I NGHIEN c u l l KHOA HOC
DANH GIA HIEU QUA CUA HUYET THANH TlT THAN NHO MAT TRONG DIEU TRI BONG MAT DO HOA CHAT
I fl Anh Le, \i;iirin .^.^gc Anh vd Cgng sir*
TOM TAT . . Muc tieu: Ddnh gid hieu qud ciia hiivi'i thanh ti.r thdn (HTTT) nhd mdt trong qud trinh lien vet ti
^idc mgc .\au bang hda chdt dg I!, lit.
Phuo-ng phap: Ngliien ciru can ihicp Idm umg 27 iiidl cua 22 hi-iih nhan (BN) bdng mdt do kiem dq II. dg 111. B\ dugc chia ngau nhien thdnh 2 nhdm: nhdm nhd HTTT gom 14 mdt vd nhdm nhd Salein gom 13 mdt trong 3 tudn So \anh su liin hiiu md gidc mgc, ti !(• BN lien hiiu md hodn todn vd dg phii gidc mgc cihl 2 nhom.
Ket qua: 7o'c dg lien biiu md ciia nhdm nhd HTTT nhanh han nhdm nho Salein coy nghia thongkea thdi diim ngdy thu 6 (p <0.05). Ti I? lien biiu md hodn todn sau 3 tudn cua nhdm nhd HTTT Id 12/14. cua nhdm nhd Salein Id 10/13. Do phii gidc mgc ciia 2 nhdm khdng khde bi4l trong sudt 3 tudn dieu tri.
Kit luan: HTTT nhd mdt giiip liin biiu md gidc mgc nhanh han Salein trong dieu trj phoi hgp dieu tri bong mdt do hda chdt
Tir khoa: Huyit thanh tu ihdn, bdng mdt do kiem I. DAT VAN DE
Bdng mat do hda chit la mot trong nhimg nguyen nhan gay giam thi lyc nghiem trpng thudng gap. Hang nam, tgi khoa Chan thucmg - Benh vipn Mit TP.HCM, ti Ie BN bj bong mit do lai nan lao ddng hogc sinh hoat chiem khoang 10%,. Trong sd dd, nhirng bien chimg nang ne ve lau dai nhu loet nhuyen giac mac, khuyet bieu md dai ding, trdc bieu md tai phat... chiem ti le khdng nhd.
Thiic day qua trinh bieu md hda ciia be m?it nhan cau ngay trong nh&ng ngay dau eiia bdng la mot trong 3 budc tiep can quan trpng (ciing vdi thiic day tai tgo nhu md va kiem soat phan ling viem) trong dieu In bdng mat [1,2], Trong cac dupe chat dimg de thiic day qua trinh bieu md hda dupe nghien ciru, fibronectin va yeu td phat trien ngoai bi (EGF) da cho thay nhieu trien vpng nhat.
Ve phuang dipn nghien ciiu ea ban, da cd nhieu
* Khoa Chdn thuang - BV Mdt TP HCM
bao cao chiing minh EGF va Fibronectin vdn cd nhieu trong HTTT. cd vai b-d quan Upng trong viec thiic day lien bieu md giac mac. HTTT nhd mit da dupe su dyng de tri nhumg b^nh ly khd ciia bl mat nhan cau cung mang lai nhumg thanh cdng cd miic dp ddi voi cac benh ly nhu khuyet bieu md dai dang (bang 7), hpi chiing trdc bieu md tai phat, khd mat khd tti...
Nhu vgy. y tudng diing fibronectin va cac yeu to phat trien cd trong HTTT de thiic day su lien bieu md sau bdng mil do hda chat la mdt de nghj hpp ly. Hon nua, \ ipc sir dyng HTTT tiem dudi ket mgc de dieu Iri nhiing trudng hpp bdng dupe ap dyng tir lau d Bpnh vipn Mat Trung uang va B?nli vi?n Mat TR HCM nhung vln chua cd bao cao nghien ciiu lam sang. Do vay, myc tieu ciia nghien eiiu nay la ddnh gid hiiu qud viec su dung HTTT nhd mdt trong qud trinh Hen bieu mo gidc mgc sau bdng hda chdt dg II, IIL
10 1 Nhan khoa Viet Nam (S6 26 - 2012)
U. DOI TUQfNG VA PHUONG PHAP NGHIEN CUtJ 1. Doi tu'tfng
27 mat eiia 22 BN bdng mit do hda chit dp II.
Ill (bang 1) dilu tri tai khoa Chin thuang - Benh vien Mit TR HCM tir thang 5/2009 - 10/2009. Tdt ca deu dupe nia din luu be mat, nia tien phdng sao cho pH do tgi cimg do dudi va tien phdng la 7-7.5. Loai trir cac trudng hop bdng dp 1. dp IV Cling nhu nhung BN ed mpt trong cac test: HbsAg, Ehsa, VDRL, HCV duong tinh.
2. Phuong phap nghien cu-u
Thilt ke nghien cuu: Nghien ciru can thiep lam sang, nglu nhien, cd nhom chirng.
Quy trinh thyc hien: BN bi bdng mil do hda chat thda man cac dieu kien tren se dupe chpn ngau nhien thanh 2 nhdm la nhom nho HTTT 14 mit;
nhdm nhd Salein 13 mat. Ngoai ra, cac BN eiia 2 nhdm cdn dupe diing thudc udng va nhd theo phac dd dieu tn bdng ciia khoa Chan thuang bao gom Col. Oflovid 0,3% nhd I gipt x 6 lan/ngay; Col.
Atropin 1% nhd 1 gipl x 2 lan/ngay; Doxicycline lOOmg Iv X 2 lan/ngay; Vitamin C Ig x 2 lan/
ngay; Paracetamol 0,5g Ivien x 3 lan /ngay; Pde Tetracylin \% tra mat 3 lan/ ngay.
BN trong nhdm HTTT se dupe phat mdi ngay mdt lp thudc nhd mat chira 1 ml huyet thanh lu than.
BN dupe hudng dan nhd 1 gipt x 10 lan/ngay sau dd lp thudc se bi hiiy, cho den khi lanh bieu md giac mac. Tat ca se dupe kham mat bang den sinh hien vi de ghi nhan kit qua cac bien sd nghien ciiu mdi ngay vao phieu theo doi trong 3 tuan. Nhirng BN khdng lanh bieu md sau 3 tuan se dupe ghep mang 6i.
Bdng 1. Phdn do lam sdng cua bong mat [1-2]
Do I
Dp II
Dp III
Do IV
Ton th irong Ton hai bieu mo, giac mac trong Khong thieu mau ria
Dye giac mac nhung thay ro m i n g mit chi tilt Thieu mau < 1/3 chu vi ria
Mat hau het bieu mo giac mac, due khong thay ro chi tiet m i n g Thieu mau 1/3 - Vi chu vi ria
Giac mac due khong thay dupe mong mat, dong tu Thieu mau > '/i chu vi ria
Ti&n lu'ong T6t
T6t Dedat
xiu Cac bien sd nghien ciru chinh: ngoai eae bien
sd nen nhu tudi, gidi, mat bi bdng, loai hda chat gay bdng, thi luc... nghien ciiu nay chii yeu danh gia sy phuc hdi bieu md giac mgc qua dp phii giac mac va dien tich khiem khuyet bieu md.
• Dg phil gidc mgc (theo phdn do Hughes cai bien) [1-2]
Dp 1: Tdn hai bieu md, giac mgc trong.
Dp 2: Giac mac md van cdn thSy nhiing ehi tiet mdng mat.
Dp 3: Giac mac md nhi^u khdng thay nhiing chi tiet mdng mit.
Dp 4: Giac mgc trang due, khong thay nhiing chi tiet mdng mat.
'Diin lich khuyet biiu md gidc mgc (chieu ddi dudng kinh dgc vd ngang)
Dien tich khuyet giac mac dupe do tren may sinh hien vi, thu hep khe sang khoang 10°, chinh num dp cao tia sang giam dan sao cho vua dudng kinh khuyet bieu md. Ghi nhgn sd tren mim, nhan vdi 10 (mm). Do dudng kinh ngang va cao.
• Ti le lien bieu mo hodn todn = sd binh liin biiu md hodn todn/tdng so nhdm.
I NGHIEN CUtJ KHOA HOC
Cdch lay hiivii thanh l^r thdn: l:iy 20ml mSu cua BN dem quay ly tam toe dp 1500rpm trong 5 phiu sg dupe khoang 10ml huylt thanh. Sau dd bam huyet thanh vao lp thuoc nhd in;ii, moi Ip 1ml huylt thanh. Ben ngoai bpc giiy tranh anh s^ng m$l trdi va dan ten tudi BN. Til ca dupe tien h^nh trong dieu kipn vd triing, bao quan thudc trong ngan da {-IO"C) va khi sir dyng thi bao quan Ignh (+4'C') trong vdng 24 gid.
Phuang phdp thdng ke: biln sd dinh lupng dupe trinh bay bing sd trung binh ± dp Ipch chuan.
Biln sd dinh tinh dupe trinh bay bing ti l§ % va khoang tin cay 95%). Cac test ehi binh phuang, Fisher,s Exact test, t test dupe diing de so sanh
cdc ti lp, cac sd trung binh. Mirc p < 0,05 dupe coi hi khde bipt cd y nghia thong ke. Tat ca cic thugt todn tren dupe thyc hipn vdi phin mem SPSS for Window 13.5.
I I I . KET QUA
1. Ddc diem ciia 2 nhdm tru&c dieu trj Nghien ciru pilot nay gdm 27 mit cua 22, BN, chil ylu la nam gidi (87%>), tudi trung binh la 37,08 ± 12,38 bi bdng kilm dp H, III, dupe chia ngau nhien lam 2 nhdm: nhdm dimg HTTT nhd va nhdm diing Salein. Dac diem lam sang trudc dilu trj dupe md td trong bang 2.
Bdng 2. So sdnh dgc diim tru&c dieu tri ciia nhdm HTTT nho vd nhom Salein Bien %h
Tu6i (TB ± Bic) Giai (% n a m ) Thi tec (n,%>l/IO) Kji BM.dai (mm, TB ± Bic) Kh.BM ngdn (mm, TB ± Die) Ton thirong ria (n; % > 1/3 ria)
Ton thuang ket mac (% > 1/3 ria) Dp trong giac m a c n, (%}
•:• Do I
•:• Dp II
•:• Dp 111
N h i m HTTT n = 14 38,42 ±13,12
8, (72,7%) 3,(21,3%) 7,86 ± 2,47 6,36 ± 2,52 2(14,3%)
4, (28,6%)
5; (35,7%) 5, (35,7 %) 4, (28,6%)
Nli6m nho Salein n - 1 3 35,75 ± l l . W
12(100%) 2,(15,4%) 8 , 0 0 * 2 , 1 2 7,07 ± 2.43 2,(15,4%)
3: (23,1%)
5.(3S,.V>.) 5, (jS..V„) 3, (23,1%)
P
0,61 (ttest)
0.87 (t test) 0,45 (t test) 0,67.
Fisher,s test 0,55.
Fisher,s test
0,95 (X2 test)
Nhan xet:
• Tudi trung binh ciia nhdm nhd HTTT la 38,42, khdng khac bipt so vdi nhdm nhd Salein 35,75 tudi (p = 0,61).
• Nhihig dgc diem tdn thuang trudc dilu tri cua 2 nhom dieu khdng khac biet cd y nghTa nhu chieu ngang khuylt bilu md (p = 0,87), chilu dpc
Clia khuyet bieu mo (p = 0,45), dp md due ciia nhu md (p = 0,95), chu vi ria bi tdn thuang (p = 0,67), dien tich ket mac tdn thuang cgnh ria (p = 0,55).
2. So sdnh kit qud dieu tri cua 2 nhdm
* Tdc dg lien bieu mo gidc mgc theo chiiu d^
Tdc dp lien bilu md giac mgc theo chieu dpc dupe tdm tit trong bang 3.
12 I Nhan khoa Viet Nam (So 26 - 2012)
Bang 3. Tien trien tien biiu mo ciia nliam nlio HTTT vd nlidm nlid Salein (cliiiu dfc)
Nhom HTTT Kh.b.m Salein Kh.b.m
Ngay Ihii
n (mm)
n (mm) p (t test)
0 14 7,8 ± 2,4
13 8 ± 2 , 1
0,87 3 14 5,9 ± 2,6
13 7 ± 2 , 2
0,28 6 14 3,5 ± 2,3
13 5,6 ± 2 , 7
0.048 9
6 4 ± 1,7
10 5,4 ± 2
0,19 12 5 4,2 ± 1,6
9 4,4 ± 2,2
0,83 15 4 3,7 ± 1 , 5
9 4,1 ± 2 , 3
0,78 IS 4 2,2 ± 1,5
9 3,2 ± 2,8
0,48 21
2 4,0 3 5,6 ± 3
0,53
Biiu do I. Tdc dg lien bieu mo cua 2 nhdm theo chieu dgc
Nhdn xel: trong sudt 3 tuan dieu tri, tdc dp nay chi cdy nghia thdng ked thdi diem ngay thii 6 lien bieu md trung binh cua nhdm nhd HTTT (p = 0,048).
nhanh ban (cd chieu dai bieu md khuyet ngin * Tdc dp lien bieu md theo chieu ngang han) nhdm nhd Salein. Tuy nhien, su khac biet Dupe tdm tit trong bang 4.
Bang 4. Tdc dp lien bieu mo cua nhdm nhd HTTT vd nhdm nhd Salein (chieu ngang)
^~'~~~-~.I^gdy thu
HTTT Kh.b.m Salein Kh.b.m
n (mm)
n (mm) p (t test)
0 14 6,3 ± 2,5
13 7,0 ± 2,4
0,45 1 14 4,7 ± 2,5
13 6,0 ± 2,0
0,15 6 11 3,3 ± 2 , 1
11 5,2 ± 2 , 1
0,045 9 5 3,8 ± 1 , 6
10 4,1 ± 1,5
0,74 12 5 2,6 ± 1 , 5
9 3,6 ± 1 , 8
0,28 15
4 2,7 ± 1 , 7
9 2,6 ± 1 , 8
0,93 IS
3 2,0 ± 1
4 3,5 ± 2,3
0,36 21
1 2,5 ± 0,7
3 3,6 ± 2,5
0,58
I NGHIEN CUtJ KHOA HOC
Biiu dd 2. Toe dg liin biiu mo ciia 2 nhdm theo chiiu ngang Nhan xet: trong sudt 3 tuan dieu tn, tdc dp hen
bieu md trung binh ciia nhdm nhd HTTT nhanh hon (ed chilu ngang bieu md khuylt ngan han) nhdm nhd Salein. Tuy nhien, su khac biet nay chi cd y nghTa thing ke d thdi dilm ngay thir 6 (p = 0,045).
* Ti /f li&n bieu mo ciia 2 nhdm Ti 1? liin bilu md dupe tinh bing ti sd giiia so bpnh liin bilu md hoan toan tren tdng sd bpnh cua nhdm tgi mpt thdi diem. Theo dd. ti le lien bieu md ciia 2 nhdm dupe trinh bay qua bang 5 vabieud63.
riiM itloii (nB*y)
Bieu do 3. Ti If lien bieu mo hodn todn cua 2 nhom theo thdi gian
Bdng 5. Ti Ip lien bieu mo hodn todn ciia 2 nhdm theo thdi gian
Nhom
--....^^ Ngiiy thir
HTTT Salein
6
0/14 0/13
9 8/14 3/13
12
9/14 4/13
15
10/14 4/13
IS
11/14 9/13
21
12/14 10/13
14 I Nhan khoa Viet Nam (So 26 - 2012)
Nhdn xet: ti le liin bilu md hoan toan cua nhdm HTTT nhd nhanh han so vdi nhdm diing Salein trong 3 tuin diu. Sau 3 tuin, nhdm Salein cdn 3 BN, nhdm nhd HTTT cdn 2 BN bilu md chua lien phai tien hanh ghep mang di.
* So sdnh dg phii gidc mgc cua 2 nhdm theo th&i gian
Dupe torn tit trong bang 6. Theo do khdng cd su khac bipt vl dp phii giac mac giua 2 nhdm d cac thdi diem ngay thir 7, thii 14 va thii 21 sau dilu tri (p > 0.05).
Bdng 6. Dg phil gidc mgc cua 2 nhdm theo th&igian
^ ^ . ^ ^ ^ Ngay ltm Nhom —~....^_^
Nhom HTTT (n =14)
% phil QMdo 11, 111 Nhom Salein ( n - 1 3 )
% phil GMdp 11, III X2 (test)
0
64,3 61,5 0,95
7
57,1 46,2 0,76
14
14,3 15,4 0,93
21
7,1 14,4 0,59
Hinh 1. Hinh minh hga tien trien dieu tri cua 2 nhdm IV. BAN LUAN
1. Sy ttrong dvong cua 2 nhom ve mat lam sang Sir hdi phuc sau bdng hda chat, chu yeu phu thupc vao dp rpng va do tham sau vao nhan cau ciia tac nhan gay bdng.
Ve tdn thuang d be mat nhan cau, vai trd cua te bao mam d viing ria va bieu md ket mgc can ke ria la het sire quan trpng. Ddi vdi bdng do II, trong
3 tuan dau neu khdng dieu tri thich hpp, cd the cd su cham tai bieu mo hda giac mac. Vdi bdng dp III cd the CO khiem khuyet bieu mo dai dang, trdc bieu md tai phat.
Ve dp tham sau ciia hda chat, tiiy thudc miic dp tdn thuang nhu mo (danh gia qua dp due giac mac), dp pH trong tien phdng, cung nhu nhiing biln chung khac them vao ma danh gia dp nang eiia bdng.
I NGHIEN CUXJ KHOA HOC
Trong nghien ciiu nay, chiing tdi phan logi 2 nhdm mpt each ngiu nhien d^ra vao cac tieu chi tren dl danh gia dp n§ng eiia bdng. Bang 2 cho thiy cac dac dilm lam sang trudc khi dieu tri ciia 2 nhdm la tuong ddng. Trong qud trinh dilu tri, hai nhdm chi kh^c nhau d vipc diing HTTT nhd hay la Salein nhd. Dk logi trir bdt cic ylu id lam n$ng them bpnh nhit la dp thim ciia hda chat, til ea cac trudng hpp dieu dupe dan luu mit bing dung djch ringer lactat hoSc nia tiln phdng cho den khi pH trd vl binh thudng. Trong qui trinh dilu tri, khdng cd ca nao eua 2 nhdm bi t5ng nhSn lp, bpi nhilm...
von cd thi gdp phin vao vipc ehgm liin bieu md hda va do dd lam sai Ipch kit qua nghien ciiu.
2. Hifu qua ciia HTTT nhd trong q u i trinh tii bilu mo hda gi^c mac sau bong hda chat
Hieu qua cua HTTT nhd trong qua trinh tai bilu md hda giac mac sau bdng hda chat (kiem) dupe chiing minh trong nghien ciiu nay qua so sanh tdc dp liin bieu md giac mac. Ti le lien bieu md hoan toan theo thdi gian va dp trong giac mac ciia nhdm diing HTTT nhd vdi nhdm diing Salein nhd.
v l tdc dp lien bieu md giac mac theo ca chieu dpc va ngang, bang 3, bang 4, va bieu dd 1, bieu dd 2 cho thay: trong sudt 3 tuin dieu tri tdc dp lien
bilu md trung binh cua nhdm nhd HTTT nhanh han nhdm nhd Salein. Tuy nhien, sir khac bipt nay chi cd y nghTa thdng ke d thdi dilm ngay thii 6 (p = 0,045).
v l ti lp liin bleu md ciia 2 nhdm, bang 5 v^
bilu do 3 cho thiy nhdm HTTT nhd cd ti lp lien bilu md cao han vdi mpt ldc dp nhanh hem. O ng^y thir 9 ciia qua trinh dilu trj, nhdm HTTT nho c6- 57% BN liin bilu md hoan toan, nhdm diing Salein chi cd 23% BN liin. 6 ngay thir 21, ti lp nay lin lupt la 12/14 (85%) va 10/13 (76%).
v l dp phil giac mgc, bang 6 cho thay: trong suit qua trinh dilu trj, khdng cd su khac bipt ciia 2 nhdm vl su cai thipn dp phii giac mac. Co th6 HTTT khdng uu thi han Salein trong vipc tai tao nhu md trong dilu trj bdng hda chat.
V. KET LU4.N
Dil chi mdi la kit qua ban dau vdi mpt cd mau thir nghiem nhd nhung nghien cuu da cho thay diing HTTT nhd mit cd hipu qua han diing Salein trong dilu tri bdng hda chit dp II, dp III ve tdc dp va ti le lien bieu md gmc mac. Nghien ciiu dang dupe thuc hien tiep tyc vdi ed mau thich hpp. Ion han, luc dd, hi vpng nhihig ket luan rut ra se co dp tin cay idn hem.
TAI LI$U THAM KHAO
1. MICHAEL D. WAGONER. "Chemical Injuries of the Eye: Current Concepts in Pathophysiology and Therapy". Survey of ophthalmology 4\ (1997).
2. MICHAEL D. WAGONER AND KENNETH R. KENYON. "Chemical injuries:
clinical course and management in ocular trauma".
Principles and Practice. 2002 by Theme Medical Publishers.
3. T NISHIDA, S NAKAGAWA, C NISHIBIYASHIETAL,"Fibronectin enhancement of corneal epithelial wound healing of rabbits in vivo". Arch Ophthalmol 102 (1984), pp. 4 5 5 ^ 5 6 .
4. T NISHIDA, S NAKAGAWA, K WATANABE E T A L , "A peptide from fibronectin cell-binding domain inhibits attachment of epithelial cells". Invest Ophthalmol Vis Sci 29 (1988), pp. 1820-1825.
5. FUJIKAWA LS. FOSTER CS, HARRIST TJ, ET AL: "Fibronectin in healing rabbit corneal vjo\xnd&". Lab Invest 45: 1120-1129,198.
6. K FUJISAWA, C KATAKAMI AND M YAMAMOTO, "Effect of epidermal growth factor on epithelial cells and keratocytes during wound healing of alkali-bumed cornea". Invest Ophthalmol Vis 5c/ 31 (1990), p. 225 (Suppl).
16 I Nhan khoa Viet Nam (So 26 - 2012)
7. T NISHIDA, S NAKAGAWA, C NISHIBIYASHIETAL.,"Fibronectinenhancement of corneal epithelial wound healing of rabbits in vivo". Arch Ophthalmol 102 (1984), pp. 455^56.
8. T.M. Phan, C S . Foster, S.A. Boruchoff el a/.. Topical fibronectin in the treatment of persistent corneal epithelial defects and trophic ulcers. Am J Ophthalmol 104 (1987), pp. 494-501.
9. TM. Phan, CS. Foster, C D . Shaw et al..
Topical fibronectin in an alkali burn model of corneal ulceration in rabbits. Arch Ophthalmol 109 (1991), pp. 414^19.
10. A.W. Spigelman, A.J. Vemot, T.A. Deutsch et al., Fibronectin in alkali bums of the rabbit cornea. Cornea 4 (1985), pp. 169-173.
Objectives: To evaluate effects of autologous serum eye drops on corneal wound healing after chemical burn.
Methods' The pilot study including 27 eyes of 22 patients who had alkali - burned eyes with grade II, 111. randomly selected for 2 givups- 14 eyes were treated with autologous serum. 13 eyes were dropped Salein for 3 weeks Assessment of the wound healing of corneal epithelium, the rate of complete epithelial healing, and the corneal edema was recorded for two groups.
Results: The speed of the wound healing of corneal epithelium with autologous serum eye drops is faster than the one in Salein group at the sixth day of the course. After 3 weeks of treatment, the rate of complete epithelial healing in autologous serum group and Salein group was in turn 12/14 and 10/13 The corneal edema of two groups compared was not statistically significant.
Conclusions: Autologous serum eye drops lead to faster healing of corneal epithelium in chemical-
•ye than Salein drops do.
Keywords Autologous serum eye drops, alkali-burned eye
Nhan khoa Viet Nam (Sd 26 - 2012)
