<30352D30382D323228B1E8C0E7C2F92DC0D3B0E6BCB E687770>

Size: px

Start display at page:

Download "<30352D30382D323228B1E8C0E7C2F92DC0D3B0E6BCB E687770>"

경석 목
5 years ago
Views:

1 대한안과학회지 2014 년제 55 권제 4 호 J Korean Ophthalmol Soc 2014;55(4): pissn: eissn: Original rticle 실모양각막염의발생에건성각결막염과각막의폐쇄가미치는영향의비교 The Difference in Filaments between Corneal Occlusion and Keratoconjunctivitis Sicca 임경섭 김경우 전연숙 김재찬 Kyung Sup Lim, MD, Kyoung Woo Kim, MD, Yeoun Sook Chun, MD, PhD, Jae Chan Kim, MD, PhD 중앙대학교의과대학안과학교실 Department of Ophthalmology, Chung-ng University College of Medicine, Seoul, Korea Purpose: To examine histopathological findings of filamentary keratitis due to corneal occlusion. Methods: We analyzed filamentary keratitis in 11 eyes with corneal occlusion due to blepharospasm, ptosis and paralytic strabismus, 11 eyes with keratoconjunctivitis sicca, and 13 eyes with both corneal occlusion and keratoconjunctivitis sicca. The following protocols were used for filament analyses: slit lamp examination for counting filament numbers, impression cytology for grading mucin content, and histopathology (hematoxylin and eosin staining) and immunohistochemistry (with E1/E3, MUC1, 5C, 16) for histological analysis. Results: Slit lamp biomicrosopy showed a significantly smaller number of filaments in the corneal occlusion group (11 eyes, 2.7 ± 1.4) than the keratoconjunctivitis sicca group (11 eyes, 5.1 ± 2.2, p = 0.009). In impression cytology, the standard photograph grade of mucin content was significantly higher in the corneal occlusion group (2.7 ± 0.9) than the keratoconjunctivitis sicca group (1.9 ± 0.8, p = 0.034). On pathological exam, filaments showed a central filament with peripheral mucin. The central filaments were composed of core and cortex, and the core contained multiple deformed nuclei. However, the cortex was not stained by E1/E3, MUC1, 5C, 16. Conclusions: Filamentary keratitis due to corneal occlusion showed a smaller number of filaments and higher mucin content than filamentary keratitis induced by keratoconjunctivitis sicca and should be considered during treatment. J Korean Ophthalmol Soc 2014;55(4): Key Words: Corneal occlusion, Filament keratitis, Keratoconjunctivitis sicca 실모양각막염은건성안, 상윤부각결막염, 바이러스성각결막염, 재발성각막미란등많은안과적질환에의해유발 Received: Revised: ccepted: ddress reprint requests to Jae Chan Kim, MD, PhD Department of Ophthalmology, Chung-ng University Hospital, #102 Heukseok-ro, Dongjak-gu, Seoul , Korea Tel: , Fax: jck50ey@kornet.net * This study was presented as a narration at the 106th nnual Meeting of the Korean Ophthalmological Society 되는것으로알려졌다. 1,2 현재까지정확한형성기전이밝혀지지않았으나여러요인들에의해각막상피의손상이유발되면이를보완하기위해눈물막의화학주성변화가일어나고이러한변화가점액과손상을입은각막상피세포를결합시켜사상체가형성되는것으로알려졌다. 1,3-6 실모양각막염은임상적으로안구통증, 눈부심, 눈물흘림등의증상을유발하며사상체의크기, 모양, 분포는다양한형태로나타나며각막의기저부에부착되어있고플루오르세인과로즈벵갈로잘염색된다. 1,7 실모양각막염의치료는인공누액점안및물리적제거나보호용렌즈를착용하여치료하며 c2014 The Korean Ophthalmological Society This is an Open ccess article distributed under the terms of the Creative Commons ttribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 498

- 임경섭외 : 각막의폐쇄와실모양각막염 - C D Figure 1. Standard photographs of mucin debridement amount. () Grade I: filament (black arrow) without mucin debridement.

(C) Grade III: filament with moderate amount of mucin debridement (D) Grade IV: filaments with large amount of mucin debridement (PS stain, 100).

8 실모양각막염에대한원인별분류및치료에대해서국내보고가선행된바있으나 7 단순건성각결막염에의한실모양각막염보다각막의폐쇄에의한실모양각막염이치료에잘반응하지않는이유에대해알려진바가없다. 이에본연구에서는건성각결막염과비교하여각막의폐쇄에의한실모양각막염의병리학적특징을알아보고효과적인치료법을모색하고자하였다.

2 - 임경섭외 : 각막의폐쇄와실모양각막염 - C D Figure 1. Standard photographs of mucin debridement amount. () Grade I: filament (black arrow) without mucin debridement. () Grade II: filaments with scanty mucin (red arrow) debridement. (C) Grade III: filament with moderate amount of mucin debridement (D) Grade IV: filaments with large amount of mucin debridement (PS stain, 100). 그외에도스테로이드, 아세틸시스테인점안이치료법으로알려졌으나재발이잦다. 3,7 특히일차성안검경련환자, 안검하수등의안검질환환자와심한마비성사시환자처럼각막과눈꺼풀의비정상적인접촉및눈물의순환장애를보이는환자에서는일반적인실모양각막염의치료만으로는호전이잘되지않고재발이더잦은것으로알려졌다. 8 실모양각막염에대한원인별분류및치료에대해서국내보고가선행된바있으나 7 단순건성각결막염에의한실모양각막염보다각막의폐쇄에의한실모양각막염이치료에잘반응하지않는이유에대해알려진바가없다. 이에본연구에서는건성각결막염과비교하여각막의폐쇄에의한실모양각막염의병리학적특징을알아보고효과적인치료법을모색하고자하였다. 대상과방법 1995년 1월부터 2005년 12월까지본원에내원하여세극등현미경검사를통해진단한실모양각막염환자 35안중의무기록과환자문진및검진을통해기저안과적질환을 분석하여건성각결막염환자군, 각막의폐쇄를보이는환자군, 두가지특성을모두보이는군으로나누어의무기록을통한후향분석을통한비교연구를진행하였다. 본연구는본원의임상시험심하위원회 (IR) 의심사및승인을받았다. 건성각결막염환자군의진단기준은이물감, 자극감, 충혈, 가려움, 따가움혹은통증과같은건성안증상이한가지이상존재하면서쉬르머검사상 5분동안 10 mm 이하의결과치를보이고눈물막파괴시간이 10초이하이며특징적인각막또는결막의점상미란이관찰되는경우로하였다. 각막의폐쇄를보이는환자군은각막과눈꺼풀의비정상적인접촉및눈물의순환장애를보이는환자로일차성안검경련, 안검하수등의안검질환환자와심한마비성사시환자를포함시켰다. 일차성안검경련환자군은 Scott et al 9 의중증도분류 4단계중 3단계이상으로일상생활에활동장애가있는군으로정의하였고, 안검하수환자군은 erke 10 의방법에의해눈꺼풀올림근기능이 4 mm로저하되어있는환자를선정하였으며, 마비성사시환자군은일차안위에서 30프리즘디옵터이상의내사시환자를대상으로하였다. 그외에 stevens johnson syndrome, 수술후발생한경우, 499

3 - 대한안과학회지 2014 년제 55 권제 4 호 - 바이러스성각결막염, 장기간안대착용에의한경우, 렌즈착용에의한경우등다른원인에의한실모양각막염환자는배제하였으며본원또는타병원에서실모양각막염치료를시작한환자는배제하고초진환자를대상으로하였다. 사상체의부착기저부세포형태를관찰하기위해 proparacaine hydrochloride 0.5% (lcaine, lcon., Co., Ltd., Texas, US) 로점안마취를시행한후 3 3 mm 크기의니트로셀룰로스막을각막에올려놓고끝이뭉툭한유리봉으로 3-5초간부드럽게눌러준후벗겨내듯이살며시사상체를채취하여파라포름알데하이드로고정한후 Periodic acid-schiff (PS) 염색으로압흔세포검사를시행하였다. 압흔세포검사의뮤신함유량에따라없음 (1군), 경도 (2군), 중등도 (3군), 고도 (4군) 의표준사진을선정하였다 (Fig. 1). 환자의압흔세포검사결과를표준사진에따라분류한후실모양각막염의발생원인에따라뮤신의함유량을분석하였다. 병리검사는사상체의구조를보기위해중심섬유의횡단면과종단면을얻어 Hematoxylin and Eosin (H&E) 염색을시행하였고면역염색은사상체의구성성분을확인하기위해각막상피세포의 cytokeratin은 nti-pan Cytokeratin antibody (E1/E3) 로염색하였고막성뮤신의확인을위해 MUC1 과 16으로, 분비성뮤신의확인을위해 MUC5C 로염색하였다. 통계적검증은 SPSS 19.0 (SPSS Inc, Chicago, IL) 를사용하였으며세군이상의비교에는 Kruskal-Wallis 검정을, 두군간의비교에는 Mann-Whitney U 검정을사용하였다. Number of filaments 결 총 35안을대상으로평균연령은 56.0 ± 13.9세였으며건성각결막염만을가진환자군은 11안이었고각막의폐쇄만을보인환자군은 11안, 두가지특성을모두가진군은 13 안이었다. 따라서각막의폐쇄를보인군은총 24안으로그중원발성안검경련환자 10안, 마비성사시환자 10안, 안검하수환자 4안이었다 (Table 1). 치료는기본적으로모든환자에서인공누액, 점안항생제 (Cravit R, 0.5% levofloxacin, 0.5%, Santen, Osaka, Japan) 및보호렌즈 (Purevision, aush & Lomb, US) 착용등각막상피회복을위한치료를시행하였으며추가적으로모든안검경 * p = * p = KCS KCS + CO CO Figure 2. The number of filaments observed on silt lamp examination. The corneal occlusion group shows signigicantly less number of filaments than other groups (p < 0.05). KCS = keratoconjunctivitis sicca group; CO = corneal occlusion group. * Mann-Whitney U-test; p < 0.05 was considered statistically significant. 과 Table 1. Demographics of study population Demographics KCS KCS + CO CO Total Total No. of eyes, n (%) 11 (31.4%) 13 (37.2%) 11 (31.4%) 35 Gender (n) Male (45.7%) Female (54.3%) ge (years) 58.4 ± ± ± ± 12.9 Values are presented as mean ± SD unless otherwise indicated. KCS = Keratoconjunctivitis sicca; CO = corneal occlusion; SD = standard deviation. Table 2. The cause and treatment of 35 eyes of patients with filamentary keratitis patients examined Ocular disease Number of eyes Treatment Total number of Total number of filaments filaments before Tx after Tx (RP) KCS only 11 (31.4%) T + + T 56 5 (91.1%) Corneal occlusion 24 (68.6%) 89 0 (100%) Paralytic strabismus 10 (28.6%) (extra ocular muscle) + T + + T 38 0 (100%) Primary blepharospasm 10 (28.6%) (eyelid) + T + + T 38 0 (100%) Ptosis 4 (11.4%) P + T + + T 13 0 (100%) KCS = keratoconjunctivitis sicca; T = artificial tear; T = T-lens insertion; = botox injection; = antibiotic eyedrops (levofloxacin 0.5%); P = blepharoplasty; RP = recovery probability. 500

- 임경섭외 : 각막의폐쇄와실모양각막염 - 련환자는눈둘레근에, 모든마비성사시환자는외안근에보톡스주사를시행하였으며모든안검하수환자는윗눈꺼풀성형수술을시행하였고결과적으로 35안에서 6개월내건성각결막염만가진환자 1안을제외하고모두사상체가소실되는것을볼수있었다 (Table 2).

The keratoconjunctivitis sicca group shows signigicantly less amount of mucin than other groups (p < 0.05).

세극등현미경검사상각막의폐쇄를가진환자군의사상체수가 2.7 ± 1.4개로건성각결막염만가진환자군 (5.1 ± 2.2개, p=0.009) 및두가지특성을모두가진군 (4.5 ± 2.6개, p=0.044) 에비하여유의하게적은수의사상체가관찰되었다 (Fig. 2).

050) 에비하여유의하게낮은뮤신함유량을보였다 (Fig. 3). 사상체는다양한형태로나타났으나공통적으로중심섬유가관찰되었으며 (Fig.

4 - 임경섭외 : 각막의폐쇄와실모양각막염 - 련환자는눈둘레근에, 모든마비성사시환자는외안근에보톡스주사를시행하였으며모든안검하수환자는윗눈꺼풀성형수술을시행하였고결과적으로 35안에서 6개월내건성각결막염만가진환자 1안을제외하고모두사상체가소실되는것을볼수있었다 (Table 2). Mucin amount * p = * p = KCS KCS + CO CO Figure 3. The grade of mucin amount by standard photograph observed on impression cytology. The keratoconjunctivitis sicca group shows signigicantly less amount of mucin than other groups (p < 0.05). KCS = keratoconjunctivitis sicca group; CO = corneal occlusion group. * Mann-Whitney U-test; p < 0.05 was considered statistically significant. 세극등현미경검사상각막의폐쇄를가진환자군의사상체수가 2.7 ± 1.4개로건성각결막염만가진환자군 (5.1 ± 2.2개, p=0.009) 및두가지특성을모두가진군 (4.5 ± 2.6개, p=0.044) 에비하여유의하게적은수의사상체가관찰되었다 (Fig. 2). PS 염색을시행한압흔세포검사에서뮤신의함유량에따라시행한분류에서는건성각결막염만가진환자군은표준사진에의한등급이 1.9 ± 0.8로각막의폐쇄만을가진환자군 (2.7 ± 0.9, p=0.034) 및두가지특성을모두가진군 (2.8 ± 1.3, p=0.050) 에비하여유의하게낮은뮤신함유량을보였다 (Fig. 3). 사상체는다양한형태로나타났으나공통적으로중심섬유가관찰되었으며 (Fig. 4), 사상체의기저부에서는정상적인편평세포인각막상피세포와함께세포핵대세포질의비율이크고변색된세포질을특징으로하는화생된각막상피세포가뭉쳐사상체의중심섬유를구성하는소견을보였다 (Fig. 5). 건성각결막염군의사상체는중심섬유표본의크기가작아병리검사표본제작에실패하였고일부각막폐쇄군에서중심섬유표본제작에성공하였다. 중심섬유의종단면및횡단면 H&E 염색을시행한결과밝게보이는핵과어둡 C D Figure 4. Photographs of various filiament forms examined by impression cytology. The presence of central fiber (red arrows) are commonly observed (,, C, D: PS stain, 40). 501

- 대한안과학회지 2014년 제 55 권 제 4 호 - Figure 5.

They show homogeneous cells without im portant nuclear alterations, with eosinophilic

In the base of filaments, there were metaplastic cells with large N:C ratio, meta-chromatic

200). C D Figure 6. Pathologic specimens stained with H & E.

The deformed nuclei were aligned like bricks within the central fibers (red arrows).

cells (: 400 longitudinal sectio; : 400 transverse section; C: 1000 longitudinal section;

5 - 대한안과학회지 2014년 제 55 권 제 4 호 - Figure 5. Photographs obtained by impression cytology near the base of filaments. They show homogeneous cells without im portant nuclear alterations, with eosinophilic cytoplasm and a N:C ratio of 1:8 (arrow). In the base of filaments, there were metaplastic cells with large N:C ratio, meta-chromatic cytoplasm and frequent nuclear alterations such as twin-nuclei (arrow head) (, : PS stain, 200). C D Figure 6. Pathologic specimens stained with H & E. Central fibers were definitely confirmed (black arrows). The deformed nuclei were aligned like bricks within the central fibers (red arrows). The vicinity of the central fibers was composed of atypical substances with mucin and dead cells (: 400 longitudinal sectio; : 400 transverse section; C: 1000 longitudinal section; D: 1000 transverse section, H & E stain). 게 보이는 피질을 관찰할 수 있었다. 또한 중심섬유 내에 화 앞서 표본 제작에 성공한 실모양체 단면을 E1/E3, MUC1, 생된 세포의 핵들이 벽돌처럼 정렬되어 있는 것이 관찰되 16, MUC5C로 염색하여 관찰한 결과 뮤신을 염색 시 막성 었으며 중심섬유의 주변부는 비정형적인 물질과 세포사체 뮤신인 MUC1, 16은 중심섬유 외의 단면에서 국소적으로 들로 구성되어 있었다(Fig. 6). 편중되어 분포하나 비교적 균일하게 염색되는 반면 분비성 502

- 임경섭외 : 각막의폐쇄와실모양각막염 - C D Figure 7. In immunostaining, excluding the central fiber, the peripheral area is stained with MUC1 (), MUC5C (), and MUC16 (C) (blue arrows).

6 - 임경섭외 : 각막의폐쇄와실모양각막염 - C D Figure 7. In immunostaining, excluding the central fiber, the peripheral area is stained with MUC1 (), MUC5C (), and MUC16 (C) (blue arrows). The core of central fibers is stained with the pan-cytokeratin marker E1/E3 (D) (red arrows), but the cortex of central fibers (yellow arrows) is not staind with MUC1, 5C, 16 or E1/E3 ( 400). 뮤신인 MUC5C 는전반적인단면에분포하지만작게응집되어산란되어분포하는조금다른양상을보였으나공통적으로중심섬유바깥의주변부에서염색되는성향을보였다. 한편, nti-pan Cytokeratin antibody 인 E1/E3 은중심섬유의핵에서균일하게염색되는소견을보였으며중심섬유의피질은 MUC1, 5C, 16, E1/E3 에모두음성으로나타났다 (Fig. 7). 고찰 본연구에서각막의폐쇄에의한실모양각막염은건성각결막염에의해발생한실모양각막염에비해사상체의수가적고뮤신의함유량이많은것으로나타났다. 각막의폐쇄에의한실모양각막염에서사상체의수가상대적으로적은이유는첫째, 일차성안검경련또는안검하수등의안검질환환자와심한마비성사시환자에서각막의폐쇄가각막전체를침범하지않고부분적으로침범하기때문에각막전체를침범하는건성각결막염에비하여사상체가발생할수있는면적이적고둘째, 건성각결막염의경우각막의폐쇄에의한경우보다전반적인각막상피가약화되어각막 상피의탈락이쉬워 사상체의초기발생이쉬운점을들수있다. 한편각막의폐쇄에의한사상체는안검의폐쇄와눈물순환부전으로인하여건성각결막염에의한경우보다뮤신에노출될수있는시간이길고앞서기술한것처럼상대적으로사상체의수가적기때문에사상체각각에더많은뮤신이노출되어건성각결막염에의한사상체보다더많은뮤신을함유하는것으로생각한다. 그러므로실모양각막염의발생원인에따른효과적인치료법을고려해야할것이다. 사상체의형성기전에대해현재까지정확히밝혀지지는않았으나중증건성안이나각결막염등에의해각막의직접적인손상이유발되면안검의마찰력에의해손상된각막상피세포로부터사상체의중심이형성되고지속되는안검과각막의마찰력에의해각결막의점액성분이중심섬유주변에결합해사상체가형성된다고알려졌다. 6,8 그러나이런염증성질환에의한각막손상외에마비성사시, 일차성안검경련, 안검하수등의환자에서도관찰된다. 이런질환의공통적인병태생리로서각막의폐쇄가있고원발성안검경련, 안검하수는안검운동장애에의한각막의폐쇄, 마비성사시는안구운동부전에의한각막의폐쇄를유발한 503

7 - 대한안과학회지 2014 년제 55 권제 4 호 - 다. 14,15 본연구결과각막의폐쇄에의한실모양각막염은폐쇄된눈꺼풀뒤에발생하여숫자가적고점액은많은것으로보아눈꺼풀과안구표면사이의정상적인눈물순환장애와동시에퇴화된세포의정상적인탈락이저해되고상피화생이진행하여사상체가발생하는것으로생각된다. 압흔세포검사결과관찰된화생된각막상피세포가모여사상체의중심섬유를구성하는소견은사상체의기저부가각막에붙어기저부로부터자라나는점과함께사상체발생에있어서각막상피세포의화생이중요한역할을한다는근거가된다. 이는 Tanioka et al 6 이건성각결막염환자를중심으로사상체를채취하여 H&E 염색및면역염색을통해손상된각막상피와안검의마찰로인하여사상체가생성된다는주장한바와함께실모양각막염의중요한병리기전으로생각된다. 각막상피는 CK3, CK5, CK14 등에의하여강하게염색되고 CK4, CK10/13, CK19 에의하여약하게염색된다는최근보고가있고 16 안구표면을덮고있는점액은뮤신의구성성분으로 MUC5C 가결막술잔세포에서발현되고 17 각결막편평상피층에서는 MUC1, MUC16 등이발현됨이밝혀져있다 본원의병리검사상각막에서채취한사상체의형태는공통적으로중심섬유를가지고있으며중심섬유는핵과피질로구분되어있었다. 중심섬유는압흔세포검사에서관찰되었던사상체기저부의화생된세포의핵이더응축되어벽돌처럼정렬된형태를띄고중심섬유의핵은 CK 1, 2, 3, 4, 5, 6, 7, 8, 10, 14, 15, 16을염색하는 nti-pan Cytokeratin antibody (E1/E3) 에양성인것으로보아각막상피의변성물로추정된다. 하지만중심섬유의피질은 MUC 1, 5C, 16, E1/E3 에모두음성으로나타나변형된 cytokeratin 이나다른뮤신일가능성을염두에두고이에대한추가적인연구가필요할것으로생각한다. 중심섬유를둘러싸고있는주변부의비정형적물질은안구표면을덮고있는막성뮤신인 MUC1, 16 및분비성뮤신인 MUC5C 에양성인소견으로보아비록중심섬유의피질성분을밝히지는못하였으나, 변성되고응축된각막상피를안구표면에존재하는점액이둘러싸고있음을확인할수있었다. 또한뮤신용해제인아세틸시스테인이실모양각막염의치료제로서효과가알려진점은 21 이런뮤신의구성이사상체의상당량을차지함을입증한다고하겠다. Wright 2 는 PS, lcian blue, red oil 염색을통해사상체가점액과각막상피, 지질등으로구성되어있다고보고한바있다. 그후많은연구가있었으며 Tanioka et al 6 은중심섬유의주성분이각막상피세포에서특이적을발현되는 CK12 에염색되어각막상피가중심섬유의주성분임을주장한바있다. 하지만위의연구에서는모두중심섬유의핵이 나피질등의구체적인구조와성분을명확히밝히지는못하였다. 본연구에서는기존에알려진중심섬유와주변점액뿐아니라중심섬유자체가핵과피질로구성되어있다는것과비록피질의성분은밝히지못하였으나중심섬유의핵이각막상피세포에서기원했음을확인했다는데의의가있다. 과거건성각결막염에의한실모양각막염의치료는인공누액의점안, 보호용콘텍트렌즈착용, 항생제점안등이알려졌으며치료율은 90-97% 로다양하게보고되어왔으며 3,22-24 이는본원의건성각결막염에의한실모양각막염의치료율이 91.1% 인것과유사하다. 각막의폐쇄를가진환자군에서인공누액점안이나보호용렌즈등증상치료만으로는호전이잘되지않고재발이더잦은것으로알려졌으며심한마비성사시환자에서외안근보톡스주사, 8,15 일차성안검경련환자에서안검보톡스주사, 9,25 안검하수환자에서안검성형술등이실모양각막염의치료에좋은효과가있다고보고되어왔다. 26 본연구에서도각막의폐쇄원인해결을통해사상체가 100% 소실되는것을확인할수있었다. 본연구의한계로건성각결막염및각막폐쇄환자군의수가적은것, nti-pan Cytokeratin antibody (E1/E3) 는각막상피에특이적으로존재하는 cytokeratin인 CK12 를염색하지않는점, 피질의기원을밝히지는못한점을들수있으나각막패쇄로인한실모양각막염의조직학적구조및병태생리를연구했다는점에서의의가있다고하겠다. 안검경련, 안검하수등안검질환이나마비성사시환자에서사상체의발생은각막의폐쇄로설명해볼수있으며건성각결막염에의해발생한실모양각막염에비해사상체의수가적고뮤신의함유량이많은것을특징으로한다. 따라서이런경우인공누액및보호렌즈등보존적치료및안검수술, 사시수술, 보톡스치료등의각막폐쇄해결을통한근본적치료가동반되어야함은물론뮤신용해제제인아세틸시스테인에대한반응이더좋을수있음을시사하고이에대한추가적인연구를요한다. REFERENCES 1) eetham WP. Filamentary Keratitis. Trans m Ophthalmol Soc 1935;33: ) Wright P. Filamentary keratitis. Trans Ophthalmol Soc U K 1975; 95: ) lbietz J, Sanfilippo P, Troutbeck R, Lenton LM. Management of filamentary keratitis associated with aqueous-deficient dry eye. Optom Vis Sci 2003;80: ) Diller R, Sant S. case report and review of filamentary keratitis. Optometry 2005;76: ) Kakizaki H, Zako M, Mito H, Iwaki M. Filamentary keratitis im- 504

8 - 임경섭외 : 각막의폐쇄와실모양각막염 - proved by blepharoptosis surgery: two cases. cta Ophthalmol Scand 2003;81: ) Tanioka H, Yokoi N, Komuro, et al. Investigation of the corneal filament in filamentary keratitis. Invest Ophthalmol Vis Sci 2009; 50: ) Choi SK, Paek NH, Hong WS. Clinical observation of the filamentary keratitis. J Korean Ophthalmol Soc 1974;15: ) Unal M, Sarici. Filamentary keratopathy caused by corneal occlusion by large-angle paralytic strabismus. Cornea 2006;25: ) Scott, Kennedy R, Stubbs H. otulinum toxin injection as a treatment for blepharospasm. rch Ophthalmol 1985;103: ) erke RN. Congenital ptosis; a classification of 200 cases. rch Ophthal 1949;41: ) Gilbard JP, Farris RL, Santamaria J 2nd. Osmolarity of tear microvolumes in keratoconjunctivitis sicca. rch Ophthalmol 1978;96: ) Gao J, Schwalb T, ddeo JV, et al. The role of apoptosis in the pathogenesis of canine keratoconjunctivitis sicca: the effect of topical Cyclosporin therapy. Cornea 1998;17: ) Fox RI, Chan R, Michelson J, et al. eneficial effect of artificial tears made with autologous serum in patients with keratoconjunctivitis sicca. rthritis Rheum 1984;27: ) aum JL. The Castroviejo Lecture. Prolonged eyelid closure is a risk to the cornea. Cornea 1997;16: ) Good WV, Whitcher JP. Filamentary keratitis caused by corneal occlusion in large-angle strabismus. Ophthalmic Surg 1992;23:66. 16) Merjava S, Neuwirth, Tanzerova M, Jirsova K. The spectrum of cytokeratins expressed in the adult human cornea, limbus and perilimbal conjunctiva. Histol Histopathol 2011;26: ) Moore JC, Tiffany JM. Human ocular mucus. Chemical studies. Exp Eye Res 1981;33: ) rgüeso P, Spurr-Michaud S, Russo CL, et al. MUC16 mucin is expressed by the human ocular surface epithelia and carries the H185 carbohydrate epitope. Invest Ophthalmol Vis Sci 2003;44: ) Inatomi T, Spurr-Michaud S, Tisdale S, Gipson IK. Human corneal and conjunctival epithelia express MUC1 mucin. Invest Ophthalmol Vis Sci 1995;36: ) Inatomi T, Spurr-Michaud S, Tisdale S, et al. Expression of secretory mucin genes by human conjunctival epithelia. Invest Ophthalmol Vis Sci 1996;37: ) bsolon MJ, rown C. cetylcysteine in kerato-conjunctivitis sicca. r J Ophthalmol 1968;52: ) Hamilton W, Wood TO. Filamentary keratitis. m J Ophthalmol 1982;93: ) Fayet, ernard J, mmar J, et al. Treatment of dry eye by temporary punctum plug. Comparison with a control group. J Fr Ophtalmol 1990;13: ) Tuberville W, Frederick WR, Wood TO. Punctal occlusion in tear deficiency syndromes. Ophthalmology 1982;89: ) Gumus K, Lee S, Yen MT, Pflugfelder SC. otulinum toxin injection for the management of refractory filamentary keratitis. rch Ophthalmol 2012;130: ) Kitazawa K, Yokoi N, Watanabe, et al. Eyelid surgery for refractory filamentary keratitis. Nihon Ganka Gakkai Zasshi 2011; 115: = 국문초록 = 실모양각막염의발생에건성각결막염과각막의폐쇄가미치는영향의비교 목적 : 실모양각막염의발생에건성각결막염과각막의폐쇄가미치는영향을비교하고자한다. 대상과방법 : 실모양각막염환자중안검경련, 안검하수, 마비성사시로인해각막폐쇄를가진 11 안, 건성각결막염으로발생한 11 안, 두가지특징을모두갖는 13 안에서세극등현미경으로사상체의숫자를기록하고, 니트로셀룰로스막을이용하여일부의사상체를채취하여뮤신함유량에따라 1( 없음 )-4( 매우많음 ) 로분류하고, H&E 와면역염색 (E1/E3, MUC1, 5C, 16) 을실시하여그특징을분석하였다. 결과 : 각막의폐쇄만을보인환자군 (11 안 ) 의평균사상체수는 2.7 ± 1.4 개로건성각결막염만가진환자군 (11 안 ) 의평균사상체수 (5.1 ± 2.2 개, p=0.009) 에비하여유의하게적은수의사상체가관찰되었다. 뮤신의함유량은각막의폐쇄를가진환자군 (2.7 ± 0.9) 이건성각결막염환자군 (1.9 ± 0.8, p=0.034) 에비하여유의하게높았다. 병리검사상사상체의중심섬유는핵과피질로구성되어있으며핵은화생된각막상피세포가벽돌처럼정렬되어있고피질은전혀염색되지않았으며섬유주변은뮤신으로구성되어있었다. 결론 : 각막패쇄로발생된실모양각막염은건성각결막염에의한경우보다사상체의수가적고뮤신의함유량이많으므로치료에있어고려해야할것이다. < 대한안과학회지 2014;55(4): > 505

<283732372D3733312920B4D9C3CAC1A120BCD2C7C1C6AEC4DCC5C3C6AEB7BBC1EEC0C720B3EBBEC8C0C720BDC3B7C2BAB8C1A4BFA120B4EBC7D120C0AFBFEBBCBA20C6F2B0A1283035292E687770>

<283732372D3733312920B4D9C3CAC1A120BCD2C7C1C6AEC4DCC5C3C6AEB7BBC1EEC0C720B3EBBEC8C0C720BDC3B7C2BAB8C1A4BFA120B4EBC7D120C0AFBFEBBCBA20C6F2B0A1283035292E687770> 대한안과학회지 제 49 권 제 5 호 2008 J Korean Ophthalmol Soc 49(5):727-731, 2008 DOI : 10.3341/jkos.2008.49.5.727 다초점 소프트콘택트렌즈의 노안의 시력보정에 대한 유용성 평가 김현경 1 김효명 2 정성근 1 가톨릭대학교 의과대학 성모병원 안과학교실 1, 고려대학교 의과대학 안암병원 안과학교실