ANGLE GLAUCOMA PATIENTS DIEU TR!

(1)

TCNCYH Phu trwong 74 (3) - 2011

Summary

APPLICATION OF

HUMPHREY MATRIX PERIMETRY IN DETECTING THE VISUAL FIELD DEFECTS IN OPEN- ANGLE GLAUCOMA PATIENTS

To assess visual field (VF) defects found by Zyppy Estimated Test (ZEST) in a 24- 2 test pattern of Humphrey Matrix perimetry. Design: Descriptive crosSjSeetional study. Participants: Forty eight glaucoma or suspected glaucoma eyes of 27 subjects were recruited for an observational study. Methods: All eyes were eligible for study measured VF with standard automated perimetry (SAP), program 24- 2, SITA strategy and with Humphrey Matrix, program 24- 2, ZEST strategy. Results: Test duration was significantly shorter for Matrix (SAP, 351.5 ± 52.2 seconds; Matrix, 311.7 ± 17.3 seconds; p < 0.05, t- test). The Humphrey Matrrix showed VF defects more than SAP one eye. Mean threshold value was significantly lower with Matrix compared to SITA (p < 0.001, paired t- test). There was no significant difference in MD and PSD between the 2 devices (P> 0.05, paired t- test). Matrix delineated significantly smaller (p < 0.05, X^- test) and deeper (p < 0.05, t- test) defects than those found with SITA. The test-retest intervals of FDT2 was neariy uniform contraste.d with those of SAP.Conclusions: Matrix field defects were smaller and deeper than those appearing in SITA perimetry. The test-retest intervals of FDT2 was nearly uniform over the measurement range of the instrument, contrasted with those of SAP. Ability to detect VF defects of the two devices are the same.

Keywords: open angle glaucoma, visual field, perimetry

DIEU TR! BENH LOAN DyQNG NOI MO GIAC MAC DI TRUYEN FUCHS BANG GHEP GIAC MAC XUYEN

Le X u i n Cung, Hoang Minh Chau Benh vien Mat Trung uang

Danh gii kit qua cua phiu thuit ghep giac mac xuyen aiu tri benh lopn dwang npi md giac mac di truyin Fuchs va tim hiiu cie yiu td anh hudng din kit qua ciia phau thuat Ddi twang va phwang phap: Can thiep lim sing khdng doi chung. 9 mat (8 bpnh nhin) bj loan dwang ndi md giic mac di tmyin Fuchs dwac phiu thuat ghep giic mac xuyen tai khoa Kit giic mac, Benh vien Mat Trung wang tw thing 6 nam 1999 din thing 6 nim 2008. Kit qua: Sau mo mpt nam cd 5 mat (55,6%>) cd manh ghep trong, 2 mat (22,2%,) manh ghep md va 2 mit (22,2%) manh ghep due. Mac dii ty le manh ghep trong cd giam din sau md nhwng sau 4 nam vin cd 50% manh ghep trong. Sau mo mdt nim cd 3 mat co thj Iwc tot (3/10 din < 5/10), 4 mat cd thj Iwc < dim ngdn tay (DNT) 3 met (m). Sau mo 4 nam van cdn 25%, sd mat co thj Iwc tw 5/10 din 8/10. Hai mat (22,2%,) xuit hien phan img loai manh ghep dan den hong manh ghep vi mdt mat bj hdng manh ghep nguyen phat Khdng cd trudng hap nao bj biin chimg trong phiu thuit Kit luin: Ghep giac mac xuyen cho kit qua tot vdi benh loan dwdng ndi md giac mac Fuchs. Cie yiu to giy due manh ghep li: phan img loai manh ghep va hdng manh ghep nguyen phat

Tu- khoa: loan du-o-ng noi mo giac mac dl truy§n Fuchs, ghep giac mac xuyen

I. O A T V A N D £ > '^^"'^ t)'^u h'^"^ '3 nhu-ng ton thuang guttata d mgt sau viing trung t i m giic mac lim bong t i bio nSi Loan duang ndi md giac mac di truyin l i mdt ^^ Gjgj ^oan mudn, khi ton thuang guttata xuat trong cie hinh thii loan dudng giic mac di truyin hidn nhiiu, t i bio ndi md mit nhieu khdng cdn kha rit hiim gip. Benh dugc Fuchs md ta lin d i u tien pang bii trCr lim cho giic mac bj ngim nude v i trd nim 1910 [1]. Benh tiin triin d 2 m i t khdng can ndn phu, lim thj lye eua benh nhin giam nhiiu vi xCrng nhau. Giai doan sdm khi giic mac cdn trong, mit kich thich [2]. Cho den nay, phuang phip dieu

(2)

trj duy nhit l i phiu thuit ghep giic mac. TCr nim 1999 benh d i dugc nghien eCru tai khoa Kit giic mac, benh vien Mat Trung uang, mdt sd benh nhin d i dugc diiu trj bing phiu thuit ghep giic mac xuyen [3]. ChCing tdi thye hien nghien eCru niy nhim dinh g i i kit qua eua phiu thuit ghep giic mac xuyen v i eic yiu to anh hudng den kit qua cua phiu thuit tren nhdm benh ly nay.

II.

D 6 |

TU'QNG VA PHU'QNG

P H A P I.Ddi tu-gng

Benh nhan bj loan dudng npi md Fuchs dugc phiu thuat ghep giic mac xuyen tai khoa Kit giac mac, benh vien Mit Trung uang tCr thing 6/1999 den thing 6/2008 va dugc theo ddi den hit thing 12/2008.

2. Phu'ang phap

Can thiep lim sing khdng ddi chCrng.

3. Cich thipc

Trude mo: benh nhan dugc ghi nhin thj luc, nhan ip, kham xic djnh ton thuang bing sinh hien vi den khe v i hien vi npi md (niu mit ben kia giac mac cdn trong).

- Ghep giic mac xuyen vdi manh ghep dugc liy tir cac ngin hang mit My do cac to ehCrc quoe t i vien trg dung trong Ip bao quan. Cie budc phiu thuit dugc tien hanh nhu sau:

+ Giy te canh nhin c i u v i mi bing lidocain 2%, gay te be mat nhan cau bing tra dicain 2%, dat vdng co djnh cung mac vdi 4 mui chf khau 7- 0.

+ Chuan bj nin ghep: khoan giac mac ed kich thude 7 hoac 7,5mm, khoan xuyen thung de lay bd manh ghep benh ly.

Bang 1. Thj ILPC cua benh

+ Chuin bj manh ghep ngudi hien: khoan d i lay manh ghep cd dudng kinh Idn han khoan tao nin ghep 0,5mm, khoan xuyen thung tir phia ndi md de liy manh ghep.

+ Dat manh ghep len tren nen ghep va khiu manh ghep vio nin ghep bing 16 mui chi khiu rdi 10-0 each diu nhau.

+ Bam dung djch ringer lactat d i phuc hoi tiin phdng.

+ Tiem khing sinh v i corticoid canh nhin ciu, tra md khang sinh, bang m i t

Dieu trj sau phau thuat Khang sinh, corticoid, thude ha nhan ap tra tai mit va udng. Diing corticoid giam lieu din trong vdng it nhat mpt nam sau mo.

Theo ddi sau phiu thuat khi benh nhan nim vien se dugc kham lai hang ngay, khi benh nhan ra vien se dugc hen kham lai djnh ky. Cac chf tieu theo ddi: thj lye, nhan ap, tinh trang mep mo, manh ghep, nhirng biin chCrng sau mo: viem mang bd dao, nhiem khuin, phan Crng loai manh ghep.

III. K^T QUA

1. Tinh hinh benh nhan

Cd 9 mit d 8 benh nhan dugc phau thuat ghep giic mac xuyen, trong dd cd 7 benh nhin nam v i 1 benh nhin nir, mdt benh nhan dugc phau thuat 2 m i t Cd 2 mit dugc phiu thuit phoi hgp liy the thuy tinh due dit the thuy tinh nhan tao, 2 mit dugc phiu thuat ghep lai. Trong sd benh nhin nghien eCru hiu hit trong ICra tuoi 36- 60 tuoi vdi 7 benh nhan (87,5%), tuoi trung binh la 55,3 tuoi.

2. Thj liPC benh nhan tru'd'c phlu thuat nhan tru'd'c p h l u thuat

Thi lu'C DNT < 1 m DNT 1 m den < 3m DNT 3 m den < 1/10 Sd mit

Trude phau thuit t i t ca mit deu cd thi luc < 1/10.

3. Nhan ap benh nhan tru'd'c p h l u thuat

Tit ca mit trude phau thuit diu cd nhin ap binh thudng vdi mCrc nhan ap 18 ± 2,5 mmHg.

4. Thj liPc benh n h i n sau p h l u thuat

Diin bien thj luc benh nhin sau phiu thuit theo thdi gian sau khi da dugc diiu chinh loan thi bing cit chi cich quang v i deo kinh dugc the hien d bang sau (xem bang 2).

Nhu viy, sau 1,5 nim vdi 9 mit phiu thuit ghep giic mac thi cd tdi 4 mit (44,5%) van trong tinh trang mil Ida vdi thi lye < DNT 3m. Sau 5 nim ed mpt mit dat thj lye cao (5/10 den 8/10) v i mpt mit cd thj luc kdm (< DNT 3m).

(3)

"~~~~~^ TL TG ^ " ^ - ^ Trude mo 6 thing

1 nim 1,5 nim 2 nim 2,5 nim 3 nim 4 nam

< DTN3m 7 77,8%

0 0,0%

4 44,5%

3 37,5%

2 40,0%

1 25,0%

2 50,0%

Bang 2. Thj liPC DNT3m den

<3/10 2 22,2%

0 0,0%

1 11,1%

2 22,2%

0 0,0%

benh nhan 1/10 den

<3/10 0 0,0%)

9 100%

1 11,1%

0 0,0%

2 25,0%

1 20,0%

2 50,0%

1 25,0%

sau p h i u thuat 3/10 den

<5/10 0 0,0%o

0 0,0%

3 33,3%o

2 22,2%

2 25,0%

2 40,0%

0 0,0%)

0 0,0%

5/10 den 8/10

0 0,0%o

0 0,0%)

0 0,0%

1 11,1%

1 12,5%

0 0,0%

1 25,0%

Tong 9 100%

9 100%

8 100%

5 100%

4 100%

5. Nhan ap benh nhan sau p h i u thuat

Sau phiu thuit ed 2 mit ed tang nhan i p do phan u-ng loai manh ghep. Ca 2 m i t niy nhin i p diu trd v i binh thudng khi phan Crng loai manh ghep dugc diiu trj on djnh.

6. Tinh trang manh ghep sau md

Sy trong suit eua manh ghep sau mo: diin biin sy trong suit eua manh ghep sau mo theo thdi gian theo ddi dugc t h i hien d bang sau.

Bang 3. SIP trong s u i t cua manh ghep

^ ^ ^ ^ ^ TTTS

TG ^~~~^~-...^^ Tronn 6 thing

1 nim 1,5 nim 2 nim 2,5 nim 3 nam 4 nam 1

9 100%

5 55,6%

5 62,5%

3 60,0%

2 50,0%

Ma 0 0,0%)

2 22,2%

1 11,1%

0 0,0%

1 25,0%

0 0,0%)

Due 0 0,0%)

2 22,2%

3 33,3%)

3 37,5%)

2 40,0%

1 25,0%

2 50,0%

Tdng 9 100%

9 100%

8 100%

5 100%

4 100%)

4 100%

Sau mo 2 nim ed 62,5%) trudng hgp ed manh ghdp trong. Nhii-ng m i t cd manh ghep md v i dgc cung xuit hidn sdm sau phiu thuit vdi 44,4%) so mit cd manh ghdp md v i due sau mo mdt nim. Niu tinh tgi thdi diem kit thuc nghien eu-u thi ed 6 mit ed manh ghep trong v i 3 m i t manh ghdp due. Chl ed 2 mit c6 thdi gian theo ddi tCr 5 nam den 9 nim sau mo, trong dd ed mdt m i t ed manh ghdp trong v i mdt mit c6 manh ghep dye.

7. Cac y i u td anh hu'ang d i n SIP trong sudt cua manh ghep

Trong 3 mit bj due manh ghdp ed 2 m i t l i dp phan Crng Ipai manh ghdp v i mdt m i t dp hdng nfianh ghdp nguydn phit do bdnh ly cua ndi md nen ghep. Trpng 2 m i t cd phan Crng logi manh ghdp ed mdt mk ghdp lai v i mdt mit cd tin mach siu trude me ed kem theo phiu thuit the thuy tinh. Nhu viy, phiu thuit gh6p

(4)

lai, tin mach siu trude mo v i phiu thuit t h i thuy tinh phoi hgp ed t h i l i y i u td nguy ea giy ra phan Crng loai manh ghep v i gian tiip giy ra due manh ghep. Ngoii ra, chung tdi khdng gap cac biin chirng khac.

IV. BAN LUAN

Vdi benh loan dudng ndi md giic mac di truyin Fuchs, dieu trj npi khoa chi cd t i c dung tam thdi lim giam trieu chCrng kich thich va khi benh cd biin chu-ng viem hoac loet giac mac. Phlu thuat ghep giac mac xuyen vdi muc dich thay the giac mac benh ly bing md giac mac lanh td ra co hieu qua vdi nhdm benh ly nay. Tuy vay, thi luc sau mo nhin chung khdng cao, mac du thi luc cd tang han sau mo nhung van d mCrc thip, sau mpt nam nhdm mit cd thi luc ONT< 3m v i n chiim ty le cao (44,5%) va phai sau 3 nam nhom thi luc tot (5- 8/10) mdi tang din v i on dinh. Mpt nghien cCru tuang tu cua Olsen T va cpng su vdi thdi gian theo ddi trung binh 50 thing cung cho kit qua gin tuang duang kit qua nghien cu-u cua chung tdi vdi 42% so mit cd thi lye < 1/10 ma theo tie gia nguyen nhin l i do giac mac bj phu due do phan Crng loai manh ghep, tang nhan ap va die biet la manh ghep bj hong do npi md benh ly tir nin ghep di cu vao manh ghep vdi 12% sd mit [4].

Theo ddi diin bien su trong suit cua manh ghep Chung tdi nhin thiy, trong 3 thing diu sau mo tat ca cie trudng hgp manh ghep diu trong, sau mo mpt nam cd 2 mit cd manh ghep bi md va 2 mit bj due manh ghep. Theo nghien eCru cua Olsen T. va cdng sy vdi thdi gian theo ddi 50 thing cd 39% cac trudng hgp bi due manh ghep, thip han ket qua nghien cCru cua chung tdi (50%) [4]. Nguyen nhan giy ra phii due manh ghep l i do phan Crng loai manh ghep va die biet l i do hien tugng hdng manh ghep nguyen phat, diy l i hien tugng manh ghdp bi phu due din sau mdt thdi gian giir dugc trong suit m i khdng lien quan din phan Crng loai manh ghep, do benh ly cua ndi md nen ghep. Trong 2 mit bj loai manh ghep trong nghien eCru cd mpt mit ghep lai va mdt mit cd t i n mach s i u trude mo cd kem theo phiu thuit the thuy tinh, nhung mit niy diu d giai doan mit bii ndi md, giic mac phii bpng bieu md giy viem trgt bieu md tai p h i t Cf m i t cd tin mach g i i c mac, do he miin djch cua ngudi

nhin cd dieu kien tiip xue d i han vdi khang nguyen tir manh ghep ngudi hiin thdng qua he tin mach nen lim ting nguy ca gay ra phan Crng loai manh ghep. Vdi mit ghep lai do he miin djch da min cam vdi khing nguyen manh ghep tir lan ghep trude nen nguy ca xuat hien phan Crng loai manh ghep cao han lan diu. Trong nghien cCru nay, ty le phan Crng loai manh ghep la 22,2%, cao han mdt nghien cCru cua Jonas J.B. (7,7%) [5]. Do trong 9 mit dugc ghep giac mac co din 8 mit d giai doan mit bu, giac mac phii bong trgt bieu md day la yiu td giup cho he miSn djch cua ngudi nhan tiip xCic de han vdi khang nguyen manh ghep, lam tang nguy ca phan Crng loai manh ghep. Do vay, Chung tdi nhan thiy ddi vdi hinh thai LD npi md Fuchs nen chT djnh ghep giac mac d giai doan cudi, khi giira lap bieu md va mang Bowman hinh thanh mpt Idp seo xa han chi phu va viem trgt bieu mo se han c h i dugc phan Crng loai manh ghep

V. K^T LUAN

Ghep giic mac xuyen la phuang phip diiu tri cd hieu qua ddi vdi benh loan dudng npi md di truyen Fuchs. Cung vdi phan Crng loai manh ghep, benh ly npi md nin ghep la nhung yiu to giy ra hong manh ghep. Phan Crng loai manh ghep hay gap tren nhirng mat cd tin mach giic mac siu trude mo, phiu thuit due the thuy tinh phoi hgp va nhu-ng mit phai ghep lai. Phau thuat nen tri hoin din giai doan cudi cua benh khi giu-a Idp bieu md va nhu md hinh thanh mdt Idp seo xa lim giam phii va bong trgt bieu md se han c h i dugc phan Crng loai manh ghep.

TAI L I E U

THAM

K H A O

1. Duke- Elder, Leigh A.G. (1965). Corneal dystrophies. System of Ophthalmology, vol. VIII part 2. Henty Kimpton, London.

2. Wilson S.E., Bourne W.M. (1988). Fuchs dystrophy. Cornea.7: 2-18.

3. Le Xuan Cung (1999). Nhin xet die diem lam sing v i benh ly giai phiu cua benh loan dudng giic mac di truyin - gia dinh. Luin vin tdt nghiep bac sy ndi tru benh vien. Trudng Dai hpc Y H i Npi.

4. Olsen T., EhlersN., Favini E. (1984). Long

(5)

tenn results of corneal grafting in Fuehs' endothelial dystrophy. Acta Ophthalmol. 62(3): 445- 452.

5. Jonas J.B., Rank R.M., Budde W.M. (2002).

Immunologic graft reactions after allogenic penetrating keratoplasty. Am.J.Ophthalmol. 133 (4): 437- 443.

Summary

TREATMENT FUCHS ENDOTHELIAL DYSTROPHY BY PENETRATING KERATOPLASTY

To evaluate the results of corneal grafting in Fuchs' endothelial dystrophy. Method: Eight patients (9 eyes) with Fuehs' endothelial dystrophy were treated by penetrating keratoplasty in the Corneal and External Disease Department, National Institute of Ophthalmology. Two eyes were regrafted and one patient was operated in both eyes. Preoperative and postoperative visual acuity were recorded, the corneal graft were observed periodically. Result: Three eyes showed a visual acuity of 3/10- 5/10, while 4 eyes had visual acuity less 4 m of finger count in one year postoperatively. Five grafts (55,6yo) were clear and 4 grafts were cloundy. Two cases (22,2%)) had periods of graft rejection and one eye had primary graft failure. No case had inoperative complications. Conclusion: Penetrating keratoplasty is an effective procedure for treating Fuchs' endothelial dystrophy. The graft oedema might be associated with graft rejection and primary graft failure.

Keywords: fuchs'endothelial dystrophy, penetrating keratoplasty

BIEN CHU'NG MAT 6" TRE DAI THAO DLPQNG

Ngd Thj Phu'ang N g a \ Nguyin Phu Oat' 'Sen/i vien Nhi Tmng wang, ^Trwdng Dai hpc Y Ha Npi

Nhin xet cie bien chimg mit a tre em DTD dang aiu tri tai Bpnh vien Nhi Trung wang vi moi lien quan giira bien chimg mit vdi kiim soat glucose huyit Tit ca cac benh nhan da dwac chan doin DTD typ 1 dang dwoc aiu trj va theo doi tpi Bpnh vien Nhi Tmng wang, benh an theo ddi ngoai trii tw 12/1999-12/2009, cd thdi gian aiu tri tren 1 nam.

Nghien ciru md ta cd phin tich, vira hci cwu vira tiin cwu. Kit qua: Ty le biin chimg mat tang len tir 25,5% trong 5 nam dau bj bpnh len din 100% (4/4 benh nhin) sau 15 nam bj benh DTD. Benh vdng mpc gip nhiiu nhit chiim 77,8%, due thiiy tinh thi 58,3%, ton thwang kit hpp li 36,1%. Giam thj Iwc muc dp nang < 3/10 chiim ty Ip 41,7%. Ty le bien chimg mit cap gip 4 lin d benh nhin kiim soit khdng tot HbAlc so vdi kiim soat tot. Kit luan: Biin chimg mat tang din theo thdi gian mic bpnh DTD. Biin chung mat hay gap nhit li bpnh vong mac. Nguy ca biin chung mat cao gip 4 lin a bpnh nhin kiim soit glucose huyit khdng tdt so vdi kiem soit tdt

Tu- khoa: bien chu-ng mat, dai thao duang 6- tre em

I. DAT

VAN

0^

D i i thio dudng (OTO) l i mdt trong 3 bdnh khdng liy truyin cd t i e dp phat trien nhanh nhat cung vdi benh ung thu v i tim mach. OTO l i benh giy ra nhiiu biin ehCrng nguy hiim dan din t i n phi hcie tu' vong. Theo To ehu-e Y t i T h i gidi (WHO) benh OTO l i nguyen nhin dCrng hing triCr 2 giy mil Ida d ngudi trudng thanh.

Kiim soit glucose huyit bing xet nghiem HbAlc l i each tot n h i t de gigm nhii-ng nguy ca

bien ehCrng, tuy vay hidn ehi ed khoang 18% so benh nhin dang diiu trj OTO d Viet Nam dugc kiim soit tot. Cy Viet Nam ehua cd de tii nio nghien eCru diy du ve sy kiem soit glucose huyet v i cac biin ehu-ng m i t cua tre em bj DTD. Xuat phat tir thuc t i tren, chung tdi tiin hinh nghiSn cCru d i t i i vdi muc tieu:

1. Nhin xet cie biin ehCrng mit d tre em dii thio dudng dang dieu tri tai benh vien Nhi Trung uang.

2. Nhin xet moi lien quan giu-a biin chCrng mit