분류되었다. 3년간의 평균 주입술 횟수는 1군 4.68회, 2군 7.5회, 3군 7.6회로 세 군 간에 유의한 차이가 있었고(p=0.048), 1군 13명(81.3%), 2군 2명(33.3%), 3군 5명(50%)에서 초기 3회 주입술 후 36개월까지 추가 주입술이 필요하지 않았다(p=0.045). 36개월의 최대교정시력은 1군에서 초기값과 비교하여 유의한 호전이 있었으며(p=0.003), 2군에서는 다른 두 군에 비해 유의하게 낮은 값을 보였다(p=0.023). 추가 덱사메타존 임플란트 주입술을 시행 받은 6명의 환자에서 36개월의 최대교정시력은 12개월에 비해 유의한 호전이 없었으나 황반부 부피는 유의한 감소를 보였다. 결론: 당뇨황반부종에서 유리체강 내 라니비주맙 주입술 후 임상경과는 형태학적 유형에 따라 서로 다른 양상을 보였으며, 1군에서는 다른 두 군에 비해 적은 횟수의 추가 주입술로 36개월까지 시력과 해부학적 호전이 유지되었다. 황반부의 낭포성 변화가 지속되는 경우 덱사메타존 임플란트 주입술 후 시력의 유의한 호전은 없었으나 황반부종의 완화에 제한적 효과를 보임을 알 수 있었다.
Abstract
Purpose: To evaluate the 3-year visual and morphological outcomes of diabetic macular edema (DME) based on the morphological pattern observed on optical coherence tomography (OCT) after intravitreal ranibizumab injections. Methods: Thirty-two eyes of 32 patients with DME were classified according to the following OCT features: diffuse retinal thickening (DRT), cystoid macular edema (CME), and serous retinal detachment (SRD). All patients received 3 consecutive monthly intravitreal injections of 0.5 mg ranibizumab. After 3 injections, patients received ranibizumab or dexamethasone implantation as needed. The primary outcome was the number of treatments received based on the DME type over 36 months. Best-corrected visual acuity (BCVA), central subfoveal thickness, and macular volume changes were also evaluated. Results: The eyes were classified as DRT (n = 16), CME (6), or SRD (10). The mean number of injections over 3 years was significantly different among the groups: DRT (4.25), CME (7.5), SRD (7.6; p = 0.048). The number of patients who did not need additional treatment after the initial 3 injections was 13 with DRT (81.3%), 2 with CME (33.3%), and 5 with SRD (50%; p = 0.045). BCVA at 36 months significantly improved from baseline in the DRT group (p = 0.003). The CME group showed the worst BCVA among the groups (p = 0.023). Six patients who received intravitreal dexamethasone implantation showed no significant improvement of BCVA but significant decrease in macular volume from 12 to 36 months. Conclusions: Clinical courses varied according to the morphological pattern of DME after intravitreal ranibizumab injection, and patients with DRT maintained visual and anatomical improvement with fewer injections over 36 months. Additional dexamethasone implantation showed limited effect in reducing macular edema with persistent macular cystic change, but no significant improvement in visual acuity.
참고문헌 (37)
- Ciulla TA., "Diabetic retinopathy and diabetic macular edema : pathophysiology, screening, and novel therapies", Diabetes Care, 26, pp.2653~2664 (2003)
- Nentwich MM., "Diabetic retinopathy-ocular complications of diabetes mellitus", World J Diabetes, 6, pp.489~499 (2015)
- Tranos PG., "Macular edema", Surv Ophthalmol, 49, pp.470~490 (2004)
- Otani T., "Patterns of diabetic macular edema with optical coherence tomography", Am J Ophthalmol, 127, pp.688~693 (1999)
- Scholl S., "General pathophysiology of macular edema", Eur J Ophthalmol, 21(Suppl 6), pp.S10~S19 (2011)
- Yanoff M, "Pathology of human cystoid macular edema", Surv Ophthalmol, 28(Suppl), pp.505~511 (1984)
- 임종훈, "빛간섭단층촬영에 따른 당뇨황반부종의 형태학적 분류와 치료 후 임상경과", 대한안과학회지, 55(2), pp.222~229 (2014), 대한안과학회
- Kang SW., "The correlation between fluorescein angiographic and optical coherence tomographic features in clinically significant diabetic macular edema", Am J Ophthalmol, 137, pp.313~322 (2004)
- Shimura M., "Visual outcome after intravitreal bevacizumab depends on the optical coherence tomographic patterns of patients with diffuse diabetic macular edema", Retina, 33, pp.740~747 (2013)
- Wu PC., "Optical coherence tomographic patterns in diabetic macula edema can predict the effects of intravitreal bevacizumab injection as primary treatment", J Ocul Pharmacol Ther, 28, pp.59~64 (2012)
- Kim M., "Effect of intravitreal bevacizumab based on optical coherence tomography patterns of diabetic macular edema", Ophthalmologica, 226, pp.138~144 (2011)
- 김상현, "당뇨황반부종의 빛간섭단층촬영 분류에 따른 유리체강내 트리암시놀론과 베바시주맙의 효과 비교", 대한안과학회지, 51(2), pp.210~219 (2010), 대한안과학회
- 김영균, "당뇨황반부종의 종류에 따른 트리암시놀론 안내주입술의 임상분석", 대한안과학회지, 46(1), pp.13~13 (2005), 대한안과학회
- 윤상철, "당뇨황반부종의 빛간섭단층촬영 분류에 따른 트리암시놀론 안내주입술의 효과", 대한안과학회지, 49(10), pp.1611~1618 (2008), 대한안과학회
- Das A., "Diabetic macular edema : pathophysiology and novel therapeutic targets", Ophthalmology, 122, pp.1375~1394 (2015)
- Dong N., "Study of 27 aqueous humor cytokines in patients with type 2 diabetes with or without retinopathy", Mol Vis, 19, pp.1734~1746 (2013)
- Sohn HJ., "Changes in aqueous concentrations of various cytokines after intravitreal triamcinolone versus bevacizumab for diabetic macular edema", Am J Ophthalmol, 152, pp.686~694 (2011)
- Funatsu H., "Association of vitreous inflammatory factors with diabetic macular edema", Ophthalmology, 116, pp.73~79 (2009)
- Yoshimura T., "Comprehensive analysis of inflammatory immune mediators in vitreoretinal diseases", PLoS One, 4, pp.e8158~ (2009)
- Sarao V., "Intravitreal steroids for the treatment of retinal diseases", Scientific World Journal, 2014, pp.989501~ (2014)
- Felinski EA., "Glucocorticoids induce transactivation of tight junction genes occludin and claudin-5 in retinal endothelial cells via a novel cis-element", Exp Eye Res, 86, pp.867~878 (2008)
- 이승희, "난치성 당뇨황반부종에서 유리체강 내 덱사메타존 임플란트의 단기 치료 효과", 대한안과학회지, 56(8), pp.1201~1207 (2015), 대한안과학회
- Lazic R., "Treatment of anti-vascular endothelial growth factor-resistant diabetic macular edema with dexamethasone intravitreal implant", Retina, 34, pp.719~724 (2014)
- Pacella E., "Preliminary results of an intravitreal dexamethasone implant(Ozurdex(R))in patients with persistent diabetic macular edema", Clin Ophthalmol, 7, pp.1423~1428 (2013)
- Zalewski D., "Five-month observation of persistent diabetic macular edema after intravitreal injection of Ozurdex implant", Mediators Inflamm, 2014, pp.364143~ (2014)
- Seo KH., "Visual and morphologic outcomes of intravitreal ranibizumab for diabetic macular edema based on optical coherence tomography patterns", Retina, 36, pp.588~595 (2016)
- Antcliff RJ., "The pathogenesis of edema in diabetic maculopathy", Semin Ophthalmol, 14, pp.223~232 (1999)
- Aiello LP., "Vascular endothelial growth factor-induced retinal permeability is mediated by protein kinase C in vivo and suppressed by an orally effective beta-isoform-selective inhibitor", Diabetes, 46, pp.1473~1480 (1997)
- Funatsu H., "Increased levels of vascular endothelial growth factor and interleukin-6 in the aqueous humor of diabetics with macular edema", Am J Ophthalmol, 133, pp.70~77 (2002)
- Funatsu H., "Vitreous levels of interleukin-6 and vascular endothelial growth factor are related to diabetic macular edema", Ophthalmology, 110, pp.1690~1696 (2003)
- Nguyen QD., "Two-year outcomes of the ranibizumab for edema of the mAcula in diabetes(READ-2)study", Ophthalmology, 117, pp.2146~2151 (2010)
- Fischer S., "In vitro effects of dexamethasone on hypoxia-induced hyperpermeability and expression of vascular endothelial growth factor", Eur J Pharmacol, 411, pp.231~243 (2001)
- Bandi N., "Budesonide reduces vascular endothelial growth factor secretion and expression in airway(Calu-1)and alveolar(A549)epithelial cells", Eur J Pharmacol, 425, pp.109~116 (2001)
- Gillies MC., "Intravitreal triamcinolone for refractory diabetic macular edema : two-year results of a double-masked, placebo-controlled, randomized clinical trial", Ophthalmology, 113, pp.1533~1538 (2006)
- Shimura M., "Comparative therapy evaluation of intravitreal bevacizumab and triamcinolone acetonide on persistent diffuse diabetic macular edema", Am J Ophthalmol, 145, pp.854~861 (2008)
- Paccola L., "Intravitreal triamcinolone versus bevacizumab for treatment of refractory diabetic macular oedema(IBEME study)", Br J Ophthalmol, 92, pp.76~80 (2008)
- Chang-Lin JE., "Pharmacokinetics and pharmacodynamics of a sustained-release dexamethasone intravitreal implant", Invest Ophthalmol Vis Sci, 52, pp.80~86 (2011)