NGHIEN CUtJ KHOA HCpC
^/•^ismKiK^-'-
DANH GIA KET QUA CUA PHAU THUAT
CAT BE CUNG MAC DIEU TRI GLOCOM TRE EM
Phgm Thi Thdy Tien*, Trang Thanh Nghiip*, Mai Ddng ldm''', Nguyen Ng()c Anh*
TOM T A T
Muc tieu: ddnh gia hieu qua cua phdu thudt cat he cung mgc (CliCM) de i/icu tri gldcdm a tre em vd mot so yeu td nguy co lien quan den thdnh cdng cua phdu thudt nay
Doi tu'ong v;i phirang phsip: nghien cuu hdi cim 5 nam tren r')'/' benh nhdn (106 incit) tir 0 14 ludi vin glocom tre em nguyen phat va thir phat trong thdi gian 2004 2008 dieu tri lgi Benh vien Mdt TP.HCM. lat ca benh nhdn duac phau thugt ('Bi '.M dcm thudn.
Ket qua: thai gian theo ddi trung binh 54.83 ' 36.66 thdng (12-192 thdng). Sau phdu thudt, 44 mat (41,5%) dugc ddnh gia thdnh cong hodn loan. 13 mdt (12.3%) thdnh cong vd 49 mdt that hgi (46.2%). Khd ndng sdng tich liiy cua phdu thudt ('BCM theo then gian dgt 72% liic 1 ndm, 64% liic 2 ndm, 54% liic 3 ndm, 43% luc 4 ndm vii 31% sau 5 ndm. Phdn tich hot quy ('ox cho Ihay tudi tgi thin diem phdu thugt cdng nho vd mire do ndng cua bCmh vui ti le C D 0,7 co nguy ca tdng nhdn dp tdi phdt cao hon.
Ket luan: phdu thudt ('Bi '.\1 cr gldcdm ire em cd kit cjud thdnh cdng tucmg ddi thdp. Dc) tuoi cua tre a thdi diem phdu thudt vd mire do ndng ciia benh Id yen to nguy ca dnh hudng din kit qud phdu thudt.
Tir khoa: cdt be cimg mgc, glocom tre em.
\. DAT V A N D E
Gldcdm tre em la benh hiem gap tren the gidi chiem ti le 1:15.000 den 1:10.000 tre sinh song a cac nude Chau Au va 1:2500 tai A-rap Saudi, Day la mdt trong nguyen nhan chinh gav mil d tre em.
Gldcdm gay mat thi luc it nhat 5% trong tdng sd tre em mii tai My. Tan suat nav' cdn cao han d cac nude dang phat tri^n [8]. Bpnh gldcdm thd phat tre em gdp phan cho tan suat nay that su cao ban.
Dieu tri gldcdm tre em chu yeu la phau thuat.
Tai Benh vien Mat TPHCM tir 2004 den 2008, da so tre em benh gldcdm bam sinh nguyen phat hay thir phat thudng dugc chi dinh CBCM khdng diing thuoc chong chuyen hoa nhu la phau thuat dau tien.
Chirng tdi tiSn hanh nghien ciiu nay nhim danh gia hieu qua cua phau thuat CBCM dan thuin de dieu
tri gldcdm tre em va tim hieu nhirng yeu to nguy ca lien quan den ket qua ciia phau thuat CBCM d tre em Viet Nam.
II. D 6 I TUgfNG VA PHUONG P R 4 P NGHIEN CUU 1. Doi tuong nghien ciiii
Tat ca benh nhi tir 0-14 tuoi dugc chan doan gldcdm bao gdm gldcdm ticn trien va gldcdm thir phat dugc phau thuat cat be cung mac dan thuan (khdng sir dung chat chdng chuyen hoa), tir 2004 den 2008 cd ho sa theo ddi ngoai tni day du it nhat tren 12 thang.
2. Phuang phap nghien zvnx
Day la nghien cuu hdi ciru tien hanh tai phdng ngoai trii khoa Mit Nhi. Benh vien Mat TP.HCM.
* Benh vien Mdt Trung uong
('acli thitc phdu thudt:
Bcnh nhan duoe eae bae .si khoa Nhi kmh nghiem ticn hanh phau thual eat be cuii|', mae voi lieu chuan nhu sau dau lien mo ket mae |ihia eung do, t?o vat eung mae hinh ehir nhal 2\3 mm huoiii', ve phia giae mae. eat be eunj', mae bail!', dao I I, eat mong chu bie-n. khau \at eunj' mae ban;', chi iivlon
10-0. khau kel mae Tenon bang \ leiv 1 8-0 Ihiide sau md gom thuoc nho dftn ddng tu. Ihudc nho khang v iC-m \ a khang sinh lai chd Nh;in ap dmre do bang nhan ap ke Maelakov lue be \en ha\ dang ngu Vi lie em \ oi cac c\o ludi khae nhau nen \eu to thi luc khdng dugc ghi nhan \a phan lich,
3. Tieu chuan danh gia
Tliaiib cdng: dira tren \eu td nhan ap, Sau phau thuat mat cd nhan ap dudi 22mmHg cd hay khdng su- dung thudc ha nhan ap duoc coi la thanh cdng, Neu nhan ap sau mo dudi 22mmHg ma khdng sir dimg bat ky thudc ha nhan ap nao dugc coi la thanh cdng hoan toan. Mat vdi nhan ap tren 22nmiHg sau hai lan kham lien tiep dugc coi la that bai. Cac lieu chuan khac de danh gia su tien trien ciia beMih ndm dudng kinh giac mac, chieu dai triic nhan cau khdng dupe ghi nhan.
That bai dugc ghi nhan khi tang nhan ap tai phat ( - 2 ImmHg) can phai phau thuat lai, Vi chi danh gia tinh thanh cdng ciia phau thuat CBCM nen cac bien chirng
khac nhu viem mu ndi nhan. due the lhu\ linh, teo nhan, khdng dua vao lieu chuan chpn benh.
Diem kcl ibiic eua nghien ciru la lan kham cuoi euni', (loi thieu lien 12 ibang) hoac benh nhan co tan;', nhan ap ( 21 mmllg) sail 2 lan Iham kham, hoae phau thual lai de kiem soat nhan ap,
4. Tluing kc, xii li sd lieu
Nhcip, ,\ir li va phan lich sd lieu bang phan mem SPSS for Window 16 0 Bien sd dinh luang c'upc trinh bav bang sd tnmg binh ± dp lech chuan, MOI hen quan giua hai bien dinh lugng dupe kiem c inh bang Student lest Cae tesl cd v nghTa thong ke khi p -' 0.05 Phan lich Kaplan Vlcicr danh gia mue dp thanh cdng cua phau thuat theo thdi gian V di p > 9 5 % Phan tich eae ) eu td ngu) co theo thai gian (Co.x regression) bang phuang phap loai dan dc tim chi so ngu) hai (Harzard ratio),
III. K E T Q U A
Cd 71 benh nhan (110 mat) dugc phau thuat cat be cung mac, 3 benh nhan (4 mat) bi loai khoi nghien ciru v i khdng du ticu chuan nhan benh. Con lai 69 bcnh nhan gdm 37 nam (53.6%) va 32 nu (46,4"o), \ d i 106 mat dugc chgn vao nghien cira, Trong dd. 37 bcnh (5;'v6"o) bi ea hai mat. va 32 beMih (46.4" ()) bi mdt mat
Bdng 1. Dcic diem ciia hinh nhdn trudc phdu thudt Dac dicm
So benli nlian
• So benli nJian bi 1 mil (%)
• So benli nlian bi 2 iniil (%) Gidi: So benh nhan (%)
• N a m
-Nir So mil
Phan logi glocom (so mat v a %) Glocom bam sinii nguyen phat Glocom Ire em nguyen phat Glocom thir phat
• Sau phau Ihu^l lay the Ihiiy linh - Tgt khong mong null
n 69 37 37 32 106
58 32 14 1 2
%
46,4 53.6 53,6 46.4
53,6 30,4 16,1 0,9
1.9
NGHIEN CUtJ KHOA HOC
• Glocom do corticoid Bat Ihudng Pclcr
' Hpi cluing Axenfcld Rcigcr
• U spi lliin kinli
Tuoi tnmg binli liic phau thuat ± Dp lech chuan (d;i>) (thiing) Nhom Uioi
• Nhom 1 (<i2 thang) Nhom 2 (13-36 thiing) - Nhom 3 (>36 lining)
Nhan ap Ining binli ± Dp Ipch chuan (iiiml4g) Tl le C/D (%)
• C/D < 0.7 (mire dp v ira)
• C/D >0.7 (mire dp nCuig)
• Khong quan s;il dupe Phau thual tnrdc dd (so m;il \ a "o)
Khong
• Lay Ihc thuv linh
• Laser ROP
4 1 30.92 ±4^.51
59 21 26 27.66 ±4.81
38 64 4 K)4
1 1
4.7 3,8 2.8 0,9 1- 180tliaiig
55,7 19,8 24,5
35.9 60,4 3,8 98,1
0,9 0.9 Tudi tning binh d thdi diem phau thuat la
30,92 ± 43,51 thang (1-180 thang). Dua vao so tudi luc phau thuat, chiing tdi phan nhdm cac bcnh nhan nhu sau: nhdm 1 la nhdm benh nhan cd thdi diem
phau thuat dudi 12 thang, nhdm 2 cd dp tupi tir 12-36 thang va nhdm 3 tren 36 thang. Thep bang 1, nhdm 1 cd 59 mat (55,7%), nhdm 2 cd 21 mat (19,8%) va nhdm 3 cd 26 mit (24,5%).
Bdng 2. Kit qud sau phdu thudt cdt be cung mgc Ket qua
Thanh cong (so mat \ a %) - Thanli cong hoan loan - Thanh cdng khong hoan loan That bai:
- Tang nlian ap lai phat can pliau Ihual lai
Thdi gian theo doi tmng binh ± Dp Ipch chuan (day) (thang)
n 57 44 13 49 54.83 ± 36,66
% 53,8 41.5 12,3 46,2 12-192 thcing Da sd la gldcdm bam sinh nguyen phat vdi
90 mat (84,9%). Cac benh gldcdm khac nhu sau lay the thiiy tinh (1 mat), tat khdng mdng mat (2 mat), gldcdm corticoid (5 mat), hdi chirng Peter (4 mat), hdi chirng Axenfeld-Reiger (3 mat) va u sgi than kinh (1 mat),
Miic dp nang ciia benh dugc dua vao ti le C/D kham liic phau thuat, neu C/D < 0,7 dugc cho la miic do khdng doi thi C/D > 0,8 la mire do nang.
Theo thong ke, miic dp vira chiem 38 mat (35,9%).
mire dp nang la 64 mat (60,4%); cd 4 mit khdng
quan sat dugc gai thi do due giac mac nhieu.
Nhan ap trung binh trudc mo la 27,66 ± 4,81 mmHg. Thdi gian theo ddi trung binh 54,83 ± 36,66 thang (12-192 thang).
Bang 2 cho thay cd 57 mat (53,8%) cd nhan ap dieu chinh sau phau thuat, trong dd 44 mat (41,5%) thanh cdng hoan toan (khdng can diing thudc ha nhan ap) va 13 mat (12,3%) thanh cdng khdng hoan toan (dung tir 1 den 3 loai thudc ha nhan ap). Neu coi hien tugng tang nhan ap (sau 2 lan tham kham lien tiep) la su kien that bai thi
cd 62 mat/106 mat (''8,^"..) dinre eoi hi that b.ii trong dd 49 mcit (4(>.2",0 ean phau llnifil lai,
Nhan ap sau phau thual • 21 mini 1;', sau hai lan tham kham lie-n tiep ^\uoc danh gia nhu la \eu Id that bai eua phau thual Ihi kha nang song lich hi) cua phau thuat CBCM theo thai j'lan (Life time plot) tning binh ">X.77 (than!',); eu the eon 7,'"(i lue I nam. 64"ii liic 2 nam. '^4"-i lue 3 nam. I ^".i lue 4 nam va 3 V\< sau 5 nam (hinh I)
Thd'l gian theo doi sau phau t h u | t (thang)
Bieu do 1. Bieu do phdn tich khd ndng song tich luy ciia phau thuCit CliCM nguyin phdt
cy glocom tre em
So lirong mdi tgi moi llu'ri diem:
76 (liic 12 Ihdng), 64 (liic 24 Ihdng). 40 (liic 36 ihdng), IS (liic 48 Ihcing) vd 11 (liic 60 ihdng).
C;ie veil Id nhu gidi. tudi liic phau thuai chan doan loai bpnh gldcdm, mire dp nang 1;
nhung veil td ngu) ca anh hudng den than!
edng cua ph;iu Ihual Dua vao phuang phap hoi (pi\ Co.x de phan lich ccic veu Id ngu\ co ant hiraii!' den t.ing nhan ap tai phat Iheo thdi gian, chuni' tdi nluin lh;i\ nhom ludi liic phau thuat va mue do naiii', eua benh la liai veu to nguvcama s 1 thav ddi guia eae nhom ed v nghia thong kc
lie eo Ihdi diem phau thual trong do tuoi 24- 36 thang eo nguv eo lang nhan ap lai phat nhieu h,)n nhdm > 36 thang (ehi sd nguy hai: 0,7(i.
p = 0,033) (bang 3) Tre cd do tuoi cang nho
< 12 thang thi kha n;iiui tang nhan ap tai phat eao hon hai nhom cdn lai (hinh 2)
Tuong tu lie cd tmh trang Idm gai tnrdc phau thuat \ai C/D > 0.7 dc bi tang nhan ap tai phat nhicu hon tre co C D < 0.7 (HR 1.97; p = 0.023) (bang 3. hinh 3).
Sir khac nhau khdng cd v nghia thong ke giua nam va nu (p=().221) eiing nhu loai benh gldcdm tre em ngu) en phat \ a gidcom thir phat (p=0.K63) khdng anh huang den viec tang nhan ap lai phat.
10-
P,s-
0 6-
0 4-
02-
0 0 -
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1
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1
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• • ;'i 1 r , i i
i i i i i i l l i i i l i i )
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•
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tn c
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1
Thd'l gian >au phau thu^t (thing) Thd'l gian sau phSu thu$t (thdng)
Biiu dd 2. Phdn tich Kaplan-Meier ciia yiu tSnguy ca nhdm tudiphHu thugt dnh hudng
din tdng nhdn dp tdi phdt
Biiu dh 3. Phdn tich Kaplan-Meier ciia yiu to nguy ca muc do ndng (C/D) dnh hudng
(tin tdng nhdn dp tdi phdt
NGHIEN CUtJ KHOA HOC
Bang 3. Bdng phdn tich hoi quy Cox cua cdc yeu td nguy ca dnh hirc/ng (ten tdng nhdn dp tdi phdt sau phdu thu (it
Yeu to nguy c a
Gidi Nhom tuoi
Mire dp nang (CDR) Chan doan bpnli
Chi so nguy hai (Hazard ratio.s)
0.6'72 0.70
1.97 1.07
( 9 5 % Cl) 0 , 4 3 - 1.21 0 . 5 0 - 0 . 9 7
1,10- \ 5 3 0.49 2.Vi
p- value
0.221 O.Ovl*
0.023*
U,H6^
' Gid Ili p 0.05 CO \ nglua ihdng Id'.
IV. BAN LUAN
Dieu tri gldcdm ire em la phau thual cang sdm cang tot, Tnrdc nam 2007 tai B\ Mai TPHCM.
phau thuat CBCM dugc chi dinh rdng nii eho ban het cac tnrdng hop gldcdm tre em ngu) en phat \ a thir phat.
Tuy nhien. phau thuat cat be cung mac d tre em that bai cao do phan irng lanh seo qua nhanh.
Anh huang ciia chat chdng chu)cn hoa khdng chi tac dung trong vdi bao sgi vaing bpng ma cdn hu)' hpai nhiing te bap ket mac v a mac mau xung quanh.
[3,6]. Dong thdi. thdi dicm ticn hanh phau thuat tre cdn qua nhd va thdi gian sdng ciia cac em rat lau, chat chong chu)en hoa cd nguy ca ngd ddc mudn . va cd tinh chat ga)' dot bicn nen cac phau thuat v ien
thudng chgn su dung CBCM don thuan nhu la phau ' thuat dau tay ban. \ a chi su dung MMC trong cac
tnrdng hgp phau thuat CBCM tiep theo.
Cd nhieu nghien ciru bao cao phau thuat cat be Cling mac cho gldcdm tre em (< 18 tudi) khdng dimg them chit chdng chuyen hoa cd ti le thanh cdng khoang 30 den 50% cac trudng hgp. Nghien ciiu Beauchamp [ 1] bao cao ti Ic thanh cdng cao nhat (50%) vdi thdi gian theo ddi ngin (trung binh 15,5 thang). Nhung nghien ciru khac vdi thdi gian theo ddi lau ban ciing cho ket qua tir 30-35% [4.5]. Trong nghien cim ciia chiing tdi, ti le thanh cdng sau 5 nam theo ddi la 31%, tuang tir nhu cac nghien ciru ciia cac tac gia nude ngoai. Da sd tre em sau phau thuat di tai kham khdng diy du; nen nhung benh nhi thanh
eong sau phau thuat clu Ihco ddi benh trong thdi gian ngfui idi ngung, Dicu na) lam cho so lupng benh nhan phau thuat thanh edng nil khoi nghien ciru sdm ban: lam eho ti le lang ap tai phat cua nghien ciru chiing ldi tirong ddi cao (58.5%),
Chimg tdi nhan thay rang nhdm tre cd dp tudi cang nho thi cd ti le thanh cdng thap ban so vdi nhdm tre Idn. Tie cd dp tudi d nhdm 24 36 thang cd kha nang CBCM thanh cdng gap 0,7 lan so vdi tre <I2 thang va tre >36 thang thanh cdng cao ban Ire <12 thang 1,4 lan,
Bieu do 3 cho thay tre cd b(?nh gldcdm d giai doan nang vdi ldm gai rdng > 0,7 thi kha nang thanh odng ciia phau thuat thap mdt nira so vdi tre cd mire ldm gai < 0,7.
Cac yeu td danh gia mire do nang cua benh khdng chi la ti le C/D ma cdn dudng kinh giac mac, chieu dai true nhan cau 12,71. Cac yeu to nay khdng dugc ghi nhan trong qua trinh dieu tri nen khdng the phan tich da) du cac ) Cm td ngu) co. Day cimg la nhung diem yeu cua nghien ciiu ma chiing tdi se khic phuc trong cac nghien ciru sau nay.
V. KET LUAN
Phau thuat cat be ciing mac nguyen phat khdng diing thudc chong tang sinh sgi trong gldcdm tre em cd ti le tai phat cao. Nghien ciru ciing chirng minh dugc rang nhung )'eu to nhu dp tuoi va mire dp nang ciia benh Uic phau thuat la nhiing nguy ca anh hudng den thanh cdng ciia phau thuat cat be cimg mac d tre em.
T A I 1 I I - H I M A M K I I . X O
1 BEAllCll.AMI' (iR. PARKS MM (i"70)
"Filtering surgeiy in children barriers to success Ophthalmology 86 pp 170-80,
2 DII I I I IN I S . .lACOBI P C . KRIIX.I, STEIN (jK (r'^'O) I'lognosis oi |inmar\ ab externo surgerv for piimaiv eoui'emtal I'.laueoma"
Br J Ophlhalmol S3 pp 3 17-322
3 (ilAMI'ANIJRJ (ilAMPANlAS .CARANl JCI- OI.TROG(iH I W SUSANNA JR R (2008)
"elTeaev and safelv oi trabeeuleetomv with mitomvcin C i"oi childhood glauetuna a stud) of results with long term follow-up" ('linicalScience 64:pp 421-6.
4 GRESSEL MG. HEUER DK. SALAMAH K. (1984) "Trabeculectoni) in )oung patients' Ophlhalmol. 91: pp 1242-6,
5 INABA / (1982) "Long-term results of liabeeuleetoiin in Japanese: an analysis by life- table metluxl .Ipn .1 Ophthalmol. 26.pp36l-73,
6 I U N I / IIM . TROPE EG. (2005) "Full- thiekness lilteiini', glaucoma surgcrv" (ilaucoma Surgery, laylor <^ frariLis (iroiip USA, 1st lulition,
10 pp 03-100
7 M l l ' l / H , RAS( UKA B . KRIEGLSTEIN (jK (1999) Risk factors for failures of tracbeculec- tomies |)erformcd without anlimetabotiles'' Br.) Ophthalmol. 83 pp 814-821
8 WALION DS (2008) The challenge of childhood glaucoma" Glaucoma Topics <i Trends, Quarter 3. ( l l ) : p p 1-4
SUMMARY
EFFICACY OF TRABECULECTOMY FOR CHILDHOOD GLAUCOMA: A STUDY OF RESULTS WITH 5 YEAR FOLLOW - UP
Purpose: to evaluate the effectiveness of trabeculectomy m management ol childhood glaucoma and the risk factors affected the success of this surgery.
Methods: the 5 year retrospective study of 69 patients (106 eyes) from 0-14 years of age with congenital or development glaucoma al Ho Chi Minh City f'ye Ho.spital from 2004 lo 2008. These patients were performed trabeculectomies without using antifibrotic agents.
Results: the mean follow-up time was 54.83 -t 36.66 months with a range of 12-192 months. Fiftyfr'c eyes (53.8%) were considered successfiilly treated m which 44 eyes (41.5%) were absolute successes. The failure rate was 46.2% (49 eyes). Life table analysis identified that the success rates for intraocular pressure
control at 12, 24, 36, 48 and 60 mcmlhs were 72%>, 64%o, 54%. 43%. 31%, respectively Cox' regression analyses showed thai younger age al .surgery and glaucomatous eyes having CDR over 0.7 were more likely to manage lOP unsuccessfully with hazard ratio 0. 70 (p 0.033) and 1.97 (p-0.023), respectively
Conclusions: Ihe rale of success of trabeciileclomy in childhood glaucoma was not high. The patient age at Ihe lime of surgery and severity of the disease were proved to be the major risk factors for primary trabeculectomy.
Key word: trabeculectomy.
