= 증례보고 = 미용적눈꺼풀테문신술후발생한마이봄샘분비장애 1 예 대한안과학회지 2013 년제 54 권제 8 호 J Korean Ophthalmol Soc 2013;54(8):1309-1313 pissn: 0378-6471 eissn: 2092-9374 http://dx.doi.org/10.3341/jkos.2013.54.8.1309 설보람 1,2 권지원 3 위원량 1,2 한영근 1,4 서울대학교의과대학안과학교실 1, 서울대학교병원안과 2, 관동대학교의과대학명지병원안과학교실 3, 서울특별시보라매병원안과 4 목적 : 눈꺼풀테문신술을시행받고양안에광범위한각막상피결손이생긴뒤적절한치료를받고회복하였으나합병증으로건성안이발생한증례를보고하고자한다. 증례요약 : 31 세여자환자가눈꺼풀테문신술직후발생한양안의심한통증과눈물흘림을주소로내원하였다. 세극등현미경검사상양안눈꺼풀테안쪽마이봄샘개구부를침범한색소침착과함께각막하부 1/2 을침범한각막상피결손이관찰되었다. 치료용콘택트렌즈를착용하고항생제안약을점안하여각막병변은회복되었으나마이봄샘개구부의비가역적인손상으로건성안이발생하여환자는지속적인불편을겪게되었다. 결론 : 미용목적의눈꺼풀테문신으로인해각막상피결손과같은급성합병증뿐아니라마이봄샘의파괴로인한건성안같은영구적인합병증이발생할수있다. < 대한안과학회지 2013;54(8):1309-1313> 눈꺼풀테문신술은눈꺼풀외양에장애가있는여성환자들의화장을간소화하기위한목적으로 1984년 ngres 1 에의해처음시도되었다. 이후미용목적으로이시술을시행받는사람들이늘어나면서이에따른합병증도보고되고있다. 눈꺼풀테문신술후안과적합병증이발생하는경우는드물고국내에서아직보고된바가없다. 저자들은눈꺼풀테문신술후광범위한각막상피결손이발생하고각막병변이완치된후에도건성안이발생하여환자가불편을겪게된증례를경험하였기에문헌고찰과더불어보고하는바이다. 증례보고 31세여자환자가심한양안의통증을주소로본원응급실에내원하였다. 환자는평소전신질환없이건강하였으며안과적질환이나외상, 수술의과거력도없었다. 인근미용실에서눈꺼풀테문신술을받은지 2시간정도지난후였으 Received: 2012. 10. 12. Revised: 2013. 3. 6. ccepted: 2013. 6. 5. ddress reprint requests to Young Keun Han, MD, PhD Department of Ophthalmology, SMG-SNU oramae Medical Center, #20 oramaero5-gil, Dongjak-gu, Seoul 156-707, Korea Tel: 82-2-870-2114, Fax: 82-2-831-0714 E-mail: eye129@paran.com 며시술직후발생한통증이점점심해진다고호소하였으며이물감및눈물흘림이동반된상태였다. 응급실에서측정한 ph는 7.6이었으며하트만용액으로세척후재측정시에도 7.6이었다. 검진당시나안시력은양안 0.5였으며양안눈꺼풀에경도의부종관찰되었고세극등현미경검사에서양안결막중등도의충혈과각막하부 1/2에걸친광범위한각막상피결손이관찰되었다 (Fig. 1). 전방에서염증소견은관찰되지않았다. 양안 0.5% Levofloxacin 점안액 (Cravit, Santen Pharm Co., Japan) 을처방하여하루 6회점안하기로하고치료용콘텍트렌즈착용후귀가하였다. 치료시작 1일후심한통증으로인해시력은협조되지않아측정할수없었고양안의각막상피결손은거의회복되었으나그표면이불규칙하였고눈꺼풀테의충혈과부종도호전되지않았다. 이에치료용콘택트렌즈를제거하고 0.1% Fluorometholone (Flumetholone, Santen Pharm CO., LTD) 을하루 4회추가로점안하도록하고, Polymixin, neomycin, dexamethasone 안연고 (Forus, Samil Pharmaceutical CO., LTD) 를처방하여자기전양안에 1회점안하도록하였다. 치료시작 3일후나안시력은우안 0.7, 좌안 1.0으로회복되었으며환자의통증도완화되어자세한세극등현미경검사가가능해졌다. 양안윗눈꺼풀경계안쪽에문신에사용된색소의침착이관찰되었다. 색소침착은마이봄샘개구부 www.ophthalmology.org 1309
- 대한안과학회지 2013년 제 54 권 제 8 호 - Figure 1. Photograph shows a severe epithelial defect at inferior cornea in the right eye () and in the left eye () on the day of cosmetic tattooing. Figure 2. Photograph shows cosmetic tattoo at inner margin of eyelid involving meibomian gland orifices. Lid margin injection and telangiectasis were shown in the right eye () and in the left eye () 3 days after eyelid tattooing. Figure 3. Photograph shows remained pigmentation at inner margin of eyelid and severe meibomian gland plugging in the right eye () and in the left eye () 2 months after eyelid tattooing. 1310 www.ophthalmology.org
- 설보람외 : 눈꺼풀테문신술에의한안손상 - 를포함하여회색선까지침범하고있었으며눈꺼풀테의부종과모세혈관의확장과마이봄샘의분비장애를관찰할수있었다 (Fig. 2). 양안각막상피결손부위는완전히회복되었으나각막하부에미세한점상각막상피진무름이관찰되었다. 이에 0.1% Sodium hyaluronate 점안액 (Hyalein, Santen Pharm Co., Japan) 을수시로점안할것을권하였다. 치료시작 2개월후환자는지속적인이물감과불편감을호소하고있었고눈물막파괴시간은양안 5초로정상치이하였다. 세극등현미경검사상양안각막하부 1/3에걸쳐점상각막상피진무름과윗눈꺼풀마이봄샘개구부를침범하는색소침착이그대로관찰되어 (Fig. 3), 눈꺼풀마사지와인공누액점안을권유하고경과관찰하기로하였다. 치료시작 1년후양안나안시력양안 1.0 이었으며환자는별다른불편감을호소하지않았고세극등현미경검사상에서도양안각막은정상소견을보였으나눈물막파괴시간은여전히 5초이내로감소되어있었다. 고찰 문신은전통적인화장을대체하는효과가있어화장을하는데걸리는시간을줄여주며물에서도지워지지않는장점이있다. 이에미용적목적으로눈썹이나눈꺼풀테, 입술에가장많이시행되고있으며유방수술후유두착색에이용되기도하며흉터가있는환자, 백반증환자에서도적용된다. 2 눈꺼풀테문신술은속눈썹이나는위치를따라색소를침투시켜속눈썹라인을또렷이하는것으로미용적목적으로널리이용되고있고, 1초당 50-150회정도진동하는문신용펜을이용해색소를진피에침투시키는원리이다. 3 수요가늘어남에따라이로인한합병증에대한보고도점차늘고있으며대부분의경우가비전문가에의해서시행되고있는것도문제로제기되고있다. 색소침착이너무짙게되거나옅게되는경우와부적절한위치에침착하는경우가가장흔한합병증으로보고되고있다. 4 Moshirfar et al 5 은눈꺼풀테외에결막및각막윤부에색소가침착되어수술적방법으로제거한경우를보고한바있으며이외에도출혈, 붓기, 감염, 알레르기성반응, 과도한흉터의발생, 눈썹의소실, 괴사, 이차성반흔성눈꺼풀겉말림, 비후성반흔, 켈로이드반응등이다양하게보고되고있다. 2,5,6 드물지만문신술후합병증으로망막에문제가생겨시력이저하된경우도보고된바있다. 7,8 본증례에서는눈꺼풀테문신술을시행받고심한각막상피결손이발생하여내원한후항생제안약점안과치료용콘택트렌즈착용으로각막병변이호전되었으나눈꺼풀테손상에의한건성안이발생하였다. 건성안의발생원인 은첫째, 시술시사용한바늘에의한마이봄샘의직접적인손상, 둘째, 마이봄샘의분비를조절하는리올란근 (muscle of Riolan) 의손상, 셋째, 시술과정에서발생한눈꺼풀테의불규칙성, 넷째, 제대로소독되지않고검증되지않은색소의독성등으로추정할수있다. 이환자의경우문신술을시행한직후통증이발생한것으로미루어눈꺼풀테두리안쪽의손상과문신용색소에의해각막찰과상이발생했을것으로생각할수있으며, 각막손상이완전히회복된후에도눈물막파괴시간이감소된것은마이봄샘과리올란근의손상이그원인으로여겨진다. 최근에는자연스러운눈꺼풀테외양을위해문신을과거보다더마이봄샘에가까운눈꺼풀테안쪽에시행하는경향을보이고있다. 따라서리올란근과마이봄샘개구부의직접적인손상이우려되며이는마이봄샘의분비저하를일으켜건성안을유발할가능성이높다고하겠다. 또한각결막과접하는눈꺼풀테의불규칙성이심해짐으로인해안구표면에눈물을펼치고유지하는기능도저하될것으로생각한다. Kojima et al 9 은눈꺼풀테문신술후발생한광범위한마이봄샘의소실로인해눈물층이불안정해져서여러문제가발생한환자의예를보고한바있다. 환자는눈꺼풀테문신술을받은상태에서라식수술을시행받고각막염이발생하였고추후각막혼탁이동반되어각막이식술을시행받았다. 그후지속적인건성안치료에도불구하고눈물층의불안정성은지속되었고눈물막파괴시간및안구표면염색점수수치는호전되지않았고, 저자들은그원인이문신에의한마이봄샘파괴라고추정하였다. Franz 10 는문신술이후 C형간염이생긴경우를보고하며시술에있어소독의중요성을강조한바있다. 국내에는문신을정식으로교육하는공인된전문가나기관이없고무균시설에서시술을하는것도아니며공인된문신용색소도없는것이현실이며이는색소독성등에의한부작용외에도다른감염의위험을높일수있을것으로생각한다. 눈꺼풀테문신술후안와연조직염과각막상피결손이동반된예도보고된바있다. Konuk et al 11 은합병증을막기위해전문가에게시술을받는것과눈꺼풀테전층을침투시키지않고시술을하는것이중요하다고언급하였고시술시화학물질에인한손상과물리적마찰에의한각막손상을막기위해각막보호장치를사용할것을제안하였다. 저자들은본증례를통하여미용적눈꺼풀테문신술이각막의손상과같은급성합병증의위험뿐아니라건성안과같은장기적합병증도가져올수있음을보고하고그밖에각결막의물리적, 화학적손상, 감염등여러발생가능한안과적인부작용에대해고찰하여이의위험성에대해 www.ophthalmology.org 1311
- 대한안과학회지 2013 년제 54 권제 8 호 - 환기시키고자한다. 또한레이저시력교정수술을고려하는환자에서도눈꺼풀테문신술시행여부를확인하는것이필요할것으로생각한다. REFERENCES 1) ngres GG. ngres permalid-liner method: a new surgical procedure. nn Ophthalmol 1984;16:145-8. 2) De Cuyper C. Permanent makeup: indications and complications. Clin Dermatol 2008;26:30-4. 3) Rudkin K. Wake up with make-up: complication of cosmetic lid tattoo. Med J ust 2011;20:194(12):654. 4) Wilkes TD. The complications of dermal tattooing. Ophthal Plast Reconstr Surg 1986;2:1-6. 5) Moshirfar M, Espandar L, Kurz C, Mamalis N. Inadvertent pigmentation of the limbus during cosmetic blepharopigmentation. Cornea 2009;28:712-3. 6) Jacob CI. Tattoo-associated dermatoses: a case report and review of the literature. Dermatol Surg 2002;28:962-5. 7) Moschos MM, Guex-Crosier Y. Retinal vasculitis and cystoid macular edema after body tattooing: a case report. Klin Monbl ugenheilkd 2004;221:424-6. 8) lexandridou, Reginald Y, Stavrou P, Kirkby GR. Candida endophthalmitis after tattooing in an asplenic patient. rch Ophthalmol 2002;120:518-9. 9) Kojima T, Dogru M, Matsumoto Y, et al. Tear film and ocular surface abnormalities after eyelid tattooing. Ophthal Plast Reconstr Surg 2005;21:69-71. 10) Franz R. Tattooing a major route of hepatitis C infection. Dermatol Nurs 2001;13:307-8. 11) Konuk O, Evereklioglu C, Hondur, Unal M. Protective eye shield can prevent corneal trauma during micropigmentation for permanent cosmetic eyeliner. J Eur cad Dermatol Venereol 2004;18: 642-4. 1312 www.ophthalmology.org
- 설보람외 : 눈꺼풀테문신술에의한안손상 - =STRCT= Case of Meibomian Gland Dysfunction after Cosmetic Eyelid Tattooing Procedure o Ram Seol, MD 1,2, Ji Won Kwon, MD, PhD 3, Won Ryang Wee, MD, PhD 1,2, Young Keun Han, MD, PhD 1,4 Department of Ophthalmology, Seoul National University College of Medicine 1, Seoul, Korea Department of Ophthalmology, Seoul National University Hospital 2, Seoul, Korea Department of Ophthalmology, Myongji Hospital, Kwandong University College of Medicine 3, Goyang, Korea Department of Ophthalmology, Seoul Metropolitan Government-Seoul National University oramae Medical Center 4, Seoul, Korea Purpose: To report a case of meibomian gland dysfunction as a chronic complication of eyelid tattooing and the corneal epithelial defect as an acute complication of eyelid tattooing well healed with proper treatment. Case summary: 31-year-old woman presented with severe eye pain, irritation and epiphora in both eyes. The patient underwent an eyelid tattooing procedure 2 hours before and dark pigments were placed on the inner eyelid margin. Slit lamp examination showed conjunctival injection and inferior corneal epithelial defect in both eyes. fter 2 months, dry eye symptom still remained although the cornea was completely epithelialized. fter 1 year, the patient improved completely, but still showed decreased tear film breakup time (TUT). Conclusions: Due to the increased number of people who undergo cosmetic eyelid tattooing procedures, the number of reports associated with complications has increased and acute complications such as corneal epithelial defect can occur. Moreover, chronic discomfort associated with dry eye syndrome can occur when pigmentation is placed on the eyelid inner margin and lead to the destruction of meibomian glands. Thus, eyelid tattooing should be performed after careful consideration of possible complications. J Korean Ophthalmol Soc 2013;54(8):1309-1313 Key Words: Corneal epithelial defect, Cosmetic eyelid tattooing, Meibomian gland dysfunction ddress reprint requests to Young Keun Han, MD, PhD Department of Ophthalmology, SMG-SNU oramae Medical Center #20 oramaero5-gil, Dongjak-gu, Seoul 156-707, Korea Tel: 82-2-870-2114, Fax: 82-2-831-0714, E-mail: eye129@paran.com www.ophthalmology.org 1313