NGHlfiM COrU KHOA HQC I
DANH GIA KET QUA DIEU TRI BENH VONG MAC TRE DE NON BANG LASER SAU 5 NAM
va Thj Bich Thuy*, Dinh Thj Thanh**
TOM TAT
Muc tieu- ddnh gid kel qua .sau 5 ndm diiu trj benh vdng mgc & tri di non (BVMTDN) bdng laser vd nhdn xet mot so yeu to lien quan.
Doi tu9iig nghien ciru: BVMTDN dirge dieu trf la.ser lir 2003 -2006 tgi B^nh vi^n Nhi Trung uang vd Benh vien Phu sdn Trung uang.
Phmmg phap nghien cihi: quan sdl md ta.
Ket qua va ban luan: 69 9"f kei quo tdt 7,8% so mdt cd cdng sudt gidc mgc tren 43D. True ddi tru&c sau nhdn cdu trung binh Id 21.1 mm. 6.8% mat co mach mdu vong mac hi ddi hu&ng. 3.9% di lech hodng diem, 24,6% so tre bi Idc vd 8,7% co rung gidl nhdn cdu. ddc biet 23.3% so mdt bi teo nhdn cdu. Khuc xg cdu tirang duang Id - 2.5ID vd 80.8% mat nhuac thi Kit qud diiu tn lot khi tdn thuang khdng a vung I, phgm vi tdn thuang hep. dieu Iri trudc nguang vd sd lirang vet dot it
Ket luan: sau 5 ndm dieu in laser, ket qud tdi dai 6.9% 6.8% mgch mdu ddi huang. 3.9% di lech hodng diem vd 23.3% teo nhdn cdu Cd su Hen quan chdt the kel qud v&i tinh trgng binh. chi dinh vd sd vet dot laser.
I. DAT VAN DE
Benh VMTDN la tinh trang benh ly cua mat do su phat trien bat thudng cua mach mau vong mac, neu khdng dugc phal hien va dieu Iri kjp thdi Ihi cd the dan den mii Ida va xuat hien nhieu bien chiing.
Lanh ddng la phuang phap dau lien dugc de xual nhung ti le that bai rai cao cd the tdi 75%, sau dd laser dan dugc thay the do ket qua dieu In vugl irdi.
6 Viet Nam laser bat dau nghien cihi va kci qua lot budc dau dugc danh gia d thdi diem 1 nam la 85,2%o ve thj luc va 89,8% ve giai phau. Hien chua CO ket qua danh gia lau dai sau dieu trj dac biet Ihdi diem sau 5 nam laser la tudi Ire tdi trudng. Vi vay.
chimg tdi lien hanh nghien cuu nham 2 muc tieu:
/. Ddnh gid kit qud sau 5 ndm diiu tri binh vdng mac tri de non bdng phuang phdp laser
2 Nhdn xet mot so yiu to lien quan den kit qud dieu tri.
n. DOI TUONG VA PHirONG PHAP NGHIEN ClTU Tre cd BVMTDN duac dieu trj laser tu 2003 - 2006 Benh vien Nhi va Benh vien Phu san Trung uang.
• Tieu chuan lira chon: ho so dieu Iri day dii cac thdng tin can thiel cho nghien cuu va gia dinh benh nhan (BN) ddng y tham gia nghien cuu.
* Benh viin Mdt Trung uxmg
** Trung ldm Y le huyen Tir Liem
Nhan khoa Viet Nam (Sd 28 - 2012)
|NGHlgN:<Pl^'KHOAHQC
• Tieu chu4n l o ^ i trir: da dugc dieu trj bdng phirang phap khac.
• Phuo'ng phap nghien c v u md la quan sat.
C d mau nghien cuu dugc tinh theo cdng thirc.
• Phuo'ng l i ^ n nghien ciru: may soi day mSl, kinh Volk, sinh hien vi kham mfil, bang ihj l\rc hop kinh thir, may do khiic x? t y dgng, dyng c\\
. kham lac
• Quy t r i n h nghien ciru
Chuc ndng: do thj l\rc, khuc xa khach quan sau khi tra Cyclogyl 1% bang phuang phap soi bdng ddng l u . nhan ap va do thj giac hai mat.
Bdnh gid linh trgng gidi phdu maf giac m^c:
trong, due, seo hoac ioan dudng. Tinh irang liOn phdng. mdng mat, ddng tu (trdn. meo), the Ihiiy tinh Dich kinh- trong, due, tang sinh xa, td chuc hoa. Day mat: vdng mac, gai Ihi, mach mau vdng mac, hoang diem va nhan cau, T i le iac, rung giat nhan cau, teo nhan cau. Do true nhan cau bang sieu am. Ket qua giai phau chia 2 muc:
+ Kit qud tot vdng mac lam seo tdt, gai thi va vdng mac viing hoang diem khdng di lech, mach mau vdng mac viing hoang diem khdng bj co keo.
ddi hudng.
+ Ket qud xau: mach mau vdng mac bj co keo, dl lech hoang diem, co nep gap vdng mac viing hoang diem, lang sinh xa phal Irien vao Irang buong dich kinh hoac bong vdng mac. teo nhan cau.
- Ddnh gid su lien quan giira kel qua giai phau vdi giai doan, viing, pham vi bi benh \ i i chi djnh dieu tn (trudc ngudng, den ngudng). sd \ c l ddi laser.
Cac sd lieu dugc \ u ly theo phSn mdm SPSS,
m . KET QUA NGHIEN CUt)
1. Dac diem benh nhan d t h o i diem duac dieu trj laser
Trung binh can nang khi smh la i406.14 g (800 - 1900g), tudi thai khi sinh la 30,39 tuan (27 -
35) \ii tu6i thai khi A\h\x trj la 36,44 luan (32 - 42).
Tinh trgng b?nh: 9,7% mfil giai do^in I, 7,8%
mat giai dogn I i , 82,5% giai dogn IIL 2 9 , 1 % m i l Ion thuong d viing 1, 45,6% mSI viing 2 va 25,3%
viing 3. 52.4% mat dieu Irj cd Ion thuong tir S din 8 nuii gid. 57.3% mai dugc dieu irj den ngudng v^ 42,7% iiiSi Irudc ngudng. So lugng laser Irung binh la 3480,9 not.
2. Kel i|Uii
- Ve chuc ndng: 78 mfil do dugc khuc xg trong dd 94.9% mat cd tgi khuc xg bao gdm 16.7% mfic Igt khiic \a LAU va 78.2% bj logn i h j . Khuc xg cau tuong duong la 2,51 ± V 8 2 I ) 83,3%so B N c d I f c h khuc xg. 71,9% sd mat cd Ihj Ivc dudi 6/12 trong dd 47,6% mat dudi 6/60 khi da chinh kinh toi da.
- Ve gidi phdu:
Giac mgc, 77.8% mai cd cdng suat khuc xa tren 43D 75,7% mat G M trong. 23,3% loan dudng, due.
lien phdng 23.3''o ndng hogc mat (24 mat).
Ddng lir: 23,3% sd mat cd ddng l i i dinh bit.
The thiiy linh: 76.7" o trong va 23.3% khdng kham dugc do leo nhan cau.
Dich kinh- 37,9% due dgng mang va sgi.
23.3% td chirc hda djch kinh.
l)a\ mat: 8,7% cd mang tnrdc \ d n g mgc, gai Ih} bj CO ki.H> Li 4.9" u d.S" .> mgch mau vdng mac doi hudng va 3.9% hoang didm di lech dgc bicl 23,3%
sd mat bl ico nhan can T i Ie lac la 24.6%, rung gi.il nhan cau la 8,7*'o Tnic nhan cau trung binh la 21.11 ± 2,84 mm (tir 15.2 mm den 26,4 mm).
3. Ki'l qua giai phau va mot so yeu to lien quan - Lien quan vai giai doan tdn llucang 100%
sd mat cd benh d giai doan 1 kel qua tdt. T i le nay la 87.5% mai d giai dogn 2 va 64,7% mat d giai dogn 3. Sir khac nhau ve ket qua tdt giira cac nhdm khac nhau cd y nghTa (p < 0,005)
- Lien quan viutg ton Ihuang: khac nhau ve Ii le ket qua Idt giiia cac nhdm mat bi benh d cac viing khac nhau. Ket qua tdt a viing I la 46,7%
32 I Nhan khoa Viet Nam (Sd 28 - 2012)
NGHIJN CtfU KHOA HQC I
vung II la 72,3% va vung III la 92,3%. Su khac biel CO y nghTa thdng ke vdi p < 0,05,
- Lien quan pham vi tdn Ihuang: k6t qua tdt la 87,5% d nhdm mSI cd phgm vi ldn Ihuong dudi 5 mui gid, 83,3% nhdm mfil cd pham vi ion Ihuang lir 5 den 8 miii gid va 71.4% nhdm mfil cd pham vi tir 9 den 12 miii gid S(r khac nhau v^ li le dai ket qua tdt khac nhau gifra cac nhdm mfit cd pham vi tdn Ihuong khac nhau, cd y nghTa thong ke vdi p <0,05.
- Lien quan giira benh vdng mgc egng vdi kel qud gidi phdu :I00% dat ket qua tdt khi klunig cd benh \ dng mac cdng.
- Lien quan chi dinh dieu Iri: ket qua giai phau ldl khac nhau giira cac nhdm duoc dieu trj Irudc nguang va den ngudng (95,5% so \i)i 50.8"»). su khac biet cd >' nghia thdng ke \6i p < 0,05.
- Lien quan vai lieu laser, nhirng mat duoc dieu tri laser dudi 2000 xung cd ti Ie ldl la 100%, khac biet \di nhdm mai cd lieu tren 2000 xung (56,3%). Su khac nhau cd >' nghTa thdng ke vdi p < 0.05.
rV. BAN LUAN L Ban luan ket qua dieu tri
/./. Ve kel qua chirc nang
Tinh trang khiic xa: 94.9% sd mai cd lal khiic xa cao hon cac tac gia nudc ngoai nhu Axer (55,2%), Yang (77%) Ospina (62%) va Mcloone (50%). Ket qua trong nghien ciru nay cd khiic xa cau tuang duang la -2,51D, thap hon Connolly (-3,05D vdi thdl diem 11 nam sau laser) nhirng ti le can Ihj nang (> 6D) ciia chung tdi cao hon Yang (19.6% so vdi 16,7%). Su khac biel \'c ti le tat khuc xa cung nhu muc do can thi chiing toi cho la do dac diem benh lat, lieu dieu tri va Ihdi gian Iheo ddi sau khac nhau.
So vdi cac tac gia trong nudc, ti le sd mai bi canthjlrongnghien cuu la 71,8%, cao ban Nguyen
Vfin Huy (61,1%), Nguyin Ihi Ha (46,51% d thdi diem sau dieu trj 3 thang) va Nguyen Xuan Tjnh (62,5% sau I nfim). Cd s^ khac bi?l giii-a cac nghien cuu trong nudc la do thdi diem Iheo ddi lau dai khac nhau (lir 3 thang den 5 nam) luy nhien cac lac gia deu cho rfing ti le can thi cao la do s\r bat Ihirdng ve khiic xa giac mgc, dp sau lien phdng, chieu dai true nhan cau va cdng suat the thiiy linh.
Thi l\rc: 29,1 % mfil so mfit dgt ihj Igc tren 6/12, thap hon nhieu so vdi Mcloone (73%), Ospina (71.4%i), Axer (56,3%). Sukhac biet nay la do li le mat bi b?nh viing I la viing quyet djnh kel qua thi Ivrc ciia chiing ldi cao ban cac tac gia nay.
1.2. \'e linh Irang gidi phdu
Nghien cuu cho thay cd tdi 77,8% sd mat cd cdng suat khiic xa iren 43D. Tgi sao giac mac chi la niul trong cac yen td quyet dinh tinh Irang khuc xa mat. hau nhu khdng chju su chi phdi cua laser ma Irong nhom nghien ciiu na\ lai co cdng suat cao nhu vay? Ral tiec la chua tim dugc nghien cuu nao thdng ke ttnh Irang khiic xa giac mac trong dieu Iri laser va lieu day cd phai la dac diem rieng d nhung mat cd BVMTDN ha> khdng can phai cd sd lugng nghien ciiu ldn hon.
True nhan cau trung binh la 21,1 mm, Ihap hon Connolly (22,9 min) cd Ihe do tudi Irung binh trong nghien cuu ciia chiing ldi la 5,93. thap han Connolly (10 tudi) va su khac biet ve Iriic nhan cau giua chau A va chau My. 24 mat (23.3%) teo nhan cau va deu cd true nhan cau dudi 18 mm.
kiJi qua luiy tuong tu kel qua ciia Tsitsis khi theo ddi 31 mat BVMTDN dugc dieu tri bang laser vdi thdl gian Ining binh la 46 thang, Tac gia bao cao cd 19,4% mat chuyen sang giai doan 4B, bong vdng mac, lea nhan cau Nhieu lac gia nhan djnh BVMTDN khi khdng dugc dieu tri hoac dieu Irj khong cd kel qua benh se nhanh chdng chuyen sang giai doan 4 hoac 5 va nguy ca bong vdng
Nhan khoa Viet Nam (So 2 8 - 2 0 1 2 ) I 33
iNGlHENCUtJKI KHOA HOC
mgc ho$c teo nh3n cau la s\r ti^n trien tat y^u ciia b?nh. Do vgy doi vdi nhO'ng mfit BVMTDN vi^c theo ddi skt sao sau dieu tn laser 1^ het sire can thiet v^ nhu the mdi cd the dieu trj kjp thdi khi bong vdng mgc xay ra,
Ket qua gifii phau tot dgt 69,9%, thap hon Yang (98,3%), Gnanaraj (90%). S\r khac bi?t n^y cd the la do nghien ctru ciia chung I6i co ton thuong vimg 1 nhifiu hon tac gia tren.
Mach mau bj co keo ddi hudng Ifi hgu qud ciia qua trinh tang sinh xo djch kt'nh co keo gay di l?ch hoang diem. Nghien ciru nay cd 6,8% mat mgch mau CO keo ddi hudng va 3.9% mat hoang diem bj di lech.
Lac- ehifim 24,6% thap hon Yang (30%) nhung cao hon O Keefe(13,9%). Su khac biet nay cd thfi do thdi gian theo doi khac nhau. Cac tac gia deu cho rang, lac la mdt bien chung kha phd bien tren tre de non va ti le lac nay d tre mfic BVMTDN cao hon tre de non khong mfic BVMTDN (34% so vdi 16%).
2. Ban luan ve mot so yeu to lien quan voi ket qua - Lien quan v&i giai dogn Ion thuang: cd su lien quan giira giai doan tdn thuang va ket qua tot.
Bfinh cang d giai doan nang Ihi ket qua giai phau cang kem, phu hgp vdi nhan dinh ciia cac tac gia la nhirng mat co benh d giai doan 1 dat dugc ket qua Idt hon so vdi nhung mai c6 benh d giai doan 2, giai doan 3.
- Liin quan vdi vung ton thuang cd su lifin quan giira viing bj benh va kel qua tdi, mfil cang cd ton thuang d trung tam (viing 1) Ihi ket qua cang kem, phii hgp vdi nhan xet ciia Capone.
- Lien quan vdi phgm vi tdn thuang: cd sir lien quan giiia ket qua giai phau va pham vi tdn
Ihuang, phgm vi t6n thuong c^ng rgng thi ket qua giai phSu CEkng kcni
- Li^n quan vifi cht djnh dliu tri: cd su lien quan giO'a kel qufi tot vdi chi djnh dieu In. dieu tri trudc ngudng cho kel qud cao Hon khi di^u trj d^n ngudng mgt each cd y nghTa ihdng ke (95,5% so vdi 50.8%), Ket qua nay luong tuvoi nh^n xel la dicn Irj d gjai dogn trudc ngudng cho ket qua thanh cdng cao hon so vdi giai dogn den ngudng.
- Lien quan v&i so lir^g laser: cd su lien quan chat chS giOa ket qua va so lugng vet ddt. Kel qua Idt (T 100% so mfil nhan dudi 2000 vet dot. Ket qufi nay hoan loan phii hgp vdi nhgn xet cua Axer la sd lugng vet dot cang nhieu thi kel qua dieu In cang kem.
V. KET LUAN
1. Ket qua dieu tri benh vdng mac tre de non Sau 5 nfim laser ket qua tdt dgt 69.9%. 77,8%
sd mat cd cdng suat giac mgc tren 43D, khiic xa nhan cau trung binh la -2.5ID 6.8% so mat co mach mau bj co keo ddi hudng. 3,9% di lech hoang diem, 23,3% icti nhan cau va 80,8% mfit nhugc Ihi.
24,6% sd tre bj lac \ a 8.7% cd rung gial nhan diu.
2. Mot so y^ii ti) lien quan
Cd su lifin quan chat che giira ket qua vdi tinh Irang bfinh, chi dinli \.i so vet ddt laser. Kel qua giai phau ldl khi bfinh d giai doan I. viing III. phgm vi ton Ihuang hep. dieu irj trudc ngudng, luong vet dot laser dudi 2000.
Laser la mdt phuang phap dieu trj hieu qua lam giam mil Ida do BVMTDN gay ra va dem lai kel qua ldl ca vfi giai phau cung nhu chuc nfing sau 5 nam difiu tri
34 I Nhan khoa Viet Nam (Sfi; 28 - 2012)
TAI LIEU THAM KHAO
1. NGUYEN THj HA (20l0j, "Danh gifi kfil qua dieu tri benh vdng mgc Ire de non bfing laser dudi tac dyng ciia an than gay ngii". Liign vdn Tot nghiep Chuyen khoa II. Truang Dgi hgc Y Hd Noi
2. CAPONE A. JR, DIAZ-ROHENA R.
(1993). "Diode laser photocoagulation for zone
! threshold retinopathy of prematurity", Am J Ophthalmol. 116(4), pp 444-450.
3 GNANARAJ J . BRENNANR.,COTTREL D.G. (2003), "Retinopathy of prematunly in practice II. longtein result following treatment for threshold disease", fvt', 17(2). pp. 189-193.
4. KIESELBACH G.F., RAMHATER A., BALDISSERA I., KRALINGER M.T (2006),
"Laser photocoagulation for retinopathy of prctnaturily: structural and functional outcome".
Acta Ophthalmol, 84 (I), pp. 21-22.
5. YANG C.S., WANG A.G., SUNG C.S., ET AI. (2010). "Long-term visual outcomes of laser- treated threshold retinopathy of prematurity: a study of refractive status at 7 years". Eye. 24, pp.
14-20.
SUMMARY
TO EVAI I lATE THE RESULS OF LASER TREATMENT FOR RETINOPATHY OF PREMATURITY AFTER FIVE YEARS Purpose: lo evaluate the result of laser treatment far ROP after 5 years.
Methods: obsen'ational study on children with ROP treated at Nationnal Obslretnc-Gyneacology and Pediatric hospital from 2003 to 2006.
Results and discussion: successful rate in 69.9%. 6.8% corneal power > 43D. Axial leghlh is 21.1 mm.
6,8% retinal vessels contraction. 3.9% macular dragging 24 6% strabismus and 8.7% nystagmus. 23.3%
phthisis Spherical equivalent IS 2.5 ID 80 8%) amblyopia. Good outcomes if ROP out of zone 1 treatment at prethreshold and less laser spots
Conclusion: the good resuU of laser ireatmenl for ROP after 5 years is 69.9%. 6.8% changed vessel way. 3.9% macular dragging and 23.3% phthisis There are relationship of ROP and number of laser .spots
Nhan khoa Viet Nam (So 28 - 2012) I 35
