NGHIEN CLfU KHOA HOC
K E T Q U A D I E U T R I T A C N H A N H T I N H M A C H V O N G M A C HINH THAI THIEU MAU BANG LASER 532 nm
(Hoang Thi Thu Ha*. Hoang Thj Phuc*) TOM TAT
Muc tieu: danh gia hieu qua dieu tri benh tdc nhanh linh mach vdng mac (tdc NTMVM) hinh thai thieu mdu bang laser 532nm.
Doi tuong va phirong phap nghien cuu: md la him sdng. 44 mdt (44 henh nhdn - BN) bj tdc NT Ml M hinh thai thieu mdu duac dieu tri bang laser 532 nm tai khoa Day mdt - MBD. Benh vien Mdt Tl "tii thdng 1 - 20(1 den lining 12 200S. Danh gid ket qua phdn then miic dp: hieu qua (rdi lot. tdi) vd khdng hieu qua.
Ket qua nghien cuu: suit dieu trj laser I thdng cd 37 mdi (84,1%) hieu qua kit. sau 12 thdng la 29 (65.9%,).
('d I mat dieu trj khdng hieu qua qua thdi gian theo ddi 12 thdng. Da sd tin luc khdng thav ddi trudc vd sau (lieu tii laser Tin lire tang sau dieu tri I thdng cd 6 mat 115. 7%). sau 12 lining hi 14 mdt. chiem tv le 31.9%,.
Mot mat cd hien cluing king sinh .xa vong mac sau then tri. 23 BN cd kem theo king huyet dp (52.3%,). 3 B.\ vira mdc henh ddi thao dining vd king huyet dp. Moi sd henh ly loan than khde nhu rdi loan md mdu (4), benh ly van lim (3), benh ly he mach canh cd (4). ('hira lim thay nguyen nhdn henh toim thdn chiem 36.3%, (16 BN).
Ket luan: sir clung laser Id phirong phap dieu trj duy nhdi. cd hieu qua ngdn ngiiu kin much cao ddi vdi benh Idc NTMVM hinh thai thieu man. ( ac yeu tu loan than huy gap Id tdng huyit dp. rdi loan md mdu.
henh ly much canh cd...
I ir khoa: tdc nhanh linh mach vdng mac. laser 532nm.
I. DAT VAN DE
Tac tTnh mach vong mac (tac TMVM) la benh K vong mac (VM) tuong doi pho bien (d My. tan suat benh dirng thir hai sau benh vong mac dai thao duang). Benh thudng gap a lira luoi tren 50 \;i la nguyen nhan ga\ giam silt thi lire tram trong. tham chi cd the dan den mil loii do nhung bien cluing nang ne. Benh xuat hien thuong kem theo cac benh ly toiin than nlur benh tang huyet ap. dai thao dudng. benh van tim... ga\ anh huong rat Idn den sire khoe cua BN. l ac TMVM phan theo \ i tri giai phau gdm: tac nhanh tTnh mach vong mac (tac NT- MVM) va tac tTnh mach trung tam vdng mac (tac
'Benh vien Mdi Trung uang
TMTTVM). Tac TMVM phan theo lam sang gdm hinh thai thieu man va khdng thieu man cho ca hai
\ i tri tac giai phau. Hinh thai thieu mau la hinh thai dac biet nang ne, ngoai gay giam thi lire tram trong benh cdn nhanh chdng mil loa do bien chirng tang sinh tan mach rat nhanh gay xuat huyet dich kinh.
bong vong mac co keo. Sir dung laser la phuong phap dieu tri duy nhat cd hieu qua ngan ngira tan mach cao ddi vdi benh tac TMVM hinh thai thieu man.
Muc tieu nghien ciru: danh giti hieu qua diiu tri henh Idc nhanh linh much vung mac hinh thai thieu mdu bang laser 532nm.
Nhan khoa Viet Nam (So 17 4/2010) 27
NGHIEN CLTU KHOA HOC
II. DOI Tl ONG VA PHI ONG PHAP 1. Doi tirong nghien ciiu
Cac BN bi tac NTMVM hinh thai thieu mau duoc chan doan xac djnh theo tieu chuan cua nhom nghien ciiu \e benh tac NTMVM ciia M\ nam 1986
\a duoc dieu tri bang laser 532 nm tai khoa Da\
mat - MBD. Benh \ ien Mat TL tir thang 1 - 2007 den thang 12 - 2008.
Tieu chuan logi trir. tinh trang toan than nang.
gia \eu khong ngoi lam laser duoc. BN co benh l\
tai mat nlur due the thu_ tinh nhieu. seo giac mac.
thoai hoa hoac viem giac mac...can tro tia laser.
BN tir choi dieu tri.
2. Phuong phap nghien ciru
Mo ta lam sang khong doi chirng. Cae BN tac NTMVM duoc dieu tri bang laser 532nm. Laser toan bp viing VM thieu tuoi mau vdi ciic not laser sat nhau. Dieu chinh cac thong so ky thuiit de hieu qua tao diroc la cac \et man trang due tren VM.
Thong so ky thuat:
- Cudng dp laser: 150 - 350 miii Oat.
- Thdi gian xung: 0.2 - 0.3 giay.
- Kich thudc vet laser: 150 - 500 nanomet.
Danh gia ket qua phan theo mire tip: cti hieu qua (rat tot va tot), khdng bieu qua.
Bang 1. Danh gid ket qua
~7~7 ~ — ______ Hieu qua
Danh gia ' Thi lire
Rut tot Tang > I
hang
Tdi khdng lang hoac lang 1 hang
klidng hieu i/uu Giam
Thi irirdng khong
lha_\ ddi khong tha\ ddi Ton hai tang Dim hieu him siing: vuat liet bong, xuat Mat i i i.i m Tirng hu\ ct VM. phu dia thi...
Tun much mdi Khong cd Khdng co Co
Tun much cu Mai 1 hoai trien Khong thoai trien
1 img thieu mint mdi Khong cd Khdng cd Cd
Bien chirng: Kin mach. xuat huyet dich kinh... Khong co Khdng cd Cd III. KET QUA
Tdng so 44 mat cua 44 BN tac NTMVM hinh thai thieu man dupe dieu tri bang laser 532nm. 24 mat tac nhanh tinh mach thai duong tren \a 20 mat tac nhanh tinh mach thai duong dudi. Khdng gap BN nao tac NTMVM o ca hai mat va khdng gap BN nao tac NTMVM phia mui.
Bang 2. Phdn hd henh nhdn theo tudi vd gidi
Tudi 41 -49 SO - 60 61 -T9 Tung sd
Gidi n "'• n % u O
0 n o
Nam 1 2.3 9 20.5 7 15.9 17 38,6
Nu 0 15.6 8 18,1 15 29,6 11 61.4
l ong so 15.9 I"7 58.6 20 45.5 44 100
Benh nhan nir nhieu hon nam. clui \en d lira tudi 50 -79.
NGHIEN Cut) KHOA HOC
Being 3. Cdc yen to nguy ca
Benh ly So BN %
Tang huyet ap 52,3
Dai thao dudng 3 6.8
Roi loan mo man 4 9,1
Benh ly mach canh 4 9.1
Benh ly van tim 3 6.8
Benh than 3 6.8
Benh glocom i 2,3
Khdng thay K do .6 36.3
Tang huyet ap la benh toan than ha\ gap nhat chiem 52.3%.
Bang 4. Thi luc trudc va sau diiu tri (DT)
Thi luc <0J 0,1 -<0,3 0,3 -<0,7 >0,7 Ton <> sd Thoi giaii""—— n "•• ii n % ii % u %
Thi lire trudc D T 16 36.4 12 27.3 1 1 25 5 1 1,3 44 100 Sau DT 1 thang .18 40.9 13 29.5 10 22.8 3 6.8 44 100 Sau DT3 thdng 17 38.6 12 27.3 12 27,3 3 6.8 44 100 Sau DT 6 thdng 15 34.1 I 3 29,5 12 27.3 4 9,1 44 100 Sau DT 12 lining 13 29,5 14 31,8 12 27,3 5 11,4 44 100 Thi luc tru'dc va sau dieu tri da sd khdng thay ddi.
Biing 5. Cdc ddu hieu lam sdng trudc vd sau dieu tri
"~~~~-\^Thd'i gian TD Trudc
DT Sau DT 1
thung Suu DT3
thiing Sau DT6
thdng Sau DT 12 thung
Dau hieu LS n n % n n % n /(>
Thieu mdu VM 44 100 1 s 34,1 0 0 0
Xudt huyet VM 44 100 44 100 34 77.2 22 50 7
Tdn mach dia thi + VM 2 2 7 1 0
Phii hodng diem 8 18.2 5 11.4 3 0 0
Phii iliu thi 1 1 25 11 25 7 15,9 7 0
Thieu mdu hodng diem I 1 1 1 1
Nhan khoa Viet Nam (So 17 4/2010) 29
NGHIEN CLCU KHOA HOC
Xuat tiet bong 44 100 44 100 14 31,9 ~) 0 0 - 5 vet 26 54.1 28 65,6 10 22,8 "j 0
6 - < 10 vet 16 36,4 15 34,1 3 1 0
> II) vit 2 1 i 0 0
Xuat tiet ciing r — -> 1 0
Truoc dieu tri. tat ca BN deu co thieu mau VM, xuat huy&t VM va xuat tiet bong vcVi so luong xuat tiet khac nhau (100%). Sau 6 thang cln con 50% sd BN co xuat huyet VM. Sau 12 thang cac trieu chung lam sang tieu gin het. chi con 2 ca xuat huyet VM. Co 1 ca trudc va sau dieu trj thieu mau hoang diem khdng thay ddi nhung \ ung thieu mau VM duoc thay the hoan toan bang seo laser, khdng xuat hien them viing VM thieu mau mdi va tan mach. Trudc dieu trj 1 ca da cd tin mach o dTa thi va 1 ca cd tan mach o VM. Sau 1 nam dieu tri. tan mach da thoai trien.
Bang 6. Thi trudng trudc vd sau dieu tri Thi truong
riidi gian
Khuyet gdc Khdng lam chrffc Tdng so Thi truong
riidi gian n n %
Trudc DT 43 97,7 1 2,3 44 100
Sau DT 1 thdng 43 97,7 1 2.3 44 100
Suit DT 3 thung 43 97.7 1 2,3 44 100
Suit DT 6 tilling 43 97.7 1 2,3 44 100
Sua DT 12 thdng 43 97,7 2.3 44 100
Thj trudng trudc va sau dieu tri khdng thay ddi.
Biing 7. Sd Idn dieu tri laser Ty le
Sd lan ——
So BN "a
1 9 20.5
2 25 56.8
3 7 15.9
4 6,8
Tong sii 44 100
Da sd benh nhan phai dieu tri tir 2 lan tro len (56,8%).
NGHIEN CLrU KHOA HOC
Bdn<> 8. Hieu qua dieu tri
~~ Thoi gian TD I lining 3 lining 6 thung /2 //;<(//','
Hieu qua n "', n % n n " o
Rut tot 6 13.7 Kl 22.8 14 3 1,9 14 3 1,9
Tin 37 84,1 3 3 75 2° 65,9 29 65,9
Khdng tot i 1 -> -i 1 2 -i 1 -) i
Tdng \d 44 100 44 100 44 100 44 100
Sau 1 thang dieu trj co den 84.1% so BN co hieu qua tot. Sau 12 thang con so nay la 65.9%. Sau 12 thang co 3 1,9% so BN co hieu qua dieu tri rat tot.
Biing 9. Bien cluing trong vd sau dieu tri Thoi gian
Bien clui ng ""--^
Tmn» DT / lilting .? thdng 6 lining 12 thiing Thoi gian
Bien clui ng ""--^ n n /ti n % n Ai n
Dun 16 36,4 0 0 0 0
lung sinh xo' 1 M 0 1 1 1 1
I'hii liming diem 0 5 1 1.3 0 0 0
Trong khi lam laser. 16 BN bj dau. Sau 3 thang co 1 BN bj tang sinh xo trudc VIM. Sau
BN phii hoang diem lan toa. thane co 5
IV. BAN LUAN
Trong nhiim nghien ciru cua chimg toi. benh tac NTMVM gap chu \eu o lira tuoi 50 70 phii bop vdi cac nghien ciru trong nirdc [1.2] va ngoai nude [3 ]. day eimg la lira tudi xuat hien cac benh ly toan than, cd den 18/44 BN khi bj benh mat. di kham toan than mdi biet minh cd benh tang huyet ap. rdi loan md mau va benh l\ mach canh. Benh gap d nir nhieu hon nam (61.4% so vdi 38.6%). sir khac biet cd y nghTa thdng ke vdi p < 0.05. Ket qua nay ciing ph LI hop vdi nghien ciru cua Le Van Tha (2002) [2].
Thj lire v a thi trudng cua BN trudc \ a sau dieu trj rat it tha) ddi. ket qua na) ciing phu bop \di cac nghien ciru trong va ngoai nude [1.2.3.4]. Do vay.
trude khi dieu tri can giai thich k\ vdi BN, tranh
trudng hop BN nan long khdng hop tac dieu tri va theo ddi benh khi thay thi lire khdng hoac it cai thien.
Tang huyet ap la benh ly toan than dupe phat bien nhieu nhat (52.3%), nguyen nhan nay chi diing thir 2 trong nghien ciru ciia Le Van Tha (2002) [3], chiing tdi cho rang cd sir khac nhau nay do ty le benh tang huyet ap o Viet Nam ngav cang gia tang.
Nam 1992, ty le benh tang huyet ap d Viet Nam la 11.6% da tang len 16.3% nam2002. Theo nghien ciru cua Hayreh S.S va cdng sir (2001) [6], tang huyet ap la nguyen nhan bang dau chiem 40%.
Ngoai ra cdn cac nguyen nhim khac nhu rdi loan md man. dai thao dirdng. benh K he mach canh...
eimg gap d nhirng BN bi tac NTMVM cua cluing tdi. Day la cac yen td ngu) co cd \ nghTa trong benh
Nhan khoa Viet Nam (So 17 4/2010)
I NGHIEN CLTU KHOA HOC
tac NTMVM [6].
Cac dau hieu lam sang sau dieu tri 1 thang hau nhu khong thay doi. Thieu mau VM la dau hieu dupe quan tam nhieu nhat. Sau 1 thang dieu tri. chi con 15 mat con viing thieu mau chua laser dii tren anh chup mach ky huynh quang VM (mot so BN phai lam laser 2.3 tham chi 4 lan do BN dau hoac do nhieu ly do BN khong hop tac dieu tri. cluing toi chii dong lam tiep laser sau 4 den 5 ngay). Sau 3 thang dieu tri. khong BN nao con sot viing VM thieu man va khong BN nao xuat hien viing thieu man moi. Ket qua nay cao hon nghien ciru ciia Biii Minh Ngoc (1994) [1] va Le Van Tha (2002) [2]
co y nghia thong ke vdi p<0.001. Chimg tdi cho rang sd di cd duoc ket qua cao nhu vay la do the he laser mdi. kich thudc va cudng dd laser dam bao sd not laser phii kin het v iing VM thieu mau. Hon nira. theo thdi gian. kinh nghiem dieu tri laser ciia cac bac sy dupe nang cao cung gdp phan tang hieu qua dieu tri. giam bien chirng trong va sau dieu tri.
Trong sd 11 BN cd phii dia thi trudc dieu tri, phai den sau 12 thang cac dau hieu nay mdi het. trong khi dd chi cdn 5 BN phii hoang diem sau dieu tri I thang, sau 6 thang khdng cdn BN nao phii hoang diem. Trudc va sau dieu tri khdng cd BN nao cd phii hoang diem dang nang. 100% BN cdn xuat hu>et VM sau 1 thang dieu tri vdi nhieu hinh thai khac nhau. Sau 6 thang theo ddi xuat huyet VM v an cdn d 50% tdng sd BN va sau 12 thang con sd na\ la 4.5%. Xuat tiet bong mat di nhanh hou xuat huyet VM. sau 6 thang theo ddi chi cdn 4,5% BN cdn xuat tiet bong va sau 12 thang theo ddi, xuat tiet bong hoan toan mat het. Ket qua nay phii hpp vdi nghien ciru ciia Biii Minh Ngpc (1994) [1] va Le Van Tha (2002) [2]. Trudc dieu trj cd I BN cd tan mach dTa thi va I BN cd tan mach VM. sau dieu tri laser 6 thang, tan mach VM thoai trien khdng cdn xuat hien tren anh chup huynh quang nhung phai sau 12 thang dieu tri tan mach dTa thi mdi thoai trien.
Trong khi lam laser, cd den 16 BN. chiem 36,45% cd cam giac dau. tuy cam giac dau nhieu it tuy tung BN nhung khdng cd BN nao bd dieu tri vi dau. Dau do tia laser vdi cac cudng dp khac nhau tac ddng vao than kinh the mi dai va than kinh the mi ngan. Bien cluing nav cua chimg tdi it hon Le Van Tha va Biii Minh Ngpc cd le do loai laser cd budc sdng khac nhau. Bien chirng tang sinh xo trudc VM xuat hien d 1 BN sau dieu tri 3 thang.
Nhdm nghien ciru ve benh Tac NTMVM ciia My nam 1986[7] eimg gap bien chirng nay do cudng dp laser qua cao. Cac bien chirng khac y van nhac tdi nhu: bong mdng mat, bong giac mac, phan xa mat - tim... cluing tdi khdng gap cd le do sd lupng nghien cuu chua nhieu. Tat ca cac BN dau nhieu cluing tdi phai lam laser it nhat 2 lan de dam bao toan bp viing thieu man vdng mac dupe thav the bang seo laser.
Ca biet cd den 3 BN cluing tdi phai lam laser den 4 lan do BN so dau qua gay tang huyet ap. Nlur vay van de giai thich, tu van cho BN het sire quan trpng de BN hop tac hon vdi bac sy dieu tri.
Ve hieu qua dieu tri. sau 1 thang cd den 84,1 % sd BN cd hieu qua dieu tri tot. Sau 12 thang cd 31.9% sd BN cd hieu qua dieu tri rat tot tire la khdng nhirng ngan ngira dupe bien chirng tang sinh tan mach vdng mac ma thi lire ciia BN dirpc cai thien. Khdng gap trudng hpp nao xuat huyet dich kinh trudc. trong va sau dieu tri. Mdt trudng hop BN xuat hien tang sinh xo trudc VM nhung ngoai v iing hoang diem nen khdng gay anh hirdng den thi lire. Qua theo ddi 12 thang theo ddi BN nay. cluing tdi thay tang sinh xo khdng phat trien them, khdng gay them bien chirng gi khac.
V. KET LUAN
Laser quang ddng VM dieu tri benh Tac NT- MVM hinh thai thieu mau la phuong phap dieu tri duy nhat va cd hieu qua cao trong viec ngan ngira tang sinh tan mach VM - nguyen nhan gay mat thj lire. Dau la bien chirng hay gap nhat khi lam laser.
NGHIEN CU'U KHOA HOC
Chua gap bien chiing nguy hiem nao anh hudng tdi ket qua dieu tri benh. Tang liu\et ap la benh toan than ha\ gap nhat, ngoai ra cdn gap mdt sd TAI LIEU THAM KHAO
benh nhu: dai thao dudng. rdi loan md man. benh ly mach canh.
I. BUI MINH NGOC (1994). ' Sudung laser trong dieu tri benh trang thieu tudi mdu ". Luan van tot nghiep bac s\ chuyen khoa cap II, Trudng Dai hoc Y Ha Ndi.
2. LE VAN THA (2002). "Ddi chieu gida soi din' mat vd chup mach huynh quang trong chdn doim benh tdc tinh mach vdng mac vd sir dung laser Diode de phdng bien chirng", Luan van tot nghiep bac sy chuyen khoa cap II.
Trudng Dai hoc Y Ha Ndi.
3. BRANCH VEIN OCCLUSION STUDY GROUP (1986), "Argon laser scatter photocoagulation for preven- tion of neovasculation and vitreous hemorrage in branch vein occlusion ", Arch. Ophthalmol. 104: 34-41.
4. ELEX E.K.. DESMOND A.. AND FRANK W.N (1971). "Photocoagulation in complications secondary to branch vein occlusion ", Arc. Ophthalmol. 85: 48 -60.
5. FRANCIS A.L/ESPERANCE JR (2005). Ophthalmic lasers. The C. V. Mosby Company, 2005, 11: 752 - 788.
6. HAYREH S.S, ZIMMERMAN B.. MCCARTHY M..I ET AL (2001). "Systemic diseases associated with various types of retina! vein occlusion ", AJO. vol 131(1): 1-12.
7. IKUNO Y.. IKEDA T..SANTO Y. ET AL (1998). "Tractional retinal detachment after branch vein occlusion ".
Ophthalmol vol 105 (3): 417 - .423.
SUMMARY
LASER 532NM PHOTOCOAGULATION FOR PREVENTION OF NEOVASCULARIZATION IN ISCH- EMIC BRANCH RETINAL VEIN OCCLUSION
Objectives: to evaluate the efficacy of laser 532nm photocoagulation for prevention of neovascularization in ischemic branch retinal vein occlusion (BRI O).
Methods: clinical observation, noncomparative case series.
Results: 44 ischemic BRl'O eyes were treated by diode laser 532 nm photocoagulation in the Retinal &
Uveal Department of Vietnam National Institute of Ophthalmology from Jan 2007 to Dec 2008. After 12 months follow-up. retinal neovascularization is not seen in all BRVO eyes. The visual acuity is improved in 31.5% of the cases. One case had fibrous pre-retinal after laser. Macular or papilla edema exists long lime in 8 patients with associated general disease such as t 'holesteremia. t'ardiovalvular diseases. Carotid diseases...
Conclusions: laser 532nm photocoagulation is effective procedure for prevention of neovascularization in ischemic BRVO. The risk factors for treatment results is associated severe general diseases.
Keywords: ischemic branch retinal vein occlusion, laser 532nm.
Nhan khoa Viet Nam (So 17 4/2010)
