Y HOC VIET NAM THANG 4 • SO 2/2014 trj nhieu hdn nhdm ngudi ed thu nhap cao va cd
xu hu'dng tang nhanh. Ket qua nay phu hdp vdi bao eao eiia Bd Y te va Bao hiem xa hdi Viet Nam ve ty le KCB eua ngffdi tham gia BHYT chia theo khu vu'c va theo nhdm thu nhap [ 1 ] .
4 . 2 . Ve chi tieu cho y t e
Bieu do 3.1 va 3.2 cho thay, nhdm 5 cd chi tieu eho y te rat eao, gap khoang 6 lan so vdi nhdm 1. Nam 2010, ty le hd ngheo d Viet Nam la 14,2% tinh theo chuan ngheo cua Chinh phii giai doan 2011 - 2015 [ 2 ] . Sd hd du'de hffdng Idi tff chinh saeh xda ddi giam ngheo la 26,7%, trong dd 10,2% hp dffdc ho trp mua the BHYT, 11,5%
hd du'de mien giam chi phi KCB eho ngu'di ngheo.
Mac dil cac hp ngheo da du'de ho t r d nhffng khoang each giau ngheo van cdn la sff each biet.
Ham hoi qui ve chi tieu cho y te ciia nhdm 5:
y = 483,82 + 589,72x; p = 0,28
Ham hoi qui ve chi tieu cho y te ciia nhdm 1:
y = 52,85 + 88,43x; p = 0,39
Theo chuoi thdi gian thi chi tieu cho y te cua nhdm 5 tang 589,72 nghin dong moi nam (vdi p=0,28), cdn nhdm 1 ehi tang cd 88,43nghin dong (p=0,39)
V. KET LUAN
- Ty le KCB nhdm 1 cao hPn nhdm 5 va chl tieu cho y te nhdm 1 thap hdn nhdm 5 khoang 6 lan - Ham hoi qui ve KCB ndi tru eiia nhdm 1; y = 3,62 + 0,4x; p - 0,014; MSB = 0,449 - Ham hdi qui ve KCB ndi tru cua nhdm 5: y = 3,15 + 0,19x; p = 0,03; MSB = 0,129 - Ham hdi qui ve chi tieu cho y te ciia nhdm 5: y
^ 483,82 + 589,72x; p = 0,28 {p=0,28) - Ham hdi qui ve ehi tieu cho y te cua nhdm 1: y
= 52,85 + 88,43x; p = 0,39 (p=0,39)
TAI UEU T H A M KHAO
1. Bao hiem xa hoi Viet Nam (2013), bao cao so 1163/BC-BHXH ngay 29/3/2013 ye ket qua thi/c hiln chinh sach, phap luat Bao hiem y te giai doan 2009-2013
2. Ket qua dfeu tra mffc song hp gia dinh (2012), Nha xuat ban Thdng ke
3. Nong Thanh Sdn (2003), PhiTOng phap nghien ciiij khoa hoc iiYig dung trong y - sinh hpc, Nha xuat ban Y hpc.
4. Soren Bisgaard (2011), Time series analysis and forecasting by example, Murat Kulahci technical University of Denmark
ITNG DUNG PHU'aNG PHAP PHUC HOI CHU'C NANG THI GIAC TREN NHU'NG NGU'O'I KHIEM THI TRU'O'NG T H A N H
Nguyen Thi Thu Hien*, Nguyen Xuan Hifp*
T 6 M
TAT
Myc tieu: Tim hieu dae diem khiem thi d ngUdi truffng thanh, danh gia hieu qua ciia phu'dng phap PHCN ffii giac va tim hieu mot so yeu to lien quan den hi?u qua PHCN thi giac tren ngu'di khiem thj trudng thinh. Phu'dng phcip nghien cffu: thiet ke nghien cifu ean thiep tff ddi chimg vdi c9 mau n = 167 benh nhSn khiem thi tren 18 tuoi. Ket qua: Sau khi sff dung kinh vien vpng de trd thi xa thi ed tdi 53,7% thi lue xa dat tren 0,33. Thj lUc gan trung binh ngay sau tro thi bSng eac loai kinh phong dai tang dang ke va dat tdi 0,37 ± 0,05, dong thdi tdc do doc tSng len 71,23 ± 31,66 tff/phiit. Sau trd thj cd 19,2% tru'dng hpp chat lu'i?ng thj th! Qiac cai thi?n dang ke. Mot so yeu to anh hu^ng den'hi^u qua ciia PHCN thj giae nhu': tuoi, nguy§n nhan gay khiem thi, thj lire xa va thj lUc gan
• B^nh vipn MSt Tmng udng
Phin bl$n khoa hpc: PGS.TS Pham Van Tan
trUdc trd thj. Ket luan: PHCN thi giac cai thien ca chffe nang va chat luong thi giac d ngu'di khiem thi tru'dng thanh.
Tdkhoa: Khiem thj, phuc hdi chffe nang thi giac.
S U M M A R Y
APPLICATION VISUAL REHABILITATION I N THE ADULTS W I T H LOW V I S I O N Purposes: To find the characteristic of low vision in adults, to assess the effectiveness of visual rehabilitaton and to find factors related to the effective use of it in visually impaired adults.
Methods: Research interventions designed self- control with sample size n = 167 patients over 18 years old with low vision. Results: After using telescopes, 53.7 % of cases had the distance visual acuity over 0.33. Average near visual acuity after using the magnifier increased 0.37 ± 0.05; and reading speed increased 71.23 ± 31.66 letters/min. After using
Y HOC VIET NAM THANG 4 - SO 2/2014 the low vision devices, 19.2% of cases had remarkable
improved visual quality. Some factors related to effective use of visual rehabilitation were: age, causes of low vision, distance vision and near vision before using low vision devices. Conclusions: Visual rehabilitation improves both function and quality of vision in the adults with low vision.
Keywords: low vision, visual rehabilitation.
l.DATVANDE
Theo Td ehffc Y te the gidi (WHO) nam 1992:
mdt ngffdi dffdc gpi la khiem thi khi ehffc nang thj giac ciia ngu'di dd bi giam nang, tham chi ngay ca khi da du'de dieu tri va dieu ehinh tat khiic xa tdt nhat nhffng thj Iffc d mat tdt chi d mffc dffdi 6/18 (0,33) eho den edn phan biet sang toi (ST-f-) va/iioac thj trffdng bi thu hep dffdi 10° ke tff diem djnh thj.
Doi vdi nhffng ngffdi khiem thj, dac biet ngffdi khiem thi tuoi trffdng thanh, viec phuc hoi chffe nang (PHCN) thj giac se giiip ho cd the dpc lap trong sinh hoat, song hda nhap vdi nhffng ngffdi binh thffdng, nham xoa di nhffng mae cam ve benh tat.
Chiing tdi dat van de nghien effu de tai nay nham mue tieu:
1. Mo ta nhdng dac diem khiem thi d ngddi trddng thanh.
2. Danh gia hiiu qua cua phddng phap phuc hoi chdc nang thi giac tren ngddi khiem thi trddng thanh.
3. Tim hieu mpt sd yeu to liin quan den ket qua phuc hdi chitc nang thi giac trin ngddi khiem thj trddng thanh
II. OOI TU'ONG VA PHU'CyNG PHAP NGHIEN CU'U 2.1. Ooi tffdng nghien cu'u
2.1.1. Tieu chuan Ida chpn benh nhan:
Benh nhan tren 18 tudi. Thj Iffc nhin xa sau khi dieu tn va ehinh kinh tot nhat tff ST(+) den 0,33 hoae/ va thi trffdng sau khi dieu trj thu hep du'di 10°. Benh nhan cd nhu cau du'de PHCN thi giae sau khi nghe tff van va giai thich. Benh nhan phai biet dpc, Viet va cd kha nang nhan thffc tdt de ed the phdi hdp thff cae chffe nang thj giae va tra Idi bp eau hdi danh gia chat Iffdng thj giae.
2.1.2. Tieu chuan loai trd: Benh nhan khiem thi nhffng khdng muon dung kinh trd thj.
Benh nhan dang mac benh cap tinh hay tinh than khdng on djnh.
2.2. Phu'dng phap nghien cu'u:
2.2.1. Thiei ke nghien culi: can thiep tif ddi chfftig.
2.2.2. Cdmau: n = 167.
2.2.3. Phu'dng tien nghien cihi: Ho sd nghien effu, bp cau hdi, bang thi Iffc nhin xa, bang thj Iffc nhin gan, bang tu'dng phan, cac kinli trd thi: Telescope, kinh gpng phdng dai, kinh lOp cam tay, kinh liip cd ehan.
2.3.4. Cach thu'c nghien cdu: Nghien cffu du'pc tien hanh theo cac bu'de sau
- Giai thich muc dich cua viec PHCN cho ngffcfi khiem thi.
- Hdi tien sff, phdng van bang bd cau hdi.
- Kham ehan doan nguyen nhan khiem thi.
- Danh gia chffe nang thj giac: thi Iffc nhin xa, thi Iffc nhin gan, kha nang nhay cam tffdng phan.
- Chi dinh_kinh trd thj.
- Hffdng dan eac ky nang nhin, ky nang tff phucyy - Oanh gia iai mpt so chffe nang thi giae va phdng van lal bang bo cau hdi sau 3 thang PHCN.
III. KET QUA VA BAN LUAN
3.1. Oac diem khiem thj 6 ngffcA tru'dng thanh 3.1.1. Dac diem ve tuoi
Tudi trung binh eiia 157 benh nhan trong nhdm nghien cffU la 31,46 ± 16,47; benh nhan cao tud'i nhat la 78 tuoi va benh nhan tre nhat la 18 tudi, tap trung ehu yeu d nhdm tuoi tre dffdi 40 tudi (127 benh nhan chiem 76%), khac vdi nghien effu ciia eac tac gia nffdc ngoai nhff Stelmaek[5], Ryan[3]...ty le ngffdi khiem thi can dffdc PHCN cl nffde ngoai chii yeu la ngffdi eao tudi.
3.1.2. Phan loai nguyen nhan theo b$nb hpc
Nhom nguyen nhan dffng thff nhat la cac benh ly the thiiy tinh: chiem 34,1%, nhom nguyen nhan dffng thff hai la cac benh ly vong mac hoang diem: chiem 23,3%, nhdm nguyen nhan dffng thff ba la eae tdn hai ciia thj than kinh: chieml4,4%.
3.1.3. Phan loai nguyen nhan theo td'n hai chu'c nang thi giac
Nhdm nguyen nhan gay ton hai thj Iffc - thj trffdng trung tam chiem 80,2% va nhdm nguyen nhan gay ton hai thi Iffc - thi trffdng ngoai vi 19,8%.
Nghien cffu ciia ehung toi cung phii hdp vdl
nghien ciTu cua Owsley[2] tren 651 ngffdi khiem
thj d My thay rang 74,1% trffdng hdp la do cac
nguyen nhan gay tdn hai thj Iffc - thj truing
Y HOC VIET NAM THANG 4 - SO 2/2014 trung tam tuy nhien cd diem khac la benh ly
chmh gay khiem thj la do benh thoai hda hoang diem tudi gia.
3.1.4. Tinh trang chdc nang th/giac Thi ldc xa tdt nhat
Trong sd 167 BN, cd 4 1 , 3 % tru'dng hdp du'de chi djnh kinh chinh tat khuc xa, sau dd thi Iffc nhin xa ciia benh nhan dupe cai thien hdn nhffng van d mffc kem: chi ed 27,5% tru'dng hdp dat mffc 0,1 den 0,33 va khdng cd benh nhan nao thi Iffc xa tren 0,33.
Thi ldc nhin gan
Trong so 167 benh nhan, cd tdi 35,9%
trffdng hpp thi Iffc nhin gan d mffe 0,1 den 0,33.
Thj Iffc gan ciia benh nhan nhin chung tdt hdn thj Iffe xa. Tuy nhien kha nang dpc rat kem : Tde dp dpc rat cham, ehi dat 25,34 ± 36,14 tff/phut
Lien quan giO^ thi Idc xa va thi Idc gan trddc trd thi
Chiing tdi nhan thay giffa thj Iffc xa va thj Iffc gan ed moi lien quan tuyen tinti vdi r = 0,45 cd nghTa la benh nhan cd thj Iffe xa tdt thi thi Iffe gan dong thdi cung tdt.
3.2. Hieu qua cua phu'dng phap PHCN tren ngu'di khiem thj trffdng thanh
Hi^u qua ve mSt chffe nang thj g i a c 3.2.1. Hieu qua cua kinh trd thj nhin xa Trong so 167 benh nhan ehi ed 134 trffdng hdP da dffdc thff t r d thj xa bang kinh vien vpng cong suat 4x, 6x va 8x. Trong sd 134 benh nhan, trffdc khi thff kinh vien vpng khdng cd mpt b^nh nhan nao ed thj Iffe xa d mffc tren 0,33 nhffng sau khi sff dyng kinh thi cd tdi 53,7% thj Iffe xa tren 0,33.
Nghien cu'u ciia chiing toi cung phii hpp vdi nghien cffu cua J i [ l ] tren 118 ngu'di khiem thi thay rang thj Iffe nhin xa cai thien tren 0,4 khi dung kinh vien vpng cho 5 6 % tru'dng hPp, Scott[4] tren 156 ngffdi khiem thi da chi djnh dijng kinh vien vpng cho 50,6% trffdng hpp.
3.2.2. Hieu qua cua kinh trd thf nhin gSn
Trong so 167 benh nhan, chung tdi da chi d|nh sff dung cac loai kinh nhff sau: 32,3%
diing kinh gpng phdng dal, 50,9% diing kinh liip a m tay, chi cd 1,2% diing kinh lup cd ehan.
So sanh thi Iffc gan trffde va sau khi diing kinh trd thj chiing tdi thay rang: thi Iffc gan trung binh ngay sau trp thi tang tdi 0,37±0,05 Vel on djnh sau 3 thang sff dung kinh. Sff khac
biet nay ed y nghTa thdng ke vdi p=0,001. Ddng thdi khoang each dpc trung binh sau khi dung kinh t r d th; la 12,67±6,44 em.
Toe dp dpe trung binh tru'de trd thj la 25,34±36,14; ngay sau khi diing kinh t r d tlij la 71,23±31,66 va 3 thang sau trp thi tang len 82,43±2,42. Sff khac biet nay ed y nghTa thdng ke vdi p=0,001.
3.2.3. Danh gia hieu qua ve mat chdc nang thf giac sau khi dung kinh trd thj.
Sau khi du'pc diing eae kinh trd thi, ed 57,5%
dat hieu qua tot, ed 42,5% dat hieu qua trung binh va khdng ed benh nhan nao dat hieu qua kem. Ket qua nghien effu ciia chung tdi eijng phii hdp vdl nghien effu eiia Seott[4] tren 156 ngu'di khiem thj thay rang sau khi dffpc sff dung kinh trd thi cd 53,9% dat hieu qua tot, 4 4 , 1 % dat hieu qua trung binh va khdng ed tru'dng hdp nao dat hieu qua kem
3.2.4. Danh gia hieu qua ve mat chat Idang thj giac sau PHCN
Trong sd 167 benh nhan, cd 19,2% chat Iffdng thi thj giac cai thien dang ke, cd 70,7%
chat lu'dng thi giac cai thien trung binh, ed 10,2% ehat Iffpng thj giae cai thien it va khdng cd tru'dng hdp nao chat Iffdng thj giac khong cai t h i e n .
Danh gia ehung tren 167 benh nhan, diem sd trung binh tffng eau hdi trUdc PHCN dat du'de la: 68,67 ±13,18 nhu'ng diem sd trung binh sau PHCN tang len la: 79,67 ± 12,09 va chenh lech diem so trung binh trUde - sau PHCN thj giac dat 11,0 ± 4,45; Ket qua nghien ciru eua ehiing tdi eao hPn so \i<S\ nghien effu cua Wolffsohn[6];
diem sd trung binh tffng cau hdi eua 278 benh nhan tru'de PHCN la 60,9 ± 25,1 va ehenh Ideh diem sd trung binh tru'de - sau PHCN thi giae la 6,8 ± 15,6.
3.3. I^ot so yeu to lien quan den hieu qua PHCN thj giac t r e n ngffdi khiem thj trffdng thanh
3.3.1. Ve mat chdc nang thj giac sau phuc hoi chdc nang
Tud'i: Tudi cang tre hieu qua ve mat chffe nang thi giac cang tot. Ket qua nay cua ehung tdi cung phu hdp vdi ket qua cua cac tac gia nhff: Ryan[3], Stelmack[5]..,
Nguyen nhan: nguyen nhan gay tdn hai TL-thj trffdng ngoai vi thi hieu qua trp thj se tdt hdn,
Y HOC VIET NAM THANG 4 - SO 2/2014 777/ ldc xa trddc trd thi: thj Iffc nhin xa cang
tot thi viec t r d thj cang t r d nen de dang hdn.
77?/ Idc gan trddc trd thj: thj Iffc gan trung binh tdt thi hieu qua se tot.
3.3.2. Ve mat chat Iddng thi giac sau phuc hoi chdc nang
Tuoi: tudi BN cang cao thi sff cai thien chat lu'png thi giac cang t r d nen cd y nghTa.
Nguyen nhan: nhffng tru'dng hpp tdn hai TL- thj trffdng chu bien eai thien chat Iffpng thj giae nhieu hdn.
77?/ ldc nhin xa va thi ldc nhin gan trddc trd W/V Trong nghien effu ciia chung tdi, giffa yeu to thj Iffc nhin xa va thi Iffe nhin gan trffde khi trp thj khdng thay cd mdi lien quan tdi hieu qua ve m k chat Iffdng thj giae sau PHCN (p>0,05)
Thi ldc nhin gan sau trd thf: TL gan sau trp thj cang tdt thi chat Iffdng thj giae eai thien cang nhieu.
IV. KET LUAN
4 . 1 . Oac d i e m k h i e m thj d ngu'di trffdng thanh
Tudi eiia benh nhan: Hau het d Iffa tuoi lao ddng vdi dp tudi trung binh la 31,46 ± 16,47.
Nguyen nhan gay khiem thi chu yeu la benh ly eiia the thuy tinh. Trong dd cd tdi 80,2% trffdng hpp do nhffng benh gay ton hai thi Iffc - thj tru'dng trung tam. Tinh trang thi Iffc xa rat kem, tuy nhien sau khi dffpe ehinh tat khiic xa thi Iffc xa da eai thien d 4 1 , 3 % tru'dng hpp. Thj Iffc gan tdt hPn thi Iffc nhin xa va thj Iffc gan tdt thi thi Iffc xa ddng thdi cung tdt. Toe dp dpe rat kem chi dat 25,34 ± 36,14 tff/phiit.
4 . 2 . Hieu qua cua phu'dng phap PHCN thj giac tren ngffdi k h i e m thj tru'dng t h a n h
Ve mat chffe nang thj giac: cd tdi 57,5%
trffdng hpp dat hieu qua tdt, cd 4 2 , 5 % tru'dng hdp dat hieu qua trung binh va khdng cd trffdng hdp nao dat hieu qua kem.
Ve mat ehat Iffpng thj giae: cd 19,2% tru'dng hpp chat lu'dng thj giac cai thien dang ke, co 7 0 , 7 % tru'dng hpp chat Iffdng thj giac cai thien trung binh, ed 10,2% tru'dng hdp ehat Iffpng thj giac cai thien it va khdng eo tru'dng hpp nao chat lu'png thi giae khdng cai thien.
4 . 3 . M o t so y e u t o lien q u a n den hieu qua PHCN thj giac cua ngu'di k h i e m thi
Ve mat chffe nang thi giac: Tud'i cang tre hieu qua cang tdt. Nguyen nhan do tdn hai TL- thj tru'dng ngoai bien hieu qua tdt hdn. TL xa va TL gan trffdc t r d thi cang t d t hieu qua eang tot.
Ve mat chat Iffdng thi giac: Tudi cang cao siT cai thien chat lu'png thj giac cang ed y nghia.
Nguyen nhan do tdn hai TL-thj trffdng ngoai bien cai thien chat lu'png thj giac nhieu hdn. TL xa va gan trffde t r p thj khdng anh hffdng den hieu qua ve mat chat Iffdng thi giac nhffng TL gan sau t r d thi eang tot thi ehat Iffdng thj giac cai thien eang nhieu.
TAI UEU T H A M KHAO
1. Ji, Y. H.; Park, H. J.; Oh, S. Y. (1999), Clinical effect of low vision aids, Korean J Ophthalmol, 13 (1), 52-56.
2. Owsley, C ; Lee, P. P. (2009), Characteristics of low vision rehabilitation services in United States, Arch Ophthalmol, 127 (5), 681-689.
3. Ryan, B. (2008), Measuring low vision service outcomes; Rasch analysis of the seven-item nabonal eye institute visual function questionnaire. Optometry and vision saencs, 85(2), 112-121.
4. Scott, I . U. (1999), Quality of life of low vision pabents and the impact of low vision services.
A / a 128(1), 5 4 - 6 2 .
5. Stelmack, J. (2001), Quality of Life of Low Viskin Patients and Outcomes of Low Vision Rehabilitabon, Optometry and Vision Science, 76 (5), 3 3 5 - 3 4 2 .
6. Wolffsohn, J. S.; Cochrane, A. L. and Watt, N. A., (2000), Implementabon methods for vision related quality of life questionnaires, BJO, 84, 1035-1040.
