NGHIEN ClfU KHOA HOC
DANH GIA VAI TRO SIEU AM TRONG CHAN DOAN VA DIEU TRI VET T H U Q N G XUYEN NHAN CAU VOI P H A U T H U A T C A T DICH KINH
f Nguyen Dieu Thu", Nguyen Thi Thu Yen' J
TOM T A T
Muc dich: Ddnh gid mice do chinh xdc ciia chan dodn sieu dm trudc mo tren nhung mdt due cdc moi truang trong suot sau vet thuong xuyen nhdn cdu (VTXNC) vd vai trd ciia sieu dm trong ket qud phciu thud!
cdt dich kinh dieu tri VTXNC.
Phu-oTig phap: Nghien cim tien cim 50 mdt bi VTXNC (co bong vong mgc vd/hogc di vgt noi nhdn) vd bi due cdc moi truang trong suot cdn phdi phdu thudt cdt dich kinh qua pars plana. Ddi chieu nhimg ton thuang phdt hien trong liic mo vd chdn dodn sieu dm trudc md. Nhdn xet chdn dodn sieu dm dnh hudng vai muc do ndo den ket qud ciia phdu thudt.
Ket qua: 84%> benh nhdn (BN) duac sieu dm trudc mo chdn dodn chinh xdc, trong do bong vong mgc cd ti le diing 100%, di vgt noi nhdn ti le dung 79,5%o. Sau mo, mdt cd kit qua thi luc tot; 24%>, trung binh;
24%o, xdu; 52%). Ket qud gidi phdu tdt;42%o, trung binh; 26%o, xdu; 32%o. Bong vong mgc Id yeu to nguy ca ciia ket qud phdu thudt kem. Sieu dm trudc phdu thudt cd gid tri trong chdn dodn vd tien luang ket qud sau mo nhung khong dnh huang den ket qud tot xdu ciia mdt phdu thudt.
I. DAT VAN DE
VTXNC la mgt chan thuang nang ciia mat CO the gay ton hai khong hoi phuc ve mat giai phau va chirc nang ciia mat. Nhieu BN bi due moi trudng trong suot nhu seo giac mac, xuat huyet tien phong, due the thuy tinh, xuat huyet dich kinh... lam cho viec danh gia cac ton thuong kho khan. Chan doan chii yeu dua vao sieu am, Xquang, chup CT scan hay cong huang tir. Kham nghiem sieu am A va B rat pho bien, nhanh, re tien va it gay hai. Nhung kha nang bo sot ton thuang CO the xay ra. Chiing toi tien hanh nghien ciru de tai nham hai muc tieu sau:
1. Ddnh gid phii hop giua chdn dodn sieu dm vd Idm sdng trong VTXNC.
2. Nhdn xet vai trd cua sieu dm trong kit qud phdu thudt cdt dich kinh diiu tri VTXNC.
n. DOI TU^ONG VA PHU^ONG PHAP NGHIEN CUU 1. Doi tuong nghien cuu
50 truang hgp (50 mat) bi VTXNC nam dieu tri tai khoa Chan thuong, Benh vien Mat TU' tir thang 9/2007 - 6/2008 co cac dac diem sau:
- Moi truang trong suot (giac mac, thuy dich, the thuy tinh, dich kinh) bi due.
- Sieu am A va B dugc lam sau khi da khau
NGHIEN CU'U KHOA HOC
- BN dugc cat dich kinh qua pars plana dieu tri bong vong mac hoac/va di vat ngi nhan.
- Co dieu kien theo doi trong qua trinh tien hanh de tai.
2. Phuang phap nghien ciru 2.1. Hoi benh
2.2. Khdm Idm sdng - Kham toan than.
- Xet nghiem chirc nang: do thi lire, nhan ap (khong lam neu vo nhan cau).
- Kham phat hien cac ton thuang nhan cau:
giac ciing mac, tien phong, mong mat, dong tir, the thiiy tinh, dich kinh, vong mac.
2.3. Khdm can Idm sdng
- Sieu am A, B: Danh gia tinh trang dich kinh, vong mac.
- Chup Xquang mat thuang va dat khu tni Bdng 1. Kit qud gidi phdu sau
Baltin neu nghi ngo co dj vat.
- Dien vong mac.
- CT Scan.
2.4. Phdu thudt cdt dich kinh qua pars plana theo diing quy trinh cua Bp Yte
2.5 Ddnh gid kit qud nghien cuu
• Mice do phu hap giira chdn dodn siiu dm vd lam sdng
- Thong ke nhiing truong hgp chan doan sieu am giong voi chan doan lam sang trong luc mo cat dich kinh qua pars plana.
- Tinh ti le Vo chan doan dung ciia sieu am dua tren cac ket qua thu thap dugc.
• Vai tro ciia siiu dm trong phdu thudt cdt dich kinh diiu tri VTXNC
- Ket qua giai phau.
Chiing toi danh gia giai phau dua ten ba muc do tiiy theo tinh trang dich kinh, vong mac.
cdt dich kinh qua pars plana
Muc do T6t
Trung binh xau
Tinh trang djch kinh, vong mac
Dich kinh trong, soi r5 day mat tir truac xich dao den vong mac trung tam, vong mac ap
Dich kinh due khu tni, day mat soi ro qua nhiing viing dich kinh con trong va vimg trung tam, vong mac ap
Dich kinh to chirc hoa toan bg, day mat khong soi ro dugc hoac bong vong mac, teo nhan cau
- Ket qua thi lire: Thi luc ciia BN (co chinh kinh) truac va sau m l dugc danh gia theo WHO 1993. Thj lire cua BN dugc coi la tot khi tu mire 2 tra len, kem khi tir mire 5 tra xuong.
Bdng 2. Ket qud thi luc Muc do
1 2 3 4 5 6
Thj luc 1 den bang 0,5
< 0,5 din bang 0,2
< 0,2 den bang 0,05 (dim ngon tay 3 m)
< 0,05 den bang 0,02 (dim ngon tay Im)
< 0,02 din phan biet sang tli ST(+) khong phan biet dugc sang tli ST(-)
NGHIEN CLTU KHOA HOC
- Ket qua nhan ap (do bang nhan ap kl Maclakop).
+ Nhan ap thap: duai MmmHg.
+ Nhan ap binh thuang: tir 14 - 25mmHg.
+ Nhan ap cao: tren 25mmHg.
- Cae bien chirng trong va sau phau thuat + Trong phau thuat: Cho djch truyen vao duai vong mac, cham dung eu vao the thiiy tinh gay due the thuy tinh, xuat huyet ngi nhan, rach vong mac.
+ Sau phau thuat: tang nhan ap, bong vong mac, xuat huyet tien phong, dich kinh, to chirc hoa
dich kinh, nep gap mang Descemet,viem mang bo dao, viem ngi nhan, teo nhan cau.
III. KET QUA NGHIEN CUU 1. Dac dilm BN
84% BN thugc liia tuli lao dgng (16 - 45) vai da so la nam giai (100%), do tuoi trung binh la 29,92 ± 11,27.
Trong nhom nghien ciiu, tai nan lao dgng chiem 68%. 68%) chan thuang do manh kim loai gay ra va rach giac mac la ton thuang thuang gap nhat (64%).
2. Ket qua thj lyc
Bdng 3. Thi luc trudc vd sau phdu thudt
^ ^ ^ Thj lire T h 6 i ^ ^
gian ^ ^ Truac mo
1 tuan 2 tuan 1 thang 3 thang
S6BN n 0 3 4 5 6
% 0 6 8 10 12
ST(+) - < 0,02 n
37 39 31 23 20
% 74 78 62 46 40
0,02 -<0,05 n
1 1 5 4 2
% 2 2 10
8 4
0,05 - <0,2 n 5 5 1 9 10
% 10 10 14 18 20
0,2 -<0,5 n 3 0 0 4 5
% 6 0 0 8 10
>0,5 n 4 2 3 5 7
% 8 4 6 10 14 Tm-ac mo chi co 14% mat eo thi luc tii- 0,2 tra len, sau khi phau thuat a thai diem 3 thang da tang len 24%.
3. Ket qua giai phau
Tyle %
1 thang 3 thang ^ ^ gian Biiu dd 7. Phdn bd kit qud gidi phdu theo thai gian
4. Ket qua nhan ap
Nhan ap sau theo doi 3 thang: binh thuang (68%), thdp (30%), cao (2%).
Nhiing truang hgp nhan ap thap la nhung mat teo nhan cau hoac bong vong mac.
NGHIEN CUtJ KHOA H O C '
5. Bien chirng trong phau thuat
Biln chimg hay gap nhat la rach vong mac chilm 20%), tilp din la xuk huylt dich kinh chiem 8%, cham vao thi thuy tinh chilm 2%. Dilu nay ciing anh huang tai kit qua giai phlu va chirc nang cua mat sau phlu thuat.
6. Bien chirng sau phau thuat
Trong 2 tuan dau tien sau phau thuat bien chung hay gap nhat la phii giac mac, bong vong mac. Sau 1 thang va 3 thang gap nhieu nhat la mat teo nhan cau va mat chiic nang.
7. Mirc do phii hop giira chan doan sieu am va lam sang trong VTXNC
Bdng 4. Doi chieu giua ton thuang trin siiu dm truac md vdi ton thuang phdt hien trong dich kich - vong mgc
Ton thiroTig khi phau thuat Bong vong mac Di vat dich kinh Di vat vong mac
Chan doan sieu am Bong VM
15
DivdtDK
12 1
Di vgt VM
0 19
Khong CO DVNN
0 7
Ti le chan doan diing (%)
100 100 70,4 8.Vai tro ciia sieu am trong ket qua phau thuat cat djch kinh
8.1. Kit qud vi thi luc
Sau phau thuat 3 thang, co 12 mat co thi lure tot (tir 0,2 tra len ). 75% trong so nay dugc sieu am truac mo chan doan dung.
Trong so 12 BN co mire thj luc trung binh (0,02 - <0,2), sieu am chan doan dung trong 15% truang hgp.
Trong so 26 BN co miic thi lire kem (<0,02), sieu am chan doan diing trong 92,3% truang hgp.
8.2. Kit qud ve gidi phdu
Thong ke a thai diem ket thiic nghien ciiu co 21/50 mat (42%)) tinh trang giai phlu dich kinh vong mac sau mo tot, trong so nay 76,2% truang hgp sieu am chan doan diing truac mo, 23,8% truang hgp sieu am chan doan khong dung.
Trong so 13 BN co kit qua trung binh thi 12 BN dugc sieu am chin doan diing (92,3%), 1 BN dugc chan doan sai (7,7%).
Trong so 16 mat ket qua giai phlu x§u thi ti le sieu am chin doan dung la 87,5%), sai la 12,5%o.
Nguy CO tuong doi ciia ket qua phau thuat kem la tinh trang bong vong mac.
Bdng 5. Yiu to nguy ca doi v&i kit qud thi luc kem vd gidi phdu xdu Yeu to nguy co
Thi luc kem Giai phau
xau
RR
RR
Bong vong mac 11/15(73,3%)
1,71 0,0314 8/15(53,3%)
2,33 0,0313
Di vat noi nhan 17/39(43,6%)
0,53 0,0064 8/39 (20,5%)
0,28 0,0005
NGHIEN CUtJ KHOA HOC
IV. BAN LUAN
1. Mirc do phii hop giira chan doan sieu am va lam sang
Trong nghien cuu nay 100% truang hgp bong vong mac dugc phat hien tren sieu am B truac mo va dugc kiem chimg bang phau thuat cat dich kinh qua pars plana nhin thay viing vong mac bong. Sieu am B chan doan bong vong mac co ti le dung cao trong cac nghien cim khac nhu ciia Rubsamen (100%), Gundrova (78,15%).
Doi vai di vat ngi nhan, neu dj vat nam trong buong dich kinh, sieu am phat hien dung 100%.
Neu dj vat cam vao hac vong mac, sieu am chan doan chinh xac 70,4%, trong do sieu am dinh vi nham dj vat nam tren vong mac thanh di vat nam trong djch kinh trong 1 truang hgp va 7 truang hgp khac sieu am khong phat hien dugc co di vat ngi nhan. Nhiing ca khong phat hien dugc di vat co the do dj vat nho kem theo xuat huyet dich kinh day dac va/hoac bong vong mac la nhirng yeu to gay nhieu.
Mgt nguyen nhan khac eo the xay ra la do lat cat ciia sieu am khong cat qua viing co di vat. Tat ca nhu-ng truong hgp sieu am chan doan khong chinh xac truoc mo deu dugc ho trg bai Xquang, khi can thiet CO the chup CT Scanner.
2. Vai tro ciia sieu am trong ket qua phau thuat cat djch kinh
2.1. Kit qud thj luc
Trong so 48% truang hgp (24 mat) co ket qua thj luc tir 0,02 tra len (> DNT Im), co 75% truang hgp sieu am chan doan diing truoc phau thuat.
Trong so 52% truang hgp (26 mat) co ket qua thi lire duai 0,02, co 92,3% sieu am chan doan dung.
Ti le mat dugc chan doan dung truac mo bang sieu am la cao nhung ti le nay tren tirng nhom ket qua thi luc tot, trung binh, xau la khac nhau, khong
Nhu vay, mac dii sieu am cung cap nhieu thong tin co gia tn truac mo nhung khong phai tat ca cac phau thuat deu thanh cong ve mat ket qua thi luc. Nguyen nhan dan den that bai eua phau thuat cat dich kinh trong dieu tri VTXNC la:
• Mat CO seo giac mac trung tam do vet thuong xuyen.
• Khong the trai phang dugc vong mac do ket vong mac a vet khau cung mac hoac tang sinh djch kinh - vong mac tram trgng.
• Rach, bong vong mac do vet thuong xuyen hay do bien chimg phau thuat.
• Mat CO di vat ngi nhan dien vong mac giam sut hoac tieu hiiy.
• Mat phai phau thuat nhieu lan.
• Viem ngi nhan sau VTXNC.
2.2. Kit qud gidi phdu
Trong 42% mat (21 mat) ket qua giai phau dich kinh vong mac tot, sieu am chan doan dung 16 mat (76,2%). Trong so 26% ket qua tmng binh (13 mat) sieu am chi chan doan sai 1 mat (khu trii nham vi tri di vat). Trong so 32% BN ket qua giai phau xau (16 mat) co 14 mat da dugc chan doan dung bang sieu am truoc mo cat djch kinh, chiem 87,5%.
Nhu vay, ket qua ve giai phau khong phu thugc vao viec sieu am truac mo chan doan diing hay sai.
2.3. Nguy ca tuang doi ciia kit qud gidi phdu kem Trong y van, bong vong mac la mgt benh nang. Bong vong mac xay ra tren BN co vet thuong xuyen lai cang mang tinh chat tram trgng do ton thuong khong chi a vong mac ma con a nhieu cau true ngi nhan khac.
Tac gia Nguyen Thi Thu Yen da so sanh ket qua giai phau va thi lire sau mo cat dich kinh qua pars plana dieu tri VTXNC tren 2 nhom BN bong vong mac va khong bong vong mac. Ti le thanh cong ve giai phau a nhom bong vong mac thap
NGHIEN CUtJ KHOA HOC
(75,6%)). Ti le mat co thi lire hi 0,02 tra len trong nhom bong vong mac chi chiem 35,2%o, it hon nhieu so voi nhom khong bong vong mac (63,8%)). Yeu to nguy CO ciia ket qua thj lire kem va giai phau xau sau phau thuat la bong vong mac vai RR= 1,71 va 2,33.
Nghien ciru cua Rubsamen tren 46 BN cat dich kinh qua pars plana dieu tri VTXNC ciing thay rang, co 26 BN bong v5ng mac thi sau mo 17 BN ket qua thi luc kem < 5/200. Nguy ca tuang doi ciia bong vong mac lien quan den thi luc kem sau mo la 2,62 vai p = 0,0065. Tac gia cho rang, ket qua thi luc kem dudng nhu lien quan vai dac thii giai phau, dac biet bong vong mac, rach cung mac sau, xuat huyet hac mac va duai vong mac. Sir dung sieu am, nhiing dac thii giai phau nay co the dugc xac dinh chinh xac truac phau thuat, tham chi tren nhu:ng mat khong quan sat dugc ban phan sau do due cac moi truang trong suot. Tien lugng ve thoi gian mo, thi luc, ket qua phau thuat co the du doan mgt phan nha sieu am truoc mo.
Di vat ngi nhan khong phai la yeu to nguy co ciia ket qua phau thuat kem. Trong so BN bj dj vat ngi nhan, chi co 20,5% BN co ket qua giai phau xau, 43,6%) BN co ket qua thj lire kem. Ket qua nghien cim ciia tac gia Nguyen Thi Thu Yen ciing cho thay, thanh cong ve giai phau va thi lire giiia mat CO di vat ngi nhan va khong eo di vat ngi nhan la gan tuong duong nhau. Thanh cong ve giai phau a nhom co dj vat la 71,7%, nhom khong co di vat la 71,5%. Thi luc tir 0,02 tra len a nhom co di vat ngi nhan la 56,9%, nhom khong co di vat ngi nhan la 61,2%.
V. KET LUAN
1. Mirc do phli hop giira chan doan sieu am va lam sang trong VTXNC
- 84%o BN bong vong mac va dj vat ngi nhan trong nghien ciiu dugc chan doan diing bang sieu am B truac phlu thuat cat dich kinh qua pars plana.
- Xet rieng ve miic do phu hgp cua sieu am lam sang tren tirng ton thuong:
+ Bong vong mac: 100%) sieu am chan doan diing truac mo cat dich kinh.
+ Dj vat ngi nhan: 79,5%) truang hgp dj vat npi nhan dugc sieu am phat hien truoc mo, trong do:
Neu di vat nam trong buong dich kinh: 100%
dugc chan doan dung bang sieu am B.
Neu di vat cam hac vong mac: 70,4% mat dugc chan doan diing.
2. Vai tro ciia sieu am trong ket qua phau thuat cat djch kinh dilu trj VTXNC
Sieu am truac phau thuat co gia tri trong chan doan va dinh vi dj vat ngi nhan nhat la dj vat khong can quang, xac dinh tinh trang bong vong mac va nhiing ton thuong khac kem theo tren mat bi VTXNC ma cac moi truang trong suit bj due, khong the quan sat voi mat binh thuang dugc.
Nhung phat hien cua sieu am gop phan tien lugng ket qua ve giai phau va chiic nang cua mat dugc phlu thuat. Sieu am truac ml tra loi cho eau hoi: co hay khong co bong vong mac, co hay khong CO di vat ngi nhan, gop phan giup cac nha nhan khoa quyet dinh mo hay khong, phuong phap mo, thai diem can thiep, cac phuong tien cSn c6 va phuang tien ciia phau thuat.
TAI LIEU THAM KHAO
1. DO NHU' HON (1996), "Nghien ciiu cat djch kinh trong phlu thuat dilu tn bong vong mac". Ludn dn tien si khoa hoc Y - Duac, Truang Dai hgc Y Ha Ngi.
2. T R A N T H I THANH HONG, LE MINH THONG (2003), "Danh gia vai tro cua sieu am va X - Quang trong chin doan di vat ngi nhan ban phSn sau", Y hoc TP Ho Chi Minh, Hgi nghj KHKT \ka thir 20, tap7, si I,tr.30-34.
NGHIEN CUtJ KHOA HOC
3. NGUYEN THI THU YEN (2004),
"Nghien cim iing dung ki thuat cat djch kinh trong dieu tn vet thuong xuyen nhan cau", Ludn dn tiin sy Y hoc, Truong Dai hgc Y Ha Ngi.
4. RAHMAN I, MAFNO A, DEVADASON D AND LEATHERBARROW B (2006), "Open globe injuries: factors predictive of poor outcome
",£>e,20,ppl336-1341.
5. RUBSAMEN P E , COUSINS S. W, WINWARD K.E. et al (1994), "Diagnostic ultrasound and pars plana vitrectomy in
penetrating ocular trauma", Ophthalmology, 101, pp 809-814.
6. WANI VB, AL-AMJ M, THALIB L, AZAD RV, ABUL M, AL -GHANIM M, SABI K (2003), "Vitrectomy for posterior segment intraocular foreign bodies: visual results and prognostic factors ", Retina 23 (5), pp 654-660.
7. FYH/IOPOBA PA., BblKOB B.H..
CEPE^KYH H.H (1985),' 'OnpuHHHax B03HHKH0BeHHa OTdioHKH cexHaTKH nocjieflCTBHax TpaBM rjiaaa", BecTHHK 04)TajTbMOJioHH, (2), ctp.37-41.
SUMMARY
ROLES OF ULTRASOUND IN EYES WITH PENETRATING INJURIES
Objectives: To evaluating the accuracy of ultrasound in the eyes with media opacity after penetrating eye injuries.
Methods: A prospective study to compare preoperative ultrasound and intraoperative findings in 50 eyes undergoing pars plana vitrectomy.
Results: Data show significant ultrasound in terms of sensitivity for exploring severely traumatized eye balls. The good treating outcome comes up to 68% anatomical success while visual success is at 48%.
The patients with poor vision are those with retinal detachment confirmed using ultrasound.
Conclusion: Ultrasound is a safe and accurate imaging method which can reveal obscured lesions in eyes with opacity media, especially after penetrating injuries.
