열공성 망막박리에 대한 fibrin 접착제의 효과

Abstract

[한글]

열공성 망막박리의 치료에는 공막돌융술, 전기소작법, 냉동술, 광응고술 등이 현재까지 사용되고 있으며 초자체 망막견인에 의한 망막박리도 초자체절제술로 치료가 가능하다.

그러나 심한 망막감돈(retinal incarceration), 망막단축(retinal shortening), 그리고 심한 망막하섬유증(subretinal fibrous proliferation)이 있는 복합 망막박리의 치료에는 상기 방법과 함께 망막절개술이 필요한 경우가 있다. 망막절개술은 인위적으로 거대 망

막열공을 만들게 되는 시술이므로 시술 후 즉시 액-공기 치환술, 망막 레이저 광응고술, 실리콘유 주입술, 망막 압정삽입술, 또는 조직 접착제 도포 등의 망막열공을 폐쇄하기 위한 추가적인 시술이 필요하다. 이 중 액-공기 치환술과 실리콘유 주입술은 망막절개술을

작은 범위로 시행하거나 상부 망막에 실시한 경우에 망막 재유착이 가능한 방법이며 실리콘유는 안구조직에 대한 독성이 있으므로 독성반응이 나타나기 전에 실리콘유 제거수술을 반드시 해야한다. 망막 압정삽입술도 압정 주위의 섬유증식, 망막출혈 등의 합병중이 있

으며 현재까지도 그 효과 및 합병증에 관한 연구가 진행 중이다. 조직 접착제 중 cyanoacrylate는 망막절개술 후에는 많은 양이 필요한데 그 정도의 양에 의하면 망막부종이나 괴사와 같은 심한 독성작용을 일으킨다고 보고되었으며 fibrin접착제 (fibrin adhesive)는

공기에 노출된 외안부에서는 훌륭한 조직접착 효과가 있다고 보고되었으나 망막에 대해서는 1986년 Nasaduke및 Peyman이 가토를 이용하여 실험한 결과망막의 재유착 효과는 볼 수 없었다고 하였다.

이에 저자는 가토안에 전초자체절제술을 실시하고 망막절개술로 망막열공 및 망막박리를 유발한 뒤에 액-공기 치환술을 하고 fibrin 접착제를 망막절개 부위에 도포하였으며, fibrin 접착제의 망막유착 효과를 알아보기 위해 시기적으로 구분하여 도상검안경 검사, 해부현미경 검사, 광학 및 전자현미경 검사 등을 실시하여 다음과 같은 결론을 얻었다.

1. Fibrin접착제의 흡수에는 형질세포, 대식세포, 조직구 등이 관여하는 것으로 관찰되었으며 초자체 내의 섬유소 응괴는 수술 후 6주에, 그리고 시세포층과 망막색소상피세포층 사이의 섬유소 응괴는 수술 후 4주에는 흡수되어 관찰되지 않았다.

2. 섬유세포는 시간이 지남에 따라 점차 증가하였는데 fibrin접착제만 도포한 군과 액-공기 치환술만 실시한 군에서는 수술 후 1주부터 관찰되기 시작하였으나 액-공기 치환술을 하고 fibrin잡착제를 도포한 군에서는 수술 후 1일부터 시세포층과 망막색소상피세포층 사이에서 관찰되기 시작하여6주 후에는 망막 전층에 침윤되어 있었다.

3. 망막 재유착 상태는 fibrin접착제만 도포한 군과 액-공기 치환술만 실시한 군에서는 수술 후 6주까지 망막박리가 진행되어 전망막박리가 발생하였으나 액-공기 치환술을 하고 fibrin접착제를 도포한 군에서는 수술 후 1주부터 망막이 유착되기 시작하여 6주 후에는 견고히 유착되었다.

이상의 결과로 미루어 볼 때 액-공기 치환술과 fibrin접착제의 도포를 병행한다면 훌륭한 망막 재유착 효과를 가져온다는 것을 알 수 있었으며 앞으로 더 많은 연구를 거쳐 임상적으로 거대 열공을 동반한 복합 망막박리의 새로운 치료 방법으로 활용될 수 있을 것으로 기대된다.

The Effect of Fibrin Adhesive on Rhegmatogenous Retinal Detachment

Seon Ki Whang

Department of Medical Science The graduate School, Yonsei University

(directed by Professor Hong Bok Kim, M.D., Ph. D.)

The rhegmatogenous retinal detachments can be repaired by scleral buckling,

etectrodiathermy, cryotherapy and photocoagulation. The retinal detachments caused

by vitreoretinal traction can also be repaired by vitrectomy. But some complicated

retinal detachments associated with severe retinal incarceration, retinal

shortening or subretinal fibrous proliferation may be difficult to be repaired by

using current techniques of vitreoretinal surgery. In those cases, retinotomy

should be performed to reattach the retina. As retinotomy produces giant retinal

hole, additional procedures such as air- fluid exchange, laser photocoagulation,

silicone oil injection, retinal tack insertion or sealing with tissue adhesive are

needed. Silicone oil is known to be toxic to ocular tissue, and the effect and

complication of retinal tack are still unclear. The tissue adhesives being used in

ocular surgery are cyanoacrylate and fibrin adhesive. Cyanoacrylate is known to

cause definite retinal toxic reaction such as retinal edema and necrosis. Recently,

commercially Prepared fibrin adhesive has been used for sealing leaks and wounds in

external ocular tissue. We have evaluated the effect of fibrin adhesive on

experimental retinal detachment with giant retinal hole in albino adult rabbits.

After trans pars plana vitrectomy, 2 disc diameter linear retinotomy was

performed in inferior retina. Bullous retinal detachment was made by saline

injection into the subretinal space through retinotomy site. After air=fluid

exchange, fibrin adhesive was applied on the reattached retinotomy site in

experiment group, while fibrin adhesive was applied without air-fluid exchange in

control group Ⅰ, and fibrin adhesive was not applied after air-fluid exchange in

control group Ⅱ. One day,1,2,4,6weeks after surgery, ocular examination was done

with indirect ophthalmoscope and fungus camera. After enucleation the gross finding

of the vitreous and retina was examined with dissecting microscope. The histologic

examination was done with light and election microscope.

The results are summerized as follows;

1. Fibrin clots located in subretinal space were absorbed at 4weeks and those in

vitreous carity were absorbed at 6weeks without any fibrous proliferation. It was

observed that macrophages, plasma cells and histiocytes participated in the

absorption of fibrin clots.

2. Fibrocytes began to appear on the first day postoperativaly in experiment

group, while on the first week postoperatively in two control groups, and all

retinal layers were infiltrated with fibrocytes after 6weeks.

3. In control group Ⅰ and Ⅱ, the retinal detachment progressed until 6weeks.

But in experiment group, the retina began to be reattached after 1week and

continued to be attached until 6weeks.

The above results showed that application of fibrin adhesiye is effective in

sealing the retinal hole if it is combined with air: fluid exchange. We expect that

fibrin adhesive will be clinically useful in the management of rhegmatogenous

retinal detachment through further investigations.

[영문]

The rhegmatogenous retinal detachments can be repaired by scleral buckling, etectrodiathermy, cryotherapy and photocoagulation. The retinal detachments caused by vitreoretinal traction can also be repaired by vitrectomy. But some complicated retinal detachments associated with severe retinal incarceration, retinal shortening or subretinal fibrous proliferation may be difficult to be repaired by using current techniques of vitreoretinal surgery. In those cases, retinotomy should be performed to reattach the retina. As retinotomy produces giant retinal hole, additional procedures such as air- fluid exchange, laser photocoagulation,

silicone oil injection, retinal tack insertion or sealing with tissue adhesive are needed. Silicone oil is known to be toxic to ocular tissue, and the effect and complication of retinal tack are still unclear. The tissue adhesives being used in ocular surgery are cyanoacrylate and fibrin adhesive. Cyanoacrylate is known to cause definite retinal toxic reaction such as retinal edema and necrosis. Recently, commercially Prepared fibrin adhesive has been used for sealing leaks and wounds in external ocular tissue. We have evaluated the effect of fibrin adhesive on

experimental retinal detachment with giant retinal hole in albino adult rabbits.

After trans pars plana vitrectomy, 2 disc diameter linear retinotomy was performed in inferior retina. Bullous retinal detachment was made by saline injection into the subretinal space through retinotomy site. After air=fluid exchange, fibrin adhesive was applied on the reattached retinotomy site in

experiment group, while fibrin adhesive was applied without air-fluid exchange in control group Ⅰ, and fibrin adhesive was not applied after air-fluid exchange in control group Ⅱ. One day,1,2,4,6weeks after surgery, ocular examination was done

with indirect ophthalmoscope and fungus camera. After enucleation the gross finding of the vitreous and retina was examined with dissecting microscope. The histologic examination was done with light and election microscope.

The results are summerized as follows;

1. Fibrin clots located in subretinal space were absorbed at 4weeks and those in vitreous carity were absorbed at 6weeks without any fibrous proliferation. It was observed that macrophages, plasma cells and histiocytes participated in the

absorption of fibrin clots.

2. Fibrocytes began to appear on the first day postoperativaly in experiment group, while on the first week postoperatively in two control groups, and all retinal layers were infiltrated with fibrocytes after 6weeks.

3. In control group Ⅰ and Ⅱ, the retinal detachment progressed until 6weeks.

But in experiment group, the retina began to be reattached after 1week and continued to be attached until 6weeks.

The above results showed that application of fibrin adhesiye is effective in sealing the retinal hole if it is combined with air: fluid exchange. We expect that fibrin adhesive will be clinically useful in the management of rhegmatogenous retinal detachment through further investigations.