BENH NHAN

NGHIEN CU'U BI^N CHLTNG SAU P H A U THUAT C A T DjCH KINH TREN BENH NHAN DAI THAO DU'O'NG TANG SINH NANG

Do Nhir Hon

Benh vien Mdt Trung uong, Hd Ndi

T O M T A T

Myc li6u: ngtiiSn cii'u biiu ctiiing sdm vd Idu ddi sau phfiu thuSt cdt djcti klnti trfin bdnh nhSn <3di Ihdo di/dng tang sinti npng. Di\ ti/png nghidn CCPU Id nti6m b^nti nhdn bj dai thao (lu'd'ng tSng sinh n$ng c6 chi djnh cdt dich kfnh didu trj tpi khoa Ddy mdt mSng b6 dao. Phu'O'ng phap nghidn CCPU la mfl td ti^n CLTU Qui trlnh khfim ISm sdng. siSu fim, OCT... dSnh gia t6n thu'cng v6ng mgc, djch kinh, cfic t6n thu'png ph6l hap Chl djnh cdt djch kinh, ky thu§t cdt djch kinh chudn 3 du&ng qua BIOMS, Theo dSi sau m6 nh&ng bidn chCing sd-m, mu^n sau m6. Kit qud 58 b^nh nhSn la 74 mdt. Bidn chung s6'm sau m6: tdng nhSn dp thoSng qua: 9,4%: dye thd thuy tinh: 13.5% trong tudn ddu. sau 2 tudn la 14,9% ... , Xudt huy^t d|ch kinh tdi phdt 21%. Bi^n chi>ng muijn: gl6c6m tdn mgch g$p 7/74 mdt, dye thS thuy tinh sau 2 thang la 46,1%.

Sau 3 thang Id 56%, Ket ludn: cdt djch kfnh trfen mdt bj b$nh dSi thdo du'&ng tang sinh n$ng la rdt phCpc tap, ty 1$ bi^n chi>ng cao vd c6 thd xdy ra sau m i sdm vd ISu ddi

Ti> khod: biln chi>ng sau phSu thugt cat djch kinh, b$nh vong mac ddi thdo dudng ISng sinh.

L DAT V A N D E

B?nh ddi thdo dudng tang sinh nang Id giai doan cuoi ciia benh vong mac ddi thdo duong. NSu khong dugc dilu tri hgp ly kip thiji bfinh nhan se dan den mii lod nhanh ch6ng. Cat dich kinh Id thao tdc thuong xuyen de chi dinh digu tri dai thdo dutmg tang smh nang nhdm loai trir mdu, to chiic xa seo, due dich kinh vd nham laser ciing nhu dieu tri cdc ton thuong khac cua benh vong mac ddi thdo duang. Cat dich kinh la rapt tien bp quan frpng va ciing gidi quyet tuong doi tot b?Tih vong mac ddi thdo duong tang sinh nSng. Tuy nhien, cdt dich kinh frong truong hgp benh vong mac ddi thdo duong tang smh nang gay rdt nhieu kho khan, phau thuat phfrc tap fren mat e6 nhieu ton thuong phoi hgp vd rat nhieu bien chumg.

Nghien cuu bien chiing sau phau thuat eat dich kinh fren b?nh nhan dao thdo duong tang sinh nang nham g6p phan hieu biet tien lugng cija dieu tri b?nh ddi thdo duang tang sinh ndng.

Muc tieu: nghi6n ciiu bien chiing sau m6 s6m va lau ddi cua phau thuat cat dich kinh fren benh nhan ddi thdo duang tang smh nang.

II. PHirOfNG P H A P NGHIl&N CUtJ 2.1. Doi tu'ong nghien cuu:

Nhom benh nhan bi dai thao duang tang sinh nang c6 chl dinh cat djch kinh dieu tri t^i khoa Ddy mdt mdng bo ddo, Bfnh vi?n Mdt Trung uong thdi gian tir: 2007 - 2010. Tieu chudn chgn b?nh nhan c6 bgnh vong mac ddi thdo duong the tang sinh n ^ g co chi dinh cdt dich kinh nhu: co xuat huy6t dich kinh diSu tri 2 Tac gia: Do Nhu Han

Dia chi: Benh vien Mat Trung uong Dienthoai, 0917291599 E- mail: donhuhon@vnio.vn Ngay nhan bai. 28/4/2012 Ngay dang bai:3l/6/20I2

Phan bien I: PGS.TS Hoang Thi Phuc Dai hpc Y Ha Noi Phan bien 2: PGS. TS. Pham Van Tan

Benh vien Mat Trung uang

Tap chi Y hoc du phong, Tap XXII, so 5 (132) 125

Uihn khdng tieu, ddi thdo dudng tdng sinh theo phan lojii ciia h^i v3ng m(ic ddi thdo dudng lo^i trir nhiirng b§nh nhdn c6 bong vong m^c todn b^, gl6c6m ldn m^ch, todn thdn qud gid y6u, b^nh todn thdn khdc qud n^ng.

2.2. i'liirnng phiip nghieii iiVu;

Phuong phdp nghifin cihi m6 td, c5 mau b§nli nliiin tinh dugc Id 68 mat. Cdc budc nghien ciiu Id khdm ldm sdng. sifiu am, OCT , mpch ky huynh quang neu dupe ... ddnh gid ldm sdng ton thuong vdng mac, dich kinh, cdc ton thuong ph6i hi^p. Chi dinh cat djch kinh, ky thu^t cdt djch kinh chu4n 3 dudng qua BIOMS d|ch truyen Id Ringer lactat mdy cat djch kinh c6 day du linh ndng ticn tien nhat hi^n nay.

Theo diii: trong mo xem nhirng bien chiing sdm tir liic sau mo dfin khi ra vi?n vd khdm Ipi sau hai man, mupn sau thdi gian theo doi 1 thdng den 12 thdng sau mo.

III. K £ T Q U A

3.1. Dac dicm nhdm benh nhan nghien ciiu.

Nghien cihi fren 58 b?nh nhan (74 mdt) nam: 27 (46,6%o), nir 31 (53,4%). Tuoi trung binh 56,98, cao nhat 77 tiioi, thap nhat 26 tuoi, cd 4 b?nh nhan < 40 tuoi (6,9%i), 54 b?nh nhan

(93,3%) fr6n 40; 69%) b^nh nhan cd dO hioi 50-70 tii6i. Thd b?nh: c6 7/58 bgnb nhan ddi thdo dudng typ 1: (12,1%), cdn Ipi 51/58 ddi thdo dudng typ 2 (87,9%). Theo s6 mdt: ddi thdo dirdng typ 1: cd 11/74 mdt (14.8%), ddi thdo dirdng typ 2: 63/74 mdt (85,2%) Thj l\rc nhdm b$nh nhiuv 66/74 mdt (89,2%) cd thj luc

< 20/200; 58/74 mdt (78,4%) c6 thj Ivc < DNT 3m (20/400); 18/74 mdt (24,3%o) cd thj luc ST (+) vd BBT T^n thuong: tdng sinh xo mpch (29/74) 39,2%, bong vong mpc qua hodng diem (17/74): 23%o, bong vong mpc c6 ktai theo rdch (5/74) 6,8%o. 86,4% cd xu4t huyet djch kinh trung binh vd npng, 14 mat (18,9%o) cd xuat huyet djch kinh sau mdng Hyaloide, 51/74 mat (68,9%i) cd tdng sinh xa mpch tien trien 33 mat (52,7%), cd dye the thuy tinh phoi hgp, chi c6 5 mdt (6,8%i) dirge quang dong vong mac tot;

83,8%) chua dieu trj gi.

3.2. Bien chi'rng.

.?.Z /. Bien chi'rng sdm sau phau thiiilt Trong 2 tuan dau sau phau thuat: 31/74 trudng hgp (41,9%.) cd bien chiing, frong d6 c6 3 mat cd 3 bien chumg, 7 mat cd 2 biln chiing, 21 mat cd 1 bien chiing. Cac bi8n chiing sdm sau phau thupt bao gom:

stt

1 2 3 4 5 6

Lo^i bi6n chirng Dye TTT

X u i l huy^t dich kinh t^l ph^t TSng nhan Ap XuSt huylt ti^n ph6ng TSng sinh tSn mgch tripi^c VM T6ng s6 biln chu-ng

s6 b$nh nhan 11 16 7 4 1 31/74

Ty I I (•/.) 14,9%.

21,6%

9,5%

5,4%.

1,4%.

41,9%

126 Tap chi Y hoc dv phdng, T|p XXII, s6 5 (132)

Bien chiing dye tiie thuy tinh sdm sau md gpp nhiSu nhit cd thd xay ra sau nhimg sang chan gay ra do chan thuong phau thupt.

Xuat huy6t djch kinh tdi phdi gpp khd cao.

Tang nhan dp cung gpp vdi ty 1$ cao.

3.2.3. Bien chung muon .sau phdn thuat.

Ket qua nghien ciiu cho thay: 67/74 trudng hgp dugc theo doi tfr 2 thdng frd len thdy 18 mdt cd biSn chiing, chiem ti 1? 26,9%i.

Cdc bi8n chiing bao gom: Dye the thiiy tinh 3/10 trudng hgp chiem 30%o.Bong vong mpc:

9%. Xuat huyet dich kinh tdi phdt: 7,5%.

Glocdm tan mpch: 6%i. Bidn chiing khdc gom:

2 mat phu gidc mpc do loan duong, 1 mat cd nhuyen hda ddu silicdn .

IV. BAN LUAN

4.1. Dac dicm ci'ia nhom nghien cii'u.

Nhdm nghien ciiu thay ty 1$ nir nhieu han nam, tuoi tuang ddi cao, trung binh Id 57 tuoi, ddi thdo dudng typ 2 chiem ti 1? 87,9%).

Theo Klein R va cs (1984) ti 1? vd dg nang ciia b8nh vong mpc ddi thdo dudng tang len theo tudi d nhimg benh nhan ddi thdo dudng typ 1. Tuy vpy, 90,5%) bgnh nhan frong nhdm nghien ciiu Id phy thugc Insulin. Xuat huyfet dich kinh gap d hau h6t cac mdt d cdc miic do khdc nhau, xuat huyet dich kinh trung binh va nang chiem tdi 86,4% . Tang sinh xo mach ti^n friln 68,9%o, 44,6% cd bong vong mpc, cd 23%

cd bong vong mac vung hoang diem. Nghien cim fren 46 mdt ciia 38 b6nh nhan bong vong mac cd co keo dich kinh, bong vong mac Id tbih frpng nang vd ddu higu xku. Hutton W L.

(1980) da d6 nghi phan chia ra: bong vong mpc hinh vdng, bong vong mac trung tam tda lan vd bong vong mac hinh mat bdn. Bong vdng mpc hinh vdng Id bong vong mac tnmg tam tda Ian Id do sy tang sinh xo tiirdc vong mac d c^rc sau CO k6o theo kieu tiep tuyen gdy nen bong vong mac nhidu didm vd d^t. Nghien ciiu cd 39

mat (52,7%o) cd due the thiiy tmh dg 2, dp 3.

Trong bgnh vong mpc ddi thdo dudng dye the thiiy tinh Id ton thuong cd dnh hudng d6n ket qui phau thupt. Ve thi luc nhdm nghien ciiu cd tdi 89,2% cd thi lyc <20/200 Id rat thap, nhieu b?nh nhan frong frang thdi mii loa; 78,4% cd tiij lyc < DNT 3m (20/400); 24,3% co thj lyc ST (+) vd BBT. Tien lugng thj lye eiia nhimg b^nh nhan bi ddi thdo dudng tang sinh ndng Id rat xau. vdi mgi co gang ciing khd cihi van dugc chitc nang, ton thuong thi lyc gay ra do nhieu yeu to phoi hgp: do xuat huyet dich kinh, do phii vong mpc, bong vdng mac vd due the thuy tinh.

4.2. Bicn chirng sdm sau phan thuat - Tang nhan dp: chiem 9,4%), la bi6n chiing thudng gap sau md cat dich kinh fren nhung benh nhan bi benh vong mpc ddi thao dudng vdi nhidu nguyen nhan khac nhau. Dpc bi?t la nhiing mat cd nhan dp cao td tnrdc phau thupt dudng nhu la cd nhieu nguy co tang nhan dp sau phau thupt. Hau het cac mat deu chi tang nhan dp thodng qua va deu dugc dieu chinh bdng thudc, khdng can can thi?p phlu thuat.

Tang nhan cd the do bdng khi nd day mdng mdt ra tnrdc ldm gdc tidn phdng dong, xd fri bdng each cho benh nhan nam up mat xuong giudng, de bdng khi ddn ra phia hau eye giiip cho dich tich ty d tien phdng dugc luu thodt.

Tang nhan dp do bong hae mpc lam cho mdng mdt ddy ra tnrdc gay ddng gdc tien phdng.

- Due thd thiiy tinh: chidm ti 1? 13,5%i sau 1 man, tang len 14,9% sau 2 mdn. Due thd thiiy tinh sdm sau phdu thuat la do chan thuong thd thiiy tinh bdi dung cu phau thupt gay ra hope do bdng khi tidp xuc vdi bao thd thiiy tinh, gay nen nhung hdc nhd dudi bao the thuy tinh, gay due the tiiiiy tinh ndu bdng khi tiep xiic bao thd thuy tinh keo dai. Mgt so tdc gia khuyen nen de lai sau mat sau thd thuy tinh mgt Idp dich kinh dk bdo V? thd thuy tinh khdi tidp xuc vdi dich truyen va dyng cy phau thuat. Chung tdi nhpn T^p chi Y hpc dv phong, Tap XXII, so 5 (132) 127

thay, nhChig niiit cd chdn thuong thd thiiy tinh frong phSu thu§t, sau phSu thu^t thd thdy tinh dye ticn trien rdt nhanh, thudng dSn ddn dye trdng hodn indn. cdn trd rdt nhieu den qud (rinh thdm khdm vd chdm sdc mdt sau phSu thu&t.

- Phii gidc nnic: cd li6n quan ddn nlifln dp, nhihig bill thudng d gidc mpc cua cdc b§nh nhdn ddi thdo dudng dd ldm npng thfim vdn de tdng nh3n dp trong vdng xo5n b§nh 1^ cda b?nh. Nh&n x6t tren dSy cua chiing tdi cQng tuong d6ng vdi nhieu tdc gia khdc.

- Xudt huyet djch kinh tdi phat: chicm 21.6%. irong dd 50%i djch kinh frong trd Ipi trong vdng 2 tuan, 62,5%o mau ticu todn bg sau kliodng 2 thdng. Theo nhieu tdc gid, mdu frong djch kinh Id rat Uiudng g$p sau cdt djch kinh fren nhimg bgnh nhdn bj b?nh vdng mpc ddi thdo dudng tdng sinh. Schatcbat A.F. (1983) gdp 75%. cdc trirang hgp cd xudt huyet dich kinh sau phSu thupt, frong dd 53%o xuat huydt trung binh hay ndng. xuat huyet djch kinh sau mo thudng tieu di sau vdi tuan. Tl I? cd mdu frong dich kinh cao la do no lye phau tich, cat dopn, bdc tdch cdc mang tang sinh xa mpch gay co kdo fren vdng mpc, tii be mat vong mpc noi cdc mdng xa mach phdng dugc bdc di hay tir dudi chan cua nhirng td chirc tang sinh xo mach.

4.3. Bicn chung union sau phiiu thuat Tan mach mong mat va gidcdm tan mach: Id bien chiing ndng sau phau thupt chiing tdi gap ty I? 6%. Trong nghien cdu cua Schatcbat vd cs (1983) tl 1? tan mpch mong mat sau phau thupt Id 13%o d nhirng mdt cdn the thiiy tinh so vdi 32%o d mdt khdng cdn thd thiiy tinh.

- Dye thd thuy tinh: (2 thdng Id 46,1%;

3 thang: 56%). Bien chiing dye thd thuy tinh xuat hi?n mupn sau cat dich kinh cho b?nh vong mpc ddi thdo dudng tang sinh it gdp. Ty I? dye the thuy tinh sau mo ciia Thompson J.T.

(1987) 11,5% sd mdt cdn phdn thupt thd diiiy tinh frong vdng 6 thdng diiu.

- Xudt huydt djch kinh tdi phdt mugn:

rdt hay g$p sau ph§u thupt cdt djch kinh frfin nhiJng b§nh nhdn bj b§nh vdng mac ddi thdo dudng tdng sinh, da s6 cdc tiirdng hgp xdy ra trong vdng vdi thdng dau sau phau thupt (thudng xdy ra trong vdng 6 - 8 tuan dau sau phdu thu§t). C6 2 mdt bj xudt huyet djch kinh tdi phdt vdo thdi didm 3 thdng sau phlu thuSt.

- Bong vdng mpc: gpp 5 mdt bj bong vdng mpc trong vdng 1 thdng dau sau phau lhu$t, thudng do cd chdy mdu vdng mac, cdc mdng dinh djch kinh vdng mac, cdc mdng tang smh CO kfio hudng tam mdj phat tridn fren be mdt vdng mpc.

V. K E T LUAN

Qua nghien ciru fren nhdm 74 mat cd cdt djch kinh fren b?nh nhdn ddi thao dudng tang sinh ndng chiing tdi thay rang bidn chiing co thd gap sdm hay lau dai sau md can theo doi sdt:

Bidn chumg sdm sau md: tang nhan dp thodng qua: 9,4%); dye the thuy tinh: 13,5%

frong man dau, sau 2 man Id 14,9% ... djch kinh vd tidn phdng 2 trudng hgp; phii gidc mpc.

2 mdt phii dai ddng sau phlu thuat. Xudt huydt djch kinh tai phdt: 21% da so ty tieu sau dieu tri ngi khoa.

Bien chiing mugn: gidcdm tan mach gjp 7/74 mdt, dye the thuy tinh sau 2 thang la 46,r/o. Sau 3 thang id 56%>. Xudt huydt tai phdt mugn: 2 mdt sau 3 thdng. Bong vdng mac: 1 thdng 5 mdt, 3 mat sau 3 thang.

TAI Lif U THAM KHAO

1. Charles S., Jorge C , Byron W. (2007),

"Diabetic retinopathy". In: Vifreous microsurgery, Edited by Charles S, Lippincott WiUiams & Wilkms, 95-111.

2. ColuccieIloM.(2004),"Diabeticretinopathy:

confrol of systemic factors preserves vision", Postgrad, 116, pp. 57-64.

128 Tap chi Y hpc d\r phdng, Tgp XXII, s6 5 (132)

3. Imamara Y., Kamei M., Minami M., et d (2005), "Heparin-assisted removal of clotting preretinal hemorrhage during vifrectomy for proliferative diabetic retinopathy". Retina 25, pp. 793 - 795.

4. Jahn C.E., Topfher Von Schutz K., Richter J., et al (2004), "Improvement of visual acuity in eyes with diabetic macular edema after freatment with pars plana vifrectomy", Ophdialmologica, 218, pp. 378 - 384.

5. Kono T, Shiga S., Takesue Y, et al (2005),

"Long-term results of pars plana vifrectomy combined with filtering surgery for neovascular glaucoma", OphUialmic. Surg.

Lasers. Imaging., 36, pp. 211 - 2! 6.

6. MassonJ.O.,CoIagrossC.T.,VailR (2006),

"Diabetic vifrectomy: risks, prognosis, ftiturc frends", Curr. Opin. Ophthalmol,, 17, pp.281 - 285

7. Newman D.K. (2010), "Surgical management of the late complications of proliferative diabetic retinopathy ", Eye 24,pp. 441 -449.

8. Soto-Pedre E., Hemaez-Ortega M.D., Vazquez J.A. (2005), "Risk factors for postoperative hemorrhage after vifrectomy for diabetic retinopathy", Ophthahnic Epidemiol., 12, pp. 335-341.

9. Stolba U., Binder S., Gruber D., et al (2005),

"B. Vifrectomy for persistent diabetic macular edema", Am. J Ophthalmol., 140, pp, 295-301.

POSTOPERATIVE COMPLICATIONS OF VITRECTOMY FOR SEVERE PROLIFERATIVE DIABETIC RETINOPATHY

Do Nhu Hon

Vietnam National Institute of Ophthalmology, Hanoi Objectives: to smdy the early and

long term complications of vitrectomy on severe proliferative diabetic retinopathy.

Subjects: a group of patients with severe diabetic retinopathy were freated with vifrectomy in Fundus Department, VNIO.

Methods: prospective descriptive smdy.

Vifreo-retinal lesions and other associated lesions were thoroughly evaluated on slit lamp, ultrasound, and OCT The standard 3 way vifrectomy was done under the wide angle view system (BIOMS). The early and longterm complications were followed. Result:

58 patients (74 eyes). Early postoperative complications: fransient increased lOP: 9,4%.;

cataract: 13,5%. within first week, after 2 weeks 14.9%). Recurrent vifreous hemorrhage : 21%i.

Late complications: NVG: 7/74 eyes, cataract after 2 months was 46,l%o, after 3 months was 56%). Conclusion: vifrectomy in the severe proliferative diabetic retinopathy was complicated with high rate of early and late complications.

Key words: postoperative complications, severe proliferative diabetic retinopathy.

Tap chi Y hgc dir phong. Tap XXII, s6 5 (132)