TCNCYH Phu trwong 74 (3) - 2011
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
VAN0^
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
vdi kiim soat glucose huyit.
II.
D 6 |TU'QNG VA PHU'QNG
P H A P I.Ddi tu'angTit ca eic benh nhan da dugc chan doan DTD typ 1 dang dugc dieu trj v i theo ddi tai khoa Ndi tiit- Chuyen hda- Di truyen Benh vien Nhi Trung uang, benh i n theo ddi ngoai tru tir 12/1999- 12/2009, cd thdi gian diiu trj tren 1 nam.
Tieu chuin lya chpn benh nhin:
Tieu chuan chin doan dai thao dw&ng Theo WHO (2001), OTO dugc chin doin khi cd bit ky 1 trong 3 tieu chuan sau:
+ Glucose huyit > 11,1 mmol/ L (200mg/dl) d bit ky thdi diem nio.
+ Glucose huyit > 7,1 mmol/ L (126 mg/dl) ( benh nhin nhjn ddi sau 8 gid).
+ Glucose huyit sau lim nghiem phip tang dudng huyit vdi 75 gam glucose sau 2 gid tang tir 11,1 mmol/l (200mg).
Tieu chuan chin doan dai thao dw&ng typ 1 Theo tieu chuin cua Hidp hdi dii thio dudng quoe t i (2005).
+ Khdi phit rim rd, du cac trieu chCrng
+ Bieu hien lim sang: Sut can, udng nhiiu, tieu nhiiu.
+ Nhiem Ceton, C- peptid thip hoic mit + Khing the : lAA, anti- GAD, ICA duang tinh + Diiu trj bit budc dung insulin.
Tieu chuin loai trir:
+ Benh nhin khdng t i i khim hoac khdng lam xdt nghidm HbAlc, glucose huyit, khdng kiem tra mit djnh ky 6 thing 1 lan.
+ Benh nhan cd benh v i mit trude khi bj dai thio dudng (tit ca benh nhan diu dugc khim mit va diy mit khi phat hien benh OTO de loai trir cac benh mit trude dd).
2. Phu'ang phap
2.1. Thiit ki nghien cuv
Chpn mau: phuang phip chpn mau tien ich liy tit ca cie benh nhan du tieu chuan.
- Thiit k i nghien eCru: Nghien eCru md ta ed phin tich, vira hoi ciru vCra tiin cCru.
2.2. Cac chi so nghien cuv Biin chCrng mit
- Lidn quan giua kiem soit glucose huyit v i cac biin chCrng.
2.3. Phuxyng phap thu thap so lieu va danh gia
Tiin hinh khim lam sang, danh gia kit qua xet nghiem theo miu benh an nghien cCru dudi su giam sat cua cac bac sy chuyen khoa ve ndi t i i t
Tat ca benh nhan dugc kham dinh ky it nhit 6 thing 1 lin. Kiem tra dau hieu lam sang: phit trien the chit (chiiu cao, can nang, diu hieu day thi), diu hieu benh DTD. Khim mit v i diy mit 6 thing 1 lan. Xet nghiem dudng miu v i HbAlc
Biin chwng mat: Khim phit hien biin chCrng mit dugc thye hien bdi bic sT chuyen khoa mit Benh vien Nhi Trung uang v i Khoa mit tre em Benh vien Mit Trung uang.
+ Oo thi luc bing bang thj lye Landolt kham thi trudng mit.
+ Kham mit ban phin trude bing may sinh hien vi, khim phat hien due thuy tinh the
+ Khim day mit: Nhd mdi mit mdt gipt atropine va de trong 10 din 30 phut de ddng tu- giin ra. Soi day mit viing trung tam vdng mac bing miy sinh hien vi kinh ICip 90 diop, vung chu bien vdng mac khim bing miy soi day mit giin tiep.
+ Dinh gii cd ton thuang mit khi^:
Giam thj lye < 8/10 Khim cd due thuy tinh t h i
Kiem tra day mit thiy cd ton thuang vdng mac hoac khdng nhin rd toin bd vdng mac.
Bang 1. Mu'c dp tdn thu'ang vong mac
Mipc dd Soi day mat sau gian ddng tip
Khdng cd BVMTO Khdng cd bit thudng
BVMOTO khdng ting sinh Chl cd vi phinh mach, eic mCre dp khic nhau BVMOTO ting sinh Mdt hoic nhieu han cac diu sau:
+ Tin mach
+ Xuat huyet djch kinh / trude vdng mac
TCNCYH Phu trwong 74 (3) - 2011 2.4. Xu" ly s6 lieu
Nhip sd lieu, phin tich bing phin mem SPSS 13.0 va Epi 6.04, su dung cac test Student, test Anova, test x^, test Fisher d i x i c djnh p vdi dp tin eiy cd y nghTa thong kd ( p < 0,05), tinh ty suit chdnh (OR: Odds ratips).
III. K^T QUA
1. D i e d i i m nhdm nghien ciPU
Bang 2. Phan bd benh nhan theo tuoi luc chan doan benh
Bang 3. Phan bo benh nhan theo thd'i gian bi benh
Tudi luc c h i n doan (tudi)
>5
TCr 6 din 10 TCr 10 din 15 TCr 15 trd Idn Tong
Tuoi trung binh (nim)
n 28 38 31 1 98
8,3
% 28,5 38,9 31,6 1,0 100,0
±4,36
Thai gian bj benh (nam)
< 5
TCr 6 d i n 10 TCr 10 d i n 15 TCr ,15 trd Idn Tong
Thdi gian trung binh (nim)
n % 49 50,0 27 27,6 18 18,3 4 4,1 98 100,0
6,7 ±4,88
Nhin xet: Ty Id benh nhin dugc chan doin DTD typ 1 nhieu nhit d nhdm tir 6- 10 tuoi (38,9%), sau dd la nhdm 11-15 tuoi (31,6%)).
Nhin xet: 1/2 bdnh nhin cd thdi gian mac benh < 5 nim. Nhdm bj benh tren 15 nim it gap chiim ty Id 4,1%). Thdi gian bj benh trung binh li 6,7 ±4,88 nam.
2. B i i n chipng m i t
Bang 4. Phan bd benh nhan b l l n chii'ng m i t theo thd'i gian m i c benh DTD Thd'i gian m i c benh DTD (nam)
<5
TCr 6 din 10 TCr 10 din 15 Tir 15 trd Idn Tcng
Nim trung binh (nim)
36 benh nhan 51 26 17 4 98
Benh nhan BC m i t 13
10 9 4 36
7,6: t4,71
% 25,5 38,5 52,9 100,0
36,7
Nhin xdt Ty Id bien chu-ng m i t ting Idn tCr 25,5%o trong 5 nim d i u bj benh len d i n 100% (4/4 bdnh nhin) sau 15 nim bj benh d i i thio dudng.
Thdi gian trung binh xuit hidn biin ehCrng mat l i 7,6 ± 4,71 nam.
Bang 5. Phan bd benh nhan bj benh v5ng mac theo thd'i gian m i c benh DTD Thd'i gian m i c
benh DTD (nam) 2 5
TCr 6 din 10 TCr 10 den 15 TCr 15 trd Idn Tong
n 51 26 17 4 98
Benh n 7 9 8 4 28
vong mac
% 14 34,6 47,1 100,0
28,6
Khong bidn chii'ng vong mac n
44 17 9 0 70
% 86 65,4 52,9 0 71,4
P
<0,05
Nhin xdt: Ty Id bdnh vdng mac ting len tCr 14% trong 5 nim d i u bj bdnh Idn d i n 100% sau 15 nim bj bdnh d i i thio dudng, sy khic bi0t cd y nghTa thong kd p < 0,05.
Bang 6. Phan loai tdn thu'ang mit Cac loai tdn thu'ang mit n = 36
T h i khdng ting sinh 24 66,7 Bdnh vdng mac j h i ting sinh
Dye thuy tinh t h i
Bj ea Ol 1 1 v i benh vdng mac
<3/10 4/10-7/10
4 21 13 15 21
11,1 58,3 36,1 41,7 58,3
Nhin xet: Trong so benh nhin bj ton thuang mit do d i i thio dudng, bdnh vdng mac gip nhiiu nhit chiim 77,8%, due thuy tinh the 58,3%), ton thuang kit hgp l i 36,1%). Giam thj lye mu-e dp ning < 3/10 chiim ty Id 41,7%.
3. Lien quan t i n thipang mit va SLP kiim soat glucose huyit
Bang 7. Biin chirng mit va kiim soit glucose huyit tai tho-i diem tim blln chirng
vA» U:A~. I H ' - . !,•*„ '* Khong biin chii'ng Co blln chipng -i __
Xet nghiem Mu-c k.em soat 4 t n = 6 2 ) mit(n=36) ^°"^ O "
T i t Glucose huyit
17 77,3%
5
22,7% 22
Khdng tdt 45
59,2%
31
40,8% 76
OR = 2,34 CI (1,2-11)
M±SD 13±7,11 17,5 ±6,86 p<0,01
T i t 12
85,7%
2
14,3% 14
HbAlc Khdng tot 50
59,5%
34
40,5% 84
OR = 4 01(1,4-18)
M±SD 9,8 ±2,59 11,5 ±2,30 p < 0,05
ChO thich:
M: Glucose huyit trung binh hoic HbAlc trung binh tai thdi diim xdt nghidm tim biin ehu-ng mit.
Nhin xdt: Ty Id biin chCrng mit cao gip 4 lin d benh nhin kiim soit khdng tot HbAlc so vdi kiim soit tot.
Glucose huyit trude i n v i HbAlc trung binh d nhdm cd biin chCrng mit cao han so vdi nhdm khdng bj biin ChCrng, sy khic bidt cd y nghTa thong kd.
IV. BAN LUAN
Trong 98 trudng hgp DTD t^p 1, tuii chin doin bdnh gip nhiiu nhit d lu-a tuoi .tCr 6 din 10 tuoi chiim ty Id 38,9%, sau dd den ICra tuoi tCr 10 din 15 tuoi (31,6%). Tuii trung binh khi chin doin DTD trong nghidn cCru niy l i 8,3 ± 4,36 tuoi (kit qui bang 2).
Kit qua niy tuang ty vdi nhiiu nhin djnh cho thiy DTD typ 1 l i b$nh man tinh hay g i p d tuoi tre, ed thi xuit hi$n d mpi ICra tuii v i thudng dugc chin doin trude 20 tuii.
Theo kit qua bang 2 v i phin b i bdnh nhin theo thdi gian bj bdnh, cd 50% bj bdnh dudi 6
nim, 27,6%) bdnh nhin ed thdi gian bj bdnh tCr 6 - 1 0 nim, chi 4 bdnh nhin (4,1%) bj bdnh trdn 15 nim. Thdi gian bj benh trung binh l i 6,7 ± 4,8 nim.
Kit qua nghien cCru eua chung tdi tuang ty nhu nghidn cCru eua Vd Thj My Hda [1] l i 6,3 ± 5,1 nim. Trong nghien eu-u eua Maria Craig, thdi gian mie benh trung binh thap han nghidn cu-u eua ChCing "tdi 4,4 ± 1,9 nim do thdi gian theo ddi dpc eua nghidn eu-u niy l i 5 nim [4]. Trpng nghidn eCru niy thdi gian trung binh phit hidn biin ehCrng mit k i tCr khi dugc phan doin DTD l i 7,6 ± 4,71 nim.
Phin bo bdnh nhin biin chu-ng mit theo thdi gian mic bdnh DTD ehung tdi nhin thiy, 52,9%
TCNCYH Phu trwong 74 (3) 2011
xuit hien biin ehu-ng m i t sau 10 15 nam; bj bdnh v i 100%) bj biin chCrng m i t sau 15 nam ( bang 4). Kit qua niy cung phCi hgp vdi cac t i c gia trong nude nhu nghien eu-u cua Vd Thi My Hda (2005) ed thdi gian trung binh phat hien biin ehu-ng m i t l i 7,2 ± 5,1 nam v i 65,1%) phit hidn sau 10 nam bj benh [1]. Tuy nhien se vdi nghien eu-u tai Phap (2003) eua Bouhaniek v i cdng sy l i 15 ± 6 nim, k i t qua eua ehung tdi thap han rd ret [2]. Diiu niy oho thiy bdnh nhin eua chung tdi bj biin ehCrng m i t sdm han so vdi benh nhin d cie nude phit trien. Nguyen nhin ed t h i do vide chin doin benh d i i thio dudng mudn, tre d i ed bieu hidn benh trude dd tCr liu nhung khdng dugc phit hien d i dua di khim, d i n khi benh ning mdi dua tre vao vien. Y i u td quan trpng v i hay gap l i do hiu qua cua vide kiem soit glucose huyit kem sau khi d i dugc chin doin d i i thio dudng.
Theo k i t qua bang 5, trong 5 nam d i u diiu trj chf ed 14%o bj bdnh vdng mac, tren 15 nam ty Id niy l i 100%o. Phin tich thdi gian bj bdnh d i i thio dudng din khi bj bien chCrng vdng mac, ehung tdi nhin thiy thdi gian mie benh cing d i i thi ty Id benh vdng mac do d i i thio dudng cing ting.
Diiu niy phu hgp vdi cie t i e gia khic cho ring bdnh vdng mac lien quan chit che vdi thdi gian bj benh. Nhieu t i e gia nghidn eu-u v i biin ehCrng mat d tre d i i thio dudng thiy ty Id bdnh vdng mac l i khoang 15%) trong 5 nim d i u va 80%o sau 15 nim [6]. Benh nhin DTD eua ehung tdi cd biin chu-ng mit sdm v i cd ty Id cao do kiim soit Glucose huyit khdng tdt, benh nhin khdng dugc dung thude du liiu, khdng dugc kiim tra HbAlc djnh ky, nguyen nhan chu yeu do benh nhin q u i khd khin v i kinh te.
K i t qua d bang 6, benh vdng mac gap nhieu nhit chiim 77,8%), due thuy tinh t h i 58,3%) v i 100% benh nhin ed giam thj lye. Ton thuang k i t hgp ea benh vdng mac v i due thuy tinh the gap 1/3 trudng hgp cd bien chCrng mit. Biin ehCrng m i t ting d i n theo thdi gian bj bdnh. Nhin xdt niy cung phu hgp vdi nghidn eCru eua nhieu t i e gia l i benh vdng mac gap n h i i u n h i t trong nhdm benh m i t eua ngudi benh dai thio dudng [4, 5].
K i t qua eua ehung tdi tuang ty k i t qua eua Vo Thj My Hda, tuy nhien cab han k i t qua nghien eu-u eua Pham Thj Hdng Hoa nhin thiy 70% co giam thj luc, 50%) ton thuang vdng mac v i 30%
due thuy tinh the. Sy khac biet niy la do ddi tugng nghien cu-u cua ehung tdi khic nhau. Kit qua khim m i t cua chung tdi thay cd 2 benh nhin co chl djnh diiu trj lade mit. G i n 1/2 sd benh nhan giam thj luc mu-c dp ning < 3/10.
HbAlc cua nhdm khdng biin ehCrng mit la 9,8 ± 2,59%) thip han rd ret so vdi nhdm ed biin ChCrng mat 11,5 ± 2,3%) ( bang 7). Biin ehu-ng mit i i mdt trong nhCrng biin ehCrng mudn quan trpng nhit d benh nhin d i i thio dudng, giy nen mil Ida anh hudng nghiem trpng tdi eude song cua ngudi benh. Tinh trang tang glucose huyit man tinh lim cho mach mau d vdng mac bj huy hoai [3, 4]. Chinh vi vay kiim soit glucose huyit kem la nguyen nhin gay biin ehu-ng m i t trong dii thao dudng typ 1. Vide fcin thiit l i theo ddi HbAlc djnh ky x i c dinh xem kiem soit glucose huyit cue benh nhin cd dat tdt khdng.
Trong q u i trinh theo ddi dpc chCing tdi nhin thiy: tai thdi diem phat hien thiy biin chu-ng mit, glucose huyet trude an v i HbAlc cing cao, ty Id mie biin ehCrng m i t cing nhiiu. Theo kit qua bang 7, khi glucose huyit trude i n kiem soit tdt, ty Id biin chu-ng m i t l i 22,7%, thap han so vdi 40,8%) sd benh nhin kiem soit khdng tot bj biin ehCrng mit. Glucose huyit trude in chi phan i n h kiim soit glucose huyit tai mdt thdi diim, tuy nhien vdi HbAlc cung cho kit qua tuang ty khi benh nhin kiim soit HbAlc khong tdt, ed nguy ea bj biin chu-ng m i t cao gip 4 lin so vdi kiem soit tot (OR = 4). K i t qua eua chung tdi tuang ty nghien cu-u eua nhiiu tie gia vdi HbAlc eua nhdm ed biin ehCrng m i t cao han so vdi nhdm khdng bj bien chCrng v i ed 48,9% so benh nhin kiim soit glucose huyit kem bi bien ehCrng mit. So vdi nghien eCru eua Maria Svensson v i cdng su (2004) [6] tai Thuy Dien, mac dii HbAlc trung binh eua mdi nhdm thip hon so vdi nghidn cCru cua chCing tdi nhung cung cho thiy sy khic biet rd ring khi HbAlc l i 8,5% a nhdm bien ehu-ng m i t cao han so vdi 7,4% a nhdm khdng biin chCrng.
Cung giong nhu Maria Svensson, ehung tdi nghien eCru ea HbAlc trung binh eic nim k i tCr khi bj dii thio dudng d i n khi phit hien biin ehCrng v i nhin thay.38,9% sd benh nhin kiim soit khdng t i t HbAlc trung binh cie nim bj biin chCrng m i t kiim soit tdt chl gap 1 benh nhin biin ehCrng mit (OR = 4,45).
V. K^T LUAN
Biin ehCrng mit ting d i n theo thdi gian mic bdnh DTD. Biin chCrng mit hay gap nhit l i benh vdng mac. Nguy ca biin ehCrng mit cao gip 4 lin d bdnh nhin kiem soit glucose huyit khdng tot so vdi kiim soit tot.
TAI
LIEU THAM
KHAQ1. Vo Thj My Hda (2005). Nghien cCru die diim lim sing v i cin lim sing cie biin ehCrng d mit v i thin trong benh DTD d tre em diiu trj tai Bdnh vidn Nhi trung uang, Luan vin thae sy Y hpc, Trudng Dai hpc Y H i Ndi.
2. Bouhaniek B, Raguin H et al (2003).
Description of microangiopathy in children with type 1 diabetes mellitus, 19 years retrospective study.
Diabetes metabolism; 29, 395 - 402.
3. David B Dunger, M Loredana Marcovecchio, Francesco Chiarelli (2008). Complications of type 1 diabetes in adolescents. BMJ- 30 august Vol 337, 337 - 377.
4. Maria E. Craig, Timothy W. Jones et all (2007). Diabetes care, glyeemie control, and complications in children with type 1 diabetes from Asia and the Western Pacific Region, Journal of Diabetes and its Complication 21, 280 - 287.
5. Maria Svensson, Jan. Eriksson (2004). of microvascular complication Early glyeemie control, age atonsetanddevebpmentin childhood. Diabetes Care, volume 27, number 4, 955 - 969.
6. Pamianco G, Costacou T et all (2006). The 30 years natural history of type 1 diabetes complica- tions, the Pittsburgh epidemiology of diabetes te complication study experience. Diabetes; 55, 1463 -1469.
Summary
EYE COMPLICATIONS DIAETES IN CHILD
Diabetes mellitus is a disease which ean cause serious complications leading to disability or death.
Diabetes mellitus is ranked the second reason leading to blindness in adults. Blood glucose control with HbAlc test is the best way to reduce the risk of eye complications. Objectives: 1. Reviews eye complica- tions of diabetes in children being treated at the National hospital of pediatrics (NHP). 2. Reviews the rela- tionship between eye complications with blood glucose control. Subjects: All patients with type 1 diabetes diagnosed for more than 1 year, treated, and monitored at the NHP since 12/1999 12/2009. Method:
Study was descriptive combined between retrospective and prospective parts. Results: The rate of eye complication increased from 25.5%) in first 5 years of illness up to 100%o (4/4 patients) after 15 years with diabetes. Retinopathy was the most common, accounting for 77.8%o. Cataract occupied 58.3%; combined lesion 36.1%. Severe vision loss with acuity ^ 3/10 accounted for 41.7%. In patients with poor HbAIC control, eye complication rate was 4 times higher than that in patients with good HbAlc control. Conclusion:
Eye complications increases over time with diabetes. The most common eye complication is retinopathy.
The risk of eye complication was 4 times higher in patients with poor blood glucose control compared with good control.
Keywords: eye complications, diabetes in children
