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1 대한안과학회지 2019 년제 60 권제 6 호 J Korean Ophthalmol Soc 2019;60(6): ISSN (Print) ISSN (Online) Original Article 백내장수술후마이봄샘기능부전과눈물지질층분석 Meibomian Gland Dysfunction and Tear Lipid Layer Analysis after Cataract Surgery 오주현 박창현 황웅주 나경선 김현승 Ju Heun Oh, MD, Chang Hyun Park, MD, Woong Joo Whang, MD, Kyung Sun Na, MD, PhD, Hyun Seung Kim, MD, PhD 가톨릭대학교의과대학여의도성모병원안과및시과학교실 Department of Ophthalmology and Visual Science, Yeouido St. Mary s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Purpose: We report the clinical manifestations of dry eye syndrome after cataract surgery involving meibomian gland structure, meibomian gland function, and tear lipid layer analysis. Methods: The clinical manifestations of dry eye syndrome were retrospectively evaluated in 34 eyes of 31 patients who underwent cataract surgery from September to November The ocular surface disease index (OSDI), tear break-up time (tbut), Oxford stain score, presence or absence of blepharitis, and meibomian gland expression were measured preoperatively and at 1 week, 1 month, and 2 months postoperatively. Lipid layer thickness (LLT), partial blinks, and meibomian gland images were measured using LipiView (TearScience, Morrisville, NC, USA), an interferometric eye surface measuring device. Results: The postoperative OSDI was significantly higher than preoperative OSDI (17.09 ± 1.81): ± 1.99 at 1 week, ± 1.91 at 1 month, and ± 1.92 at 2 months (p < 0.05). The postoperative tbut was significantly lower than preoperative tbut (5.07 ± 0.39): 3.99 ± 0.31 at 1 week, 3.49 ± 0.27 at 1 month, and 4.72 ± 0.39 at 2 months (p < 0.05). The Oxford staining score increased after surgery, but the difference was not statistically significant. Postoperative meibomian gland expression was significantly lower preoperative values (4.9 ± 2.8): 4.4 ± 2.8 at 1 month, and 3.9 ± 2.8 at 2 months (p < 0.05). The LLT decreased at 1 month postoperatively and increased at 2 months postoperatively, but these differences were not statistically significant. Conclusions: Cataract surgery resulted in a short-term meibomian gland dysfunction, leading to deterioration of dry eye after cataract surgery. However, we could not confirm structural changes in the meibomian gland, so it will be necessary to observe the clinical features of dry eye syndrome over a longer period of time. J Korean Ophthalmol Soc 2019;60(6): Keywords: Cataract surgery, Dry eye syndrome, Meibomian gland, Tear film lipid layer thickness Received: Revised: Accepted: Address reprint requests to Hyun Seung Kim, MD, PhD Department of Ophthalmology and Visual Science, Yeouido St. Mary s Hospital, College of Medicine, The Catholic University of Korea, #10 63-ro, Yeongdeungpo-gu, Seoul 07345, Korea Tel: , Fax: sara514@catholic.ac.kr * Conflicts of Interest: The authors have no conflicts to disclose. 고령화에따른노인인구의증가와더불어노년생활의삶의질에대한인식이향상되면서고령자들에대한백내장수술건수도증가하고있다. 1 많은환자들은백내장수술후눈의불편감을호소하는데, 그중안구건조증의악화가중요한원인중의하나로생각되고있다. 백내장수술후발생하는안구건조증의악화원인은매우다양할것이다. 수술전소독제로사용되는 povidone iodine, 2 수술중사용되는눈벌리개, 3 각막신경손상으로인한각막민감도저하, 4 c2019 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 519
2 - 대한안과학회지 2019 년제 60 권제 6 호 - 높은조도의현미경빛에장시간노출로인한광손상, 5 눈물의염증성사이토카인의증가, 6 점안마취제 7 및수술후사용하는안약의보존제 8 등이수술후안구건조증을악화시킬수있다고보고되었다. Tear film and ocular surface society에서 2017년발표한 International Dry Eye Workshop II에따르면, 안구건조증은눈물막의항상성소실, 동반된안구증상, 눈물막불안정성, 눈물막삼투압증가, 안구표면의염증및손상, 신경감각손상으로인해발생하는안구표면의다요인성질병이다 라고정의하였다. 눈물막은점액층, 수성층, 지질층으로구성되어있으며, 지질층은수성층의증발을막아주는역할을한다. 9 마이봄샘기능부전은눈물지질층이불안정하여눈물층증발을유발하고눈물의삼투압을상승시켜안구표면을손상시킨다. 10 눈물지질층두께는마이봄샘분비변화의지표로써눈물지질층두께측정을통해마이봄샘기능이상을평가할수있을것이다. 특히백내장수술후눈물지질층두께와마이봄샘배출력이감소되는등백내장수술은눈물지질층에영향을주는것으로알려져있으나 11 백내장수술후눈물지질층두께에초점을맞춘연구가거의없다. 이번연구에서는마이봄샘의기능검사및간섭을이용한안구표면측정장치인 LipiView (TearScience, Morrisville, NC, USA) 를이용하여눈물층의지질층두께측정, 마이봄샘구조변화에대한영상분석을후향적으로시행하였으며, 이에대해백내장수술후안구건조증의단기임상양상에대하여보고하고자한다. 대상과방법 본원에서 2017년 9월부터 11월까지가톨릭대학교여의도성모병원안과에서백내장수술을시행받은 34안 (31명) 을대상으로후향적으로연구하였다. 본연구는헬싱키선언에입각한가톨릭대학교여의도성모병원의학연구윤리심의위원회의승인 (SC18RESI0141) 하에진행되었다. 모든환자는경도이상의백내장이있으며, 백내장수술전마이봄샘기능부전을진단받은환자를포함했으며, 수술전마이봄샘기능부전환자는총 27명으로마이봄샘 0등급 11명, 1등급 10명, 2등급 6명, 3등급 0명으로대부분경도의마이봄샘기능부전이었으며, 백내장수술후 2개월동안경과관찰하면서악화되는대상자가없어직접적인치료는수술 2개월이후필요시진행하였다. 수술전마이봄샘기능부전을치료중인환자는제외하였다. 3개월이내에안구수술을받은환자, 다른안과적병력이있었던환자, 콘택트렌즈를착용중인환자, 다른안약을점안중이었던환자는제외하였다. 수술은동일한술자 (K.H.S.) 에의해이측에 2.85 mm 크기의투명각막절개를가했으며, CENTURION Vision System (Alcon Laboratories, Fort Worth, TX, USA) 을이용하여수정체유화술을시행하고후방에연성인공수정체삽입술을시행하였다. 수술후처치는동일하게 moxifloxacin (Vigamox, Alcon Laboratories) 4회, Fluorometholone (Ocumetholon, Samil Co. Ltd., Seoul, Korea) 4회를 1개월간, bromfenac (Bronuck, Taejoon Pharm., Seoul, Korea) 2회를 2개월간점안하였으며, 술전, 술후 1주, 1개월, 2개월에경과관찰하였다. 동일한연구자가매내원시마다모든환자들의안구표면질환지수 (ocular surface disease index), 눈물막파괴시간검사 (tear break up time), 안구표면염색점수 (Oxford stain score), 안검염유무, 마이봄샘배출평가를시행하였으며, 간섭을이용한안구표면측정장치인 LipiView (TearScience) 를이용한눈물층지질층두께측정 (lipid layer thickness), 부분눈꺼풀깜빡임횟수 (partial blink), 마이봄샘구조영상분석을시행하였다. 안구표면질환지수설문지는안구건조증증상관련질문 3가지, 시야관련질문 6가지, 환경자극관련질문 3가지로구성되어있으며, 각질문마다 0에서 4점으로응답하여각점수의총합을답변한질문수로나누어전체점수를측정한다. 0점에서 100점으로평가하며점수가클수록증상이심함을나타낸다. 정상 (0-12점), 경도 (mild, 13-22점 ), 중등도 (moderate, 23-32점 ), 중증 (severe, 33점이상 ) 으로등급을나누고있다. 12 눈물막파괴시간검사는 Fluorescein (Haag- Streit International, Koniz, Switzerland) 이묻어있는검사지에멸균생리식염수 (Daihan Pharm Co., Ltd., Seoul, Korea) 를한방울떨어뜨려결막낭에접촉시킨후피검사자가눈을 3회깜빡이고세극등현미경의코발트블루광원의빛을최대로밝게한후스스로눈을깜빡이지않고뜨게했을때염색된눈물막에첫결손이생길때까지의시간을초단위로기록하였다. 안구표면염색점수는 Oxford stain score 에따라등급을나누었으며, Fluorescein 검사지로염색한후세극등현미경에서코발트블루광원을이용하여 10배율로관찰하였을때각막과안구결막에염색된모양에따라 0부터 5까지등급을나누었다. 13 또한저자들은세극등현미경을사용하여안검연의변화와마이봄샘의배출양상을파악하였다. 소실이있으면서안검판을손가락으로압박하였을때안검염중앙의 8개의마이봄샘배출구중 5개이하에서배출되는경우폐쇄안검염군, 마이봄샘구조는정상이면서 6개이상에서배출되는과분비를보이는경우지루안검염군으로구분하였다. 14 LipiView (TearScience) 는눈물막지질층에서반사되는빛의간섭현상을이용한검사로, 나노미터단위의눈물지 520
3 - 오주현외 : 백내장수술후안구건조증의임상양상 - 질층두께를측정하고, 눈깜빡임동역학과마이봄샘구조를이미지로구현한다. 검사전안연고, 지질성분이함유된점안액사용을금지했으며, 검사전눈꺼풀이영향받지않도록 30분간안정을취한후검사를시행하였다. 관찰기간동안평균눈물지질층두께를측정했으며, 단위시간 20초동안상하안검이완전히닫히지않는횟수를측정하여부분눈꺼풀깜빡임횟수를측정하였다. LipiView (TearScience) 에서얻은마이봄샘촬영 (meibography) 을분석하여상안검과하안검의소실, 꼬임, 확장을분석했다. 마이봄샘등급에대한공통적으로일치된평가기준은없으며, 마이봄샘의 수, 마이봄샘소실, 확장, 흉터등의범위에따라등급을나눈몇가지연구들이있다. 15 본연구에서는마이봄샘의소실, 확장, 흉터가관찰되는범위에따라 1/3 이하, 2/3 이하, 2/3 이상 3등급으로나누었다 (Fig. 1, 2). 통계학적분석은 IBM SPSS ver (IBM Corp., Armonk, NY, USA) 을이용하였고, 수술후각시간대별안구표면질환지수, 눈물막파괴시간검사, 안구표면염색점수, 안검염유무, 마이봄샘배출평가, 눈물층지질층두께측정, 부분눈꺼풀깜빡임횟수를수술전값들과비교할때는반복측정분산분석 (repeated-measures analysis of variance) 을 A B C Figure 1. Images of Meibomian gland drop out, tortuosity, ectasis cases of meibographs, captured by LipiView (TearScience, Morrisville, NC, USA). Meibography image analysis examples. The freehand tool in ImageJ was used to select the area of meibomian gland, and computerized analysis of the area of Meibomian gland. (A) Meibomian gland drop out, partial or total gland loss or atrophy. (B) Meibomian gland tortuosity. (C) Meibomian gland ectasis, partial or total gland dilatation. A B C D Figure 2. The grading of Meibomian gland loss. Partial or complete loss of Meibomian gland is scored for each eyelid from grade 0 to grade 3. (A) Grade 0 means no loss of meibomian glands, normal Meibomian gland. (B) Grade 1 means the lost area was less than 1/3 of total area. (C) Grade 2 means the lost area was between 1/3 and 2/3 of total area. (D) Grade 3 means the lost area was more than 2/3 of total area. 521
4 - 대한안과학회지 2019 년제 60 권제 6 호 - 이용하였다. LipiView (TearScience) 에서얻은마이봄샘촬영으로안검판의소실, 조임확장, grade를술전과술후 2개월째에비교했으며 paired t-test와 Wilcoxon signed rank test로분석하였다. 안검염의유무, 마이봄샘배출력에따라대상자를폐쇄안검염군과지루안검염군으로나누어안구표면질환지수, 눈물막파괴시간검사, 안구표면염색점수, 마이봄샘배출평가, 눈물층지질층두께측정, 부분눈꺼풀깜빡임횟수를수술전후각시간대별비교에 paired t-test 와 Wilcoxon signed rank test로분석하였다. p값의유의수준은 0.05 미만으로하였다. 결과 대상환자는 34안 (31명) 이었으며, 34안의평균연령은 65.9세 (48-81세) 였다. 남자 17명, 여자 17명이었으며, 12명 (38.7%) 이당뇨, 15명 (48.4%) 이고혈압, 1명 (3.2%) 이천식을진단받았다. 백내장수술전환자의안구건조증상태를파악하기위해안구표면질환지수 ± 1.81, 눈물막파괴시간검사 5.07 ± 0.39, 안구표면염색점수 1.35 ± 0.19, 마이봄샘배출력 4.9 ± 2.8, 눈물지질층두께 ± 3.75, 부분눈꺼풀깜빡임횟수 0.28 ± 0.04를알아보았다 (Table 1). 안구표면질환지수는술전 ± 1.81, 술후 1주 ± 1.99, 1개월 ± 1.91, 2개월 ± 1.92로유의하게증가되었다 (p<0.05) (Table 2, Fig. 3). 눈물막파괴시간검사는술전 5.07 ± 0.39, 술후 1주 3.99 ± 0.31, 1개월 3.49 ± 0.27, 2개월 4.72 ± 0.39로눈물막파괴시간이유의하게감소되었다 (p<0.05) (Table 2, Fig. 3). 안구표면염색점수는술전 1.35 ± 0.19, 술후 1주 1.38 ± 0.17, 1개월 1.64 ± 0.20, 2개월 1.64 ± 0.19로수술후증가하는양상을보였으나유의한차이는없었다 (Table 2, Fig. 3). 마이봄샘배출력은술전 4.9 ± 2.8, 술후 1개월 4.4 ± 2.8, 2개월 3.9 ± 2.8 로유의하게감소되었다 (p<0.05) (Table 2, Fig. 3). 눈물지질층두께는술전 ± 3.75, 술후 1주 ± 3.54, 1개월 ± 4.11, 2개월 ± 3.40으로수술전에비해수술후감소되는양상을보였으나유의한차이는없었으며, 부분눈꺼풀깜빡임횟수는수술전 0.28 ± 0.04, 수술후 1주 0.25 ± 0.04, 1개월 0.19 ± 0.03, 2개월 0.19 ± 0.03 으로수술전보다수술후감소되는양상을보였으나유의하지않았다 (Table 2, Fig. 3). LipiView (TearScience) 에서얻은마이봄샘촬영으로안검판의소실, 꼬임, 확장, grade를수술후기간에따라변화를분석한결과, 술전과술후 2개월째에비교했을때모두유의한차이는없었다 (Table 3). 마이봄샘기능장애의분류별로임상양상을비교하기위해대상자중안검염의유무, 마이봄샘배출력에따라대상자를폐쇄안검염군과지루안검염군으로나누어비교하였다. 정상안검 7명, 눈꺼풀앞쪽눈꺼풀염 4명, 눈꺼풀뒤쪽눈꺼풀염 23명이었으며, 폐쇄안검염군 17명, 지루안검염군 9명이었다 (Table 4). 눈물지질층두께는술후 1주폐쇄안검염군 ± 17.59, 지루안검염군 ± 12.46, 술후 1개월 Table 1. Demographics of study group Number of eyes Gender Age OSDI tbut (seconds) Corneal staining LLT (OD:OS) (M:F) (years) 20:14 17: ± ± ± ± ± 3.75 Values are presented as mean ± standard deviation unless otherwise indicated. OD:OS = oculus dexter:oculus sinister; M:F = male:female; OSDI = ocular surface disease index; tbut = tear break up time; LLT = lipid layer thickness. Table 2. The follow up data after cataract surgery Preop Postop 1 week Postop 1 month Postop 2 months p-value OSDI ± ± ± ± 1.92 <0.001 * tbut (seconds) 5.07 ± ± ± ± 0.39 <0.001 * Corneal staining 1.35 ± ± ± ± Meibomian gland expressibility 4.9 ± ± ± ± 2.8 <0.001 * LLT ± ± ± ± Partial blink 0.28 ± ± ± ± Values are presented as mean ± standard deviation unless otherwise indicated. Preop = preoperative; Postop = postoperative; OSDI = ocular surface disease index; tbut = tear break up time; LLT = lipid layer thickness. * Significant correlations (p < 0.05); repeated-measures analysis of variance. 522
5 - 오주현외 : 백내장수술후안구건조증의임상양상 - A B C D E F Figure 3. Analysis of the Meibomian gland expressibility, lipid layer thickness, Ocular surface disease index (OSDI), tear film break-up time preop and postop. (A) Change in OSDI from preoperative value. The increase in OSDI was statistically significant at 1 week, 1 and 2 months postoperatively compared to preoperative value (p < 0.05). (B) Change in tear break-up time (tbut) from preoperative value. tbut was significantly short at 1 week, 1 and 2 months postoperatively compared to the preoperative value (p < 0.05). (C) Change in corneal staining score from preoperative value. There was an increase in the corneal staining score at 1 week, 1 and 2 months postoperatively (p > 0.05). (D) Change in Meibomian gland expressibility from preoperative value. Meibomian gland expressibility was significantly decreased at 1 and 2 months postoperatively compared to the preoperative value (p < 0.05). (E) Change in lipid layer thickness from preoperative value (p > 0.05). (F) Change in partial blink from preoperative value (p > 0.05). Repeated-measures analysis of variance, compared with preoperative values. Preop = preoperative; Postop = postoperative; w = week(s); m = month(s). * Significant correlations (p < 0.05). Table 3. Change in lid parameters of MGD before cataract surgery and postop 2 months Preop Postop 2 months Upper lid Lower lid Upper lid Lower lid Drop out (%) p-value * 9.1 ± ± ± ± Tortuosity (%) p-value * 8.8 ± ± ± ± Ectasis (%) p-value * 4.4 ± ± ± ± Grade p-value * 0.6 ± ± ± ± 1.14 Compare to lid margin abnormality, drop out, tortuosity, ectasis, grade from preoperative value. There was no statistically significant difference between 2 months postoperatively and preoperative value (p > 0.05). Values are presented as mean ± standard deviation unless otherwise indicated. MGD = meibomian gland dysfunction; Preop = preoperative; Postop = postoperative. * Wilcoxon signed rank test, compared with preoperative values. p < 0.05 were considered statistically significant, significant correlations (p < 0.05). 523
6 - 대한안과학회지 2019 년제 60 권제 6 호 - 폐쇄안검염군 ± 26.07, 지루안검염군 ± 11.69, 술후 2개월폐쇄안검염군 ± 21.11, 지루안검염군 ± 7.60으로측정되었다. 술후모든기간동안두군간에유의한차이가있었고, 지루안검염군에서눈물지질층두께가높은것으로나타났다 (Table 5). 눈물막파괴시간검사는수술후 1주폐쇄안검염군 3.00 ± 1.16, 지루안검염군 4.59 ± 1.53으로두군간에유의한차이가있었으며, 폐쇄안검염군에서눈물막파괴시간이더짧은것으로나타났다 (p<0.05) (Table 5). 수술 1개월, 2개월후에는두군간에유의한차이가없었다 (Table 5). 마이봄샘배출력은수술후 1주폐쇄안검염군 3.00 ± 2.17, 지루안검염군 6.89 ± 1.45, 수술후 1개월폐쇄안검염군 2.97 ± 2.50, 지루안검염군 6.11 ± 1.76, 수술후 2개월폐쇄안검염군 2.35 ± 2.31, 지루안검염군 6.00 ± 1.92로, 수술후관찰한모든기 Table 4. Preoperative characteristics of groups stratified by Meibomian gland disese Anterior blepharitis Posterior blepharitis Normal Staphylococcal Seborrheic Obstructive Seborrheic Table 5. The follow up data after cataract surgery compare with obstructive and seborrheic MGD Obstructive group Seborrheic group p-value LLT Preop ± ± * 1 week ± ± * 1 month ± ± * 2 months ± ± * tbut Preop 3.98 ± ± week 3.00 ± ± * 1 month 2.82 ± ± months 2.88 ± ± Meibomian gland expressibility Preop 3.21 ± ± 1.38 <0.001 * 1 week 3.00 ± ± 1.45 <0.001 * 1 month 2.97 ± ± 1.76 <0.001 * 2 months 2.35 ± ± 1.92 <0.001 * OSDI Preop 1 week 1 month 2 months ± ± ± ± ± ± ± ± Corneal staining score Preop 1 week 1 month 2 months Partial blink Preop 1 week 1 month 2 months 1.59 ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± LLT was significantly higher in obstructive MGD at preoperative value, 1 week, 1 and 2 months postoperatively compared to obstructive and seborrheic MGD. tbut was significantly short in obstructive MGD at 1 week postoperatively compared to obstructive and seborrheic MGD. Meibomian gland expressibility was significantly higher in seborrheic MGD at preoperative value, 1 week, 1 and 2 months postoperatively compared to obstructive and seborrheic MGD. There was no statistically significant difference in OSDI, Corneal staining score, partial blink compared to obstructive and seborrheic MGD. Values are presented as mean ± standard deviation unless otherwise indicated. MGD = meibomian gland dysfunction; LLT = lipid layer thickness; tbut = tear break up time; OSDI = ocular surface disease index. * p < 0.05 were considered statistically significant, significant correlations (p < 0.05); Wilcoxon signed rank test compared with preoperative values. 524
7 - 오주현외 : 백내장수술후안구건조증의임상양상 - 간동안두군간에유의한차이가있었고, 폐쇄안검염군에서마이봄샘배출력이떨어지는것으로나타났다 (Table 5). 안구표면질환지수, 안구표면염색점수, 부분눈꺼풀깜빡임횟수는폐쇄안검염과지루안검염두군간에모두유의한차이가없었다 (Table 5). 고찰 과거눈물막은점액층, 수성층, 지질층의세층으로구성되어있다고알려져있었으나, 현재의눈물막-안구표면구조의개념은수성겔과안구표면에서안쪽지방층까지점점줄어드는점액성분으로이루어진준안전성의눈물막으로이해하고있다. 10 그러므로눈물의적절한생성및증발로인한균형있는눈물막의유지는안구표면의안전성유지를위해필수적이다. 그러나마이봄샘기능부전은눈물지질층이감소하여눈물막이불안정해지고이는증발성안구건조증을심화시킨다. 16 백내장수술후많은환자들이안구건조증으로인한눈의불편감을호소하고있으며, 안구건조증의중요한악화원인중하나가마이봄샘기능부전으로생각되고있다. Lee and Cho 17 의연구에서백내장수술전마이봄샘질환이심할수록안구건조증악화가능성이크다고하였으며, Park et al 18 은백내장수술을시행한환자중비안구건조증군에비해안구건조증이있는군에서마이봄샘기능부전이악화되었다고한바, 백내장수술과마이봄샘기능부전의밀접한관련이있음을보고하였다. 본연구는더나아가증발성안구건조증의주요요소인눈물층의지질층두께와부분눈꺼풀깜빡임횟수, 안검판에서의마이봄샘구조의변화를포함하여다양한안구건조증의객관적검사징후와환자의주관적증상정도를분석하여백내장수술후발생하는안구건조증의임상양상을알아보고자한다. 안구건조증의진단과정도의평가에는눈물막안정성을평가하는눈물막파괴시간, 각막염색, 쉬르머검사등여러객관적인검사방법들이존재하나절대적인표준이될수있는검사법은없다. 19 본연구에서는안구표면질환지수, 눈물막파괴시간검사, 마이봄샘배출력, 안구표면염색점수, 눈물지질층두께, 부분눈꺼풀깜빡임횟수를안구건조증평가에이용하였다. Oh et al 20 은백내장수술후각막민감도와눈물막안정성은점점수술전상태로회복되는양상이나안구건조증증상점수는백내장수술후 3개월이지나서야개선을보였다고했다. 본연구에서는안구표면질환지수는백내장수술 2개월후까지유의하게감소된것을확인했으며개선을확인하기위해서는 3개월이상의긴관찰기간이필요할것이다. Sahu et al 21 은수정체유화술후눈물 막파괴시간검사, 쉬르머검사, 눈물띠높이가수술전에비해악화되었다고하였다. 이는본연구에서평균눈물막파괴시간이수술전과비교하여수술후관찰한모든시점에서유의하게감소한것과일치하는결과이다. 마이봄샘배출력은술후 1개월이지난후부터유의하게감소되었으며, 안구표면질환지수와평균눈물막파괴시간은모든시점에서유의한차이를보인것으로미루어보아최소 1개월이상의장기간관찰이필요할것으로생각된다. 본연구에서마이봄샘배출력은수술후유의하게더악화되는양상을보였으나, 안구표면염색점수는수술후관찰기간동안유의하지않게약간증가하는양상을보였다. 그러나 Foulks and Bron 22 에따르면상안검의마이봄샘폐쇄와하안검의소실이심할수록안구표면염색점수가유의하게높았다고하였다. 이는수술후사용한안약의영향이거나마이봄샘의구조적문제가아직기능적으로안구표면염색점수에영향을미치기전이라고추측하였다. 눈물지질층두께는수술전보다수술후감소하는양상을보였으나유의한차이는없었으며, 폐쇄안검염군과지루안검염군두군간의눈물지질층두께의유의한차이는확인할수있었다. 이는 Kim et al 11 이안구건조증및마이봄샘기능저하가있는환자에서백내장수술후유의하게눈물지질층두께가감소된것을보고한것과상응하는결과이다. 또한 LipiView (TearScience) 로부분눈꺼풀깜빡임횟수를측정하여안구건조증증상을객관적으로평가하고자하였으며, 본연구에서는관찰기간동안유의한차이를보이지않았다. 컴퓨터사용, 마취안약점안, 바람등은부분눈꺼풀깜빡임을일으킬수있으며, 불완전한눈깜빡임은눈물막깨짐을증가시켜각막염색이증가한다는보고가있다. 23 또한본연구에서안검염을폐쇄안검염군과지루안검염군으로나누어시간이지남에따라안구건조증지표를비교한결과, 관찰한모든시점에서마이봄샘배출력과눈물지질층두께가유의한차이를보였으며, 안구표면질환지수, 평균눈물막파괴시간, 안구표면염색점수, 부분눈꺼풀깜빡임횟수는두군간에유의한차이가없었다. 이를통해폐쇄안검염이눈물지질층의파괴가더심하며마이봄샘배출력이떨어지는것을알수있었고, 안검염특징에따라환자가느끼는증상이차이가있거나각막병변이더잘생기는것이아님을알수있었다. 저자들은본연구의결과로백내장수술전에비해백내장수술후안구건조증에대한주관적인불편감증가, 눈물막파괴시간감소, 마이봄샘배출력감소를확인하였으며, 마이봄샘기능저하에따른안구건조증의악화로판단하였다. 백내장수술후발생하는마이봄샘의기능저하는여러가지요인이원인일수있다. 먼저, 백내장수술시사용하 525
8 - 대한안과학회지 2019 년제 60 권제 6 호 - 는눈벌리개는눈꺼풀의마이봄샘에기계적인자극을줄수있으며, 이는마이봄샘의염증을유발할수있다. 염증은마이봄샘의배출력을떨어뜨려눈물층을불안정하게하는요인이될수있다. 둘째로, 수술후각막지각이감소하면서눈깜빡임이줄어들면서마이봄샘의배출될수있는빈도가감소하면서눈물층의지질이부족할수있다. 셋째로수술후눈물층의염증매개체가증가하게되면해부학적위치상으로접해있는마이봄샘도염증성변화가생기면서마이봄샘배출구에기능적인폐쇄가생길수있다. LipiView (TearScience) 를이용한마이봄샘촬영상마이봄샘구조는유의할만한큰변화를보이지않았으나, 마이봄샘배출력이수술후 1개월이지난후부터유의한감소를보인것으로볼때더장기간의추적관찰이필요할것이다. 본연구는일반적인진료환경과유사하게백내장수술을받는환자전체를대상으로진행하였기에정상인과마이봄샘기능장애가있는환자가섞여있는한계점이있다. 안구건조증의임상양상의결과분석에있어서정상인과마이봄샘기능저하환자만을구분하여연구를진행수술전기존질환의정도에따른안구건조증변화양상을보다명확하게확인할수있었을것으로생각된다. 이번연구를통해기존보고와일치하게백내장수술은마이봄샘기능을악화시켜안구건조증이단기적으로악화되는것을확인할수있었다. 특히 LipiView (TearScience) 를사용하여눈물지질층과마이봄샘구조의단기변화를관찰하였다. 백내장수술후안구표면질환지수, 눈물막파괴시간검사, 마이봄샘배출력이유의하게악화된것을확인하였으며, 눈물지질층두께감소는유의하지는않지만경향성이있었다. 또한폐쇄안검염군과지루안검염군에서눈물지질층두께가통계적으로유의한차이가있는것을확인하였다. 마이봄샘구조는유의한변화를나타내지않았으나, 2개월은마이봄샘기능을평가하는데에상대적으로짧은시간이었을것으로생각된다. 추후백내장수술후발생한마이봄샘기능부전과안구건조증의임상양상에대해장기간추적관찰을통한연구가필요할것으로사료된다. REFERENCES 1) Lee HS. The factors influencing health-related quality of life in the elderly: focused on the general characteristics, health habits, mental health, chronic diseases, and nutrient intake status: data from the Fifth Korea National Health and Nutrition Examination Survey (KNHANES V), J Korean of Community Nutrition 2014;19: ) Ridder III WH, Oquindo C, Dhamdhere K, Burke J. Does age influence the effect of povidone iodine 5% on the cornea? Austin J of Clinical Ophthalmol 2017;4: ) Moon H, Yoon JH, Hyun SH, Kim KH. Short-term influence of aspirating speculum use on dry eye after cataract surgery: a prospective study. Cornea 2014;33: ) Xu KP, Yagi Y, Tsubota K. Decrease in corneal sensitivity and change in tear function in dry eye. Cornea 1996;15: ) Hwang HB, Kim HS. Phototoxic effects of an operating microscope on the ocular surface and tear film. Cornea 2014;33: ) Massingale ML, Li X, Vallabhajosyula M, et al. Analysis of inflammatory cytokines in the tears of dry eye patients. Cornea 2009;28: ) Nwaji ECS, Barrhah GHO. The effect of local anesthetics on tear production. J Nigerian Optometric Association 2005;12: ) Simone JN, Whitacre MM. Effects of anti-inflammatory drugs following cataract extraction. Curr Opin Ophthalmol 2001;12: ) Choi SH, Kim NJ, Jung SY, Cha MB. Lipid layer thickness in precorneal tear film. J Korean Ophthalmol Soc 1997;38: ) Kim EC. Diagnosis and treatment of dry eye syndrome. J Korean Med Assoc 2018;61: ) Kim JS, Lee H, Choi S, et al. Assessment of the tear film lipid layer thickness after cataract surgery. Semin Ophthalmol 2018;33: ) Miller KL, Walt JG, Mink DR, et al. Minimal clinically important difference for the ocular surface disease index. Arch Ophthalmol 2010;128: ) Bron AJ, Evans VE, Smith JA. Grading of corneal and conjunctival staining in the context of other dry eye tests. Cornea 2003;22: ) Shimazaki J, Sakata M, Tsubota K. Ocular surface changes and discomfort in patients with meibomian gland dysfunction. Arch Ophthalmol 1995;113: ) Pult H, Nichols JJ. A review of meibography. Optom Vis Sci 2012;89:E ) Lam SM, Tong L, Duan X, et al. Longitudinal changes in tear fluid lipidome brought about by eyelid-warming treatment in a cohort of meibomian gland dysfunction. J Lipid Res 2014;55: ) Lee JA, Cho YK. The Influence of preoperative meibomian gland disease on dryness after cataract surgery. J Korean Ophthalmol Soc 2016;57: ) Park Y, Hwang HB, Kim HS. Observation of influence of cataract surgery on the ocular surface. PLoS One 2016;11:e ) Smith J, Nichols KK, Baldwin EK. Current patterns in the use of diagnostic tests in dry eye evaluation. Cornea 2008;27: ) Oh T, Jung Y, Chang D, et al. Changes in the tear film and ocular surface after cataract surgery. Jpn J Ophthalmol 2012;56: ) Sahu PK, Das GK, Malik A, Biakthangi L. Dry eye following phacoemulsification surgery and its relation to associated intraoperative risk factors. Middle East Afr J Ophthalmol 2015;22: ) Foulks GN, Bron AJ. Meibomian gland dysfunction: a clinical scheme for description, diagnosis, classification, and grading. Ocul Surf 2003;1: ) Himebaugh NL, Begley CG, Bradley A, Wilkinson JA. Blinking and tear break-up during four visual tasks. Optom Vis Sci 2009;86:E
9 - 오주현외 : 백내장수술후안구건조증의임상양상 - = 국문초록 = 백내장수술후마이봄샘기능부전과눈물지질층분석 목적 : 마이봄샘의구조, 기능및눈물지질층분석을통해백내장수술후발생하는안구건조증의임상양상에대하여보고하고자한다. 대상과방법 : 2017 년 9 월부터 11 월까지백내장수술을받은 34 안 (31 명 ) 을대상으로후향적으로안구건조증의임상양상을분석하였다. 수술전, 수술후 1 주, 1 개월, 2 개월에안구표면질환지수, 눈물막파괴시간, 안구표면염색점수, 안검염, 마이봄샘배출평가를시행하였다. 간섭을이용한안구표면측정장치로눈물지질층두께, 부분눈꺼풀깜빡임, 마이봄샘을촬영하여분석하였다. 결과 : 안구표면질환지수는수술전 ± 1.81, 1 주 ± 1.99, 1 개월 ± 1.91, 2 개월 ± 1.92 로수술전보다유의하게증가하였다 (p<0.05). 눈물막파괴시간검사는수술전 5.07 ± 0.39, 1 주 3.99 ± 0.31, 1 개월 3.49 ± 0.27, 2 개월 4.72 ± 0.39 로유의하게감소하였다 (p<0.05). 안구표면염색점수는수술후증가하는양상이었으나유의한차이는없었다. 마이봄샘배출력은수술전 4.9 ± 2.8, 1 개월 4.4 ± 2.8, 2 개월 3.9 ± 2.8 로유의하게감소되었다 (p<0.05). 눈물지질층두께는유의한차이는없었다. 결론 : 이연구는백내장수술이단기적으로마이봄샘기능저하를일으켜백내장수술후안구건조증이악화된다는것을보여주었다. 하지만유의한마이봄샘의구조적인변화양상은확인할수없어안구건조증의임상양상에대한장기적경과관찰이필요할것이다. < 대한안과학회지 2019;60(6): > 오주현 / Ju Heun Oh 가톨릭대학교의과대학여의도성모병원안과및시과학교실 Department of Ophthalmology and Visual Science, Yeouido St. Mary s Hospital, College of Medicine, The Catholic University of Korea 527
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대한안과학회지 2017 년제 58 권제 7 호 J Korean Ophthalmol Soc 2017;58(7):788-796 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2017.58.7.788 Original Article 눈물지질층두께와안구표면임상인자간의상관관계분석
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The e-business Studies Volume 17, Number 4, August, 30, 2016:319~332 Received: 2016/07/28, Accepted: 2016/08/28 Revised: 2016/08/27, Published: 2016/08/30 [ABSTRACT] This paper examined what determina
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Pharmacotherapeutics Application of New Pathogenesis on the Drug Treatment of Diabetes Young Seol Kim, M.D. Department of Endocrinology Kyung Hee Univ
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Kor. J. Aesthet. Cosmetol., 및 자아존중감과 스트레스와도 밀접한 관계가 있고, 만족 정도 에 따라 전반적인 생활에도 영향을 미치므로 신체는 갈수록 개 인적, 사회적 차원에서 중요해지고 있다(안희진, 2010). 따라서 외모만족도는 개인의 신체는 타
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