Tap 5 - S o 5/2010 T/0>P CHi Y OaOC LAM SANG 108
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Anh huong cua kich thu6c mo bao tru6c den qua trinh due bao the thuy tinh sau ph^u thuat tan nhuyin the thuy tinh
The effect of anterior capsulorhexis size on development of capsular opacification after phacoemulsification
Le Thj Dong Phuung , , , Benh vienTrung uang Quan dgi 108
Tom tat
Muc dfch: nghien cffu anh hUdng ciia kfch thUdc xe bao nhd hPn 5mm va kich thUde xe bao Idn hPn 5,5mm den qua trinh due bao TTT. DUa ra kfch thUdc bao hpp If lam giam ty le due bao TTT. Ddi tUpng va phUPng phap: nghien cffu dUpc tien hanh tren 152 mat (124 BN) bi due TTT lien quan den tud'i dUpe phau thuat PHACO va dat TTTNT tai khoa Mat - Benh vien TL/QD 108 tff 7/2007 den 7/2009. Tift ca BN dUpe ehia deu hai nhdm. Nhdm I: xe bao trUde kieu dUdng eong lien tuc vdi kich thUdc < 5 mm, dong thdi bao trUdc nam ehdm len 360° tren phan quang hpe eua TTTNT. Nhdm I I xe bao trUdc kieu dUdng cong lien tuc vdi kfch thudc xe bao >5,5mm ddng thdi bao trUdc nam ngoai hoan toan hoac nam ngoai tren 180° phan quang hpe cua TTTNT. BN dUpc theo doi ft nhat 1 nam sau phau thuat. Ket qua: thj lUc trung binh dat cao nhat vao thang thff 3 va 6 d ca hai nhdm, trong dd nhdm I la 0,75 ± 0,15 va 0,15 ± 0,16, cao hPn nhdm II la 0,7 ± 0,19 va 0,69 ± 0,19 tUdng ffng sff khac biet giffa hai nhdm cd y nghia vdi P < 0,05. Due bao trUde (OBT) sau 1 nam d nhdm I la 100%, d nhdm I I la 47,47% sU khac biet cd y nghia thdng ke vdi P < 0,05. Sau 1 nam ty le due bao sau (DBS) d nhdm I la 26,32% ft hPn so vdi nhdm II la 59,21% sU khac biet nay ed y nghTa vdi P
< 0,05. Ket luan: Kfch thUde xe bao trUde anh hUdng rd ret den qua trinh due bao TTT. OBT xay ra sdm hdn, nhieu hdn so vdi DBS. DBT ty le nghich vdi kfch thUde xe bao, ngUpc lai DBS ty le thuan vdi kfch thUde xe bao. Kfch thUde xe bao nhd hdn optic TTTNT 0,5-lmm va ehdm len optic TTTNT 360° la muc tieu ed the dat dupe cho cac trUdng hpp phau thuat due TTT. Tuy nhien, PTV cung can cd dUpc mot kfch thUde xe bao thfeh hdp de cac bUde phau thuat tiep theo dien ra thuan ldi, an toan va dat dupe ket qua mong dpi.
Tff khda: xe bao, due bao TTT, Phaco, TTTNT, due TTT.
Summary
Purpose: This study examined either a capsulorhexis smaller than 5mm in diameter or a capsulorhexis larger than 5mm in diameter are effective on development of capsular opacification. This study was performed to determine whether an ideal capsulorhexis size able to reduce capsular opacification incidence exists. Methods: This study comprised 152 patients (124 patients) with senile cataract having continuous curvilinear capsulorhexis, phacoemulsification, acrylic lOL implantation from 7/2007 to 7/2009 at Ophthalmological Depatement of Hopspital 108. The patients were divided into 2 equal groups. The group I received a capsulorhexis smaller than 5mm in diameter, which lie completely on the intraocular lens (lOL).
The group I I received a capsulorhexis larger than 5mm in diameter, which lie completely off the lens optic or if it was eccentric, had to have less than 180 degrees on the lens. Follow-up was for at least 1 year after surgery. Results: Visual acuty achieved the highest average in month 3 and 6 in both groups, in which group I was 0.75 ± 0.15 and 0.15 ± 0.16, higher than group II was 0.7 ± 0.19 and 0.69 ± 0.19 respectively, the
Phan bien khoa hgc: PGS.TS. NGUYEN HONG GIANG ^Q^
difference between the two groups is significant with P <0.05. Two eyes (2.63%) in group I were anterior capsule contraction, but group II had no case,this difference is significant with P<0.05. One year after surgery, the ACO score was 100% in group I and 47.47% in group I I , there was significant difference between the two groups with P<0.05. Throughout the follow-up, there was less PCO in the small capsulorhexis group (26.32%) than in the large capsulorhexis group 59.21%, the difference between the two groups is significant with P <0.05. Conclusions: Capsulorhexis size affect significantly on the development of capsular opacification. ACO generally occurs much earlier than PCO and may occur as early as a month after the surgery. ACO inversely proportional to capsulorhexis size, reverse PCO is proportional to capsulorhexis size. Capsulorhexis size smaller than the optic diameter of lOL from 0.5mm-lmm and capsular edge fully overlaps the lOL for 360°, attainable goal for cataract surger/ cases. However, the PTV should also have been an appropriate size for the next step surgical place convenient, safe and achieve expected results in improving long-term outcomes.
Keywords: capsulorhexis, capsular opacification, phacoemulsification, lOL, cataract.
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1. Dat van de
Xay dffng mot phUdng phap xe bao thfeh hdp, nhat la xe bao dudng eong lien tue la dieu kien thiet yeu cua phau thuat tan nhuyen (PHACO) the thiiy tinh (TTT) hien dai. Xe bao dUdng eong lien tue tao sffc manh eho bao trUde mot tfnh dan hoi deo dai de chdng lai nhffng eang dan tiep theo eiia qua trinh phau thuat PHACO va dat TTT nhan tao (NT). Mot bffdc sai lam ban dau khi tao xe bao cd the dan den nhffng bien chffng nang ne cho qua trinh phau thuat tiep theo mot each nhanh ehdng.
Phau thuat PHACO vdi xe bao dUdng eong lien tuc cd dat TTTNT trong till bao ngay cang dUdc ap dung rpng rai d khap ndi tren the gidi cung nhU d Viet Nam. Mae du gan day da ed nhieu tien bp trong phau thuat lay TTT, ky thuat dat TTTNT va thiet ke mau TTTNT, nhUng due bao TTT van edn la mot van de nan giai, gay nhieu tranh eai. Due bao TTT xay ra do sff tang sinh, di cU va sff gian phan eiia eae te bao bieu md TTT cdn sdt lai sau phau thuat. Nhffng te bao bieu md nay dffde trai qua qua trinh gian phan binh thffdng hoae chuyen thanh trung md, cudi cung hinh thanh nen nhffng hon tap te bao khdng thuan nhat trong due bao trUdc va due bao sau. Sff tiep xiic ciia TTTNT vdl cae te bao bieu md se lam bao trUdc TTT bj xd hda [1,8]. Trong nhffng thap ky qua, cac nha nhan khoa da dffdc biet nhieu ve di chffng lau dai eiia mdi lien quan giffa bao -TTTNT va nhffng yeu td gdp phan due bao sau, eo riit bao trffdc, di lech tam
TTTNT, anh hUdng ciia sff thay dd'i ra vj trf TTTNT va dan den giam thi Iffe.
Trong nghien effu nay, ehung tdi muon tim hieu va so sanh nhffng thay dd'i d bao TTT vdi kfch thffdc xe bao ed dffdng kfnh nhd hdn 5mm hoae ldn hdn 5,5mm. Tff dd, ed the dUa ra mot kfch thUde xe bao hdp ly can thiet de gdp phan lam giam ty le due bao'
2. Doi tu'dng va phu'dng phap nghien cu'u 2.1. Ddi tu'dng nghien cu'u
Nghien cffu dUde tien hanh tren cac BN bj due TTT lien quan den tud'i dffde phau thuat PHACO va dat TTTNT tai khoa Mat - Benh vien TLTQD 108 tff 7/2007 den 7/2009.
Tieu chuan chpn: due TTT lien quan den tud'i cd thj Iffc nhd hdn hoac bang 0,2. Khdng cd tien sff phau thuat mat, hoae ehan thUdng mat.
Tieu chuan loai trff: due TTT khdng phan biet 6\idc sang tdi; due TTT lien quan benh ly vdng mac.
Cac benh ly ve mat anh hUdng den ket qua sau phau thuat nhu seo giac mac, viem mang bo dao, gidcdm, bong vong mae...
2.2. Phu'dng phap nghien cu'u
Nghien cffu theo phUdng phap so sanh hai nhdm, md ta lam sang, theo doi va danh gia ket qua trUde va sau dieu trj. BN d\idc theo ddi it nhat 1 nam sau phau thuat. ':•••"'''.> '"'••- ^ '.
Tift ea eac mat sau khi thda man tieu ehuan chpn va tieu chuan loai trff dUdc dUa vao nghien cffu chia
Tap 5 - S o 5/2010 TAP CHi Y DUOC LAM SANG 108
lam hai nhdm: Nhdm I: md bao trUdc kieu dUdng cong lien tuc vdi kich thudc xe bao nhd tff 3mm den 5 mm, dong thdi bao trUde nam chong len 360° tren phan quang hpe eiia TTTNT. Nhdm I I ; md bao trUde kieu dudng eong lien tuc vdi kfch thUdc xe bao rpng tff 5,5mm den 7mm, ddng thdi bao trUdc nam ngoai hoan toan hoae nam ngoai tren 180° phan quang hpe ciia TTTNT.'UJ uy 6\ i t n - ...:..; b-' '..- ../ ...M;: '.,:...
Phau thuat: Raeh giae mac vung ria vj trf phfa thai dUdng bang dao 3.2mm de md vao tien phdng.
Bdm chat nhay vao tien phdng de duy tri dp sau tien phdng. Diing kim sd 26G dat tren bao trUde d trung tam TTT roi keo nhe kim ve hUdng dUdng raeh ria de tao ra mdt vat bao hinh tam giac nhd. Diing kim da be cong dau keo la bao trUde TTT liie nay da lat len va xe theo dUdng cong lien tue. Nhffng mat due TTT
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ehi'n trang hoac due hoan toan ehiing tdi nhuom bao bang trypan blue. Sau khi xe bao dUdc hoan thanh tien hanh do kfch thUde Id md bao trUde bang kim bdm tien phdng ed khae vach milimet (hinh 1). Tach nhan bang nUdc. Tan nhuyen nhan TTT bang sieu am. Tiiy theo dp cffng ciia nhan ehiing tdi ap dung eac ky thuat khac nhau ciia PHACO. Rffa hut sach chat TTT va chat vd TTT tff ngoai vi dUdi bao trUde ra tdi xi'eh dao TTT vao trung tam bao sau. Bdm chat nhay vao tien phdng va trong tiii bao. Gap TTTNT bang pince chuyen dung, dat TTTNT nam can ddi vao trong tiii bao. Rffa hut sach chat nhay. Ket thiie phau thuat tat ca cac BN deu dUde tiem canh nhan eau l/2ml Gentamyein 80mg phdi hdp vdi l/2ml Depo- medrol 40mg. Tra mS Tobradex va bang kin.
Hinh l.Do kfch thUde xe bao qua dUdng mo
Danh gia ket qua: Sau khi BN ra vien, dMc hen kham lai djnh ki: sau 2 tuan, 3 thang, 6 thang va 1 nam. Moi lan kham tat ea BN deu dUde do thi Iffc cd chinh kfnh, do nhan ap, do kfch thUde 16 md bao va kham xet tinh trang bao TTT qua sinh hien vi. Tren ed sd kham xet dieu ehinh che dp di'eu trj thude eho phii hdp. Cac sd lieu thu dUdc dUa vao Foxpro 6.0 va Excel de thdng ke va xff ly. V"^ " ; , , . , . ' '" " "
K/'ch thu'dc lo md bao tru'dc sau phau thuat do chieu dpc va chieu ngang bang tia sang den khe sinh hien vi (SHV) ed thang chia dp tien hanh nhU sau:
dan dong tff mat BN ft nhat 6mm. Dp rdng den khe 0.2mm, gdc 0 dp, tieu diem trung tam TTTNT, dp eao khe sang khae nhau dii cham bd lo md bao liic dd dpc ket qua kfch thffdc ghi tren thUde do ciia may kham SHV.
Danh gia tinh trang bao tru'dc: Mffc dp nhan bao trUde dUde ehia nhU sau: Nhan nhe ehi d khoang 1/4;
nhan vffa la khoang 2/4 va nhan nang la d khoang 3 hoae 4 phan.
Due bao trUde (DBT) chia 4 mffc: Binh thffdng:
bao trUde trong sudt; Nhe: trang nhe khdng cd nhan bao; Vffa: trang vffa ed the cd nhan bao; Nang: trang nhff sffa ed nhan bao. : fti.
Danh gia tinh trang bao sau: Mffc dp nhan bao sau dffdc ehia gidng nhff bao trUdc. Vi tri due bao sau dupe tfnh nhU sau: chu bien la viing nam ngoai phan quang hpe (optic) eiia TTTNT, trung tam la viing nam trong phan quang hpe ciia TTTNT dffdng kinh 3mm, canh trung tam la vung nam giffa ehu bien va trung tam.
103
Due bao sau (DBS) dffa tren dau hieu den khe, quan sat day mat rd rang va giam thi Iffc. Mffe dp ehia ra nhff sau: Dp 0= khi dong tff dan 6mm khdng thay cd hinh anh due bao sau; Dp 1= bao sau edn trong, cd eac nhan hoac dai xd rat manh nhd mjn, soi day mat cdn thay 6Mc rd dia thj va mach mau, khi dong tff dan rpng tren 4mm cd hinh anh due bao sau viing ngoai vi, khdng hoae cd giam thi Iffc 1 hang. Dp 2=
due nhe, soi day mat thay rd dffdc gai thj nhUng eae Idp sdi than kinh va maeh mau khdng thay rd dUde ehi tiet, giam thj Iffc 2-3 hang; Dp 3= due trang sffa, khdng soi rd dupe day mat, thj Iffc giam tren 3 hang.
3. Ke't qua nghien cu'u
Nghien cffu eiia chiing tdi tien hanh tren 124 BN (152 mat) chia deu cho hai nhdm, trong do ed 28 BN
phau thuat 2 mat, moi mat dffde xep vao mdt nhdm.
Nhdm I gom 31 BN nam ehiem 50% va 31 BN nff chiem 50%. Nhdm II gdm 30 BN nam ehiem 48,39%
va 32 BN nff ehiem 51,61%. Tud'i trung binh eiia BN d nhdm I tai thdi diem phlu thuat la 69,76 ± 9 tud'i.
Thap tuoi nhat la 50 va Idn tud'i nhat la 87. Tud'i trung binh eiia BN d nhdm II la 70,77 ± 9,86 tud'i. BN ed tud'i thap nhat la 42 va eao nhat la 90 tud'i. Khdng ed sff khac biet ve tuoi va gidi ciia BN giffa hai nhdm vdi P > 0,05. Due TTT vd va nhan trung tam ehiem ty le eao nhat 62,5%; thap nhat la due dffdi vd sau ehiem 5,26%. Due TTT hoan toan 15,79%, due TTT chin trang 9,87% va due nhan trung tam 6,58%. Khdng ed sff khac biet giffa hai nhdm ve hinh thai due TTT P>0,05.
Bang 1. Thj Iffc ed chinh kinh tai cac thdi diem theo doi d hai nhdm Thdi gian
TrUdc mo Sau 1 nqay Sau 14 nqay Sau 1thanq Sau 3 thanq Sau 6 thanq Sau 12 thanq
Nhdm I (Trung binh ± SD)
0,08 ± 0,06 0,41 ± 0,19 0,53 ± 0,21 0,73 ± 0,17 0,75 ± 0,15 0,75 ± 0,16 0,73 ± 0 . 1 5
Nhdm I I (Trung binh ± SD)
0,07 ± 0,07 0,38 ± 0,22 0,6 ± 0,22 0,68 ± 0,19
0,7 ± 0,19 0,69 ± 0,19 0,71 ± 0,16
Gia tri P
0,48 0,22 .0.,,14.
0,06 .Q,..Q4 0,02 0.26
Thj Iffc trung binh dat eao nhat vao thang thff 3 va 6 d ca hai nhdm, trong dd nhdm I la 0,75 ± 0,15 va 0,15 ± 0,16, eao hdn nhdm II la 0,7 ± 0,19 va 0,69 ± 0,19 tffdng ffng sff khae biet giffa hai nhdm ed y nghia vdi P < 0,05. Tuy nhien, d thdi diem sau 1 nam nhffng trUdng hdp DBS da xff If nen ket qua thj Iffc giffa hai nhdm la tffdng dUdng nhau. ,^_ . ,, „c, ,. .-,{, w,;
Bang 2. Kfch thUdc 16 md bao trUde ciia hai nhdm tai cae thdi diem theo doi
Thdi gian theo ddi Tronq khi md
Sau 1 nqav Sau 14 nqay Sau 1thanq Sau 3 thanq Sau 6 thanq Sau 12 thanq
Nhdm I Kfch thudc trung binh (mm)
4,53 ± 0,46 4,53 ± 0,46 4,53 ± 0,46 4,49 ± 0,47 4,39 ± 0,46 4,21 ± 0,45 4,06 ± 0,44
P . _ 0,36 0,01
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0.03"^
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Nhdm I I Kich thudc trung binh (mm)
5,90 ± 0,3 5,90 ± 0,3 5,89 ± 0,31 5,81 ± 0,32 5,72 ± 0,32 5.62 ± 0,33 5,4 ± 0.29
P _
» 0,29 0,04"=
0.04"^^
0.01-18 o.o?-i=
Tap 5 - S o 5/2010 TAP CHi Y DUOC LAM SANG 108
Phan tfch kie'm dinh chiing toi nhan thay kfch eo lai tdi 0,47mm. Sff thay doi nay ed y nghia vdi P <
thffdc lo md bao trUde sau phau thuat 1 ngay va 2 0,05. Gidng nhU nhdm I, sau 14 ngay phau thuat kfch tuan la nhu nhau. NhUng sau 1 thang, 3 thang, 6 thUdc lo md bao trUde d nhdm I I cd rat ft thay dd'i.
thang va 1 nam so vdi 1 ngay sau phau thuat kfch Thdi diem sau 3 va 6 thang bao trUdc co lai it va thffdc lo md bao trUdc da ed sff thay doi rd ret. Sau 1 cham 0,18mm va 0,28mm tUdng ffng, nhUng sau 1 thang bao trUdc eo lai 0,04mm; sau 3 thang co lai nam eo nhieu tdi 0,5mm. Sff thay dd'i kfch thUde nay 0,14mm; sau 6 thang da co lai 0,32mm va sau 1 nam ed y nghTa vdi P < 0,05.
•'&'''"" Bang 3. Mffc dp due bao trUdc d hai nhom theo thdi gian
Thrti nian Sau 14 ngay Sau 1thang
Sau 3 thang
Sau 6 thang
Sau 12 thnna
Nhdm I I I I II I I I I II
I I I
Trona n 36 76 21 60 9 52
0 49
Q 40
% 47,37
100 27,63 78,95 11,84 68,42
0 64,47
0 52,63
Due nhe n 40
0 50 16 60 21 66 18 64 22
% 5.2,63
0 5.5.79 21,05 78,95 27,63 86.84 23,63 84,21 28,95
Due vffa n
0 0 4 0 4 3 5 5 6 8
% 0 0 5,63
0 5,26 3,95 6,59 6,59 Z,89 10,53
Due n 0 0 1 0 3 0 5 4 6 6
nano
% 0 0 . 1,32 .
0 3,95
0 6,59 5,26 ,Z,.,8.9.
7,89
P
0,0017-"
0,0057-'
0,0027-' 0,0017-"
0,0013-'^
Bang 3 eho thiiy qua trinh DBT xay ra ngay tff tuan dau sau phau thuat d nhdm I so vdi nhdm II sff khae biet cd y nghTa vdi P<0,05. 6 nhdm I ed 2 mat bj eo riit bao trUde chiem 2,64%, 1 mat gap sau 1 thang phau thuat DBT trang day thj Iffc khong giam 1 mat gap sau 1 nam co riit bao kem theo DBS giam thj Iffc. Ca 2 mat deu xff ly phau thuat xe bao trffdc 2 dffdng hinh nan hoa ddi dien nhau. 6 nhdm I I khdng ed trffdng hdp nao.
Bang 4. Mffe dp due bao sau d hai nhdm theo thdi gian
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Mffe dd due bao sau Thdi oian
Sau 14 ngay
Sau 1 thang
Sau 3 thang
Sau 6 thang
Sau 12 thang
nhdm I I I
I I I
I I I
I I I
I I I
DdO n 76 73 71 62 67 55 64 44 56 31
% 0 96,05 93,42 81,58 86,84 72.37 84,21 57.89 73,68
40,79 n 0 3 5 14
9 18 10 17 7 19
D 6 I
% 0 3.95 6,58 18,42 11,84 23,58 13,16 22.37 9,21
29
D 6 I I n 0 0 0 0 0 3 2 11
6 11
% 0 0 0 0 0 3,95 2,63 14,47
7,90 14,47
Do IIIS n
0 0 0 0 0 0 0 4 7 15
% 0 0 0 0 0 0 0 5,26 9,21 19.74
P
0,08022
0,02729
0,02759 0,00127
0,00107
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105
Bang 4 cho thay tff 1 thang den 12 thang mffc dp DBS giffa hai nhdm la khae biet cd y nghTa vdi P<0,05. Quan sat hinh thai DBS ciia nhdm I thdi diem 1 thang cd 6,58% la dang hat chiem 1/4 chu vi gay nhan bao. Thdi diem 3 va 6 thang ty le DBS dang hat chiem 1/4 chu vi la 11,84% va 13,16%, tUdng ffng.
Tai thdi diem 1 nam, dang hat day len nam rai rae d viing effc sau chiem 17,11% (13/76 mat), cdn lai dang xd hda bao trUdc ket hdp dang hat la 9,21%. 6 nhdm I I , vao thang thff 3 hai la bao trUdc va sau dinh vdi nhau gay nhan bao sau ehiem 23,68% va DBS xd chu bien tai vj tri hai la bao trUdc va sau dfnh vdi nhau ehiem 3,95%. Sau phau thuat 1 nam, hinh thai due dai sdi xd ehu bien ehiem 14,71% gay giam thj Iffe 1 hang va due kieu hinh vdng Soemmering nam sau TTTNT chiem 19,74% gay giam thj Iffc 2 hang.
Tat ea cac trffdng hdp nay deu phai laser bao sau.
4. Ban luan
Trong nghien cffu nay, chiing tdi mudn ban den nhffng thay dd'i d bao TTT giffa hai nhom cd kfch thffdc xe bao khae nhau, nhdm cd kfch thude xe bao nhd hdn 5mm va nhdm cd kfch thUde xe bao ldn hdn 5,5mm.
4.1. Due bao tru'dc
Cd nhieu quan diem khae nhau ve anh hudng cua kfch thffdc xe bao den ty le hinh thanh va phat trien due bao TTT sau phau thuat PHACO. Ngudn te bao bieu md TTT gay ra due bao TTT eung cdn la van de dang dffde tranh cai. Quan diem te bao bieu mo cd nguon gdc tff bao trUde ddng vai trd quan trpng.
NgUde lai, ed quan diem cho rang te bao bieu md d viing xi'ch dao eiia tui bao ddng vai trd khong quan trpng bang sff di eU eiia te bao bieu md tang sinh len be mat bao trUde hoae bao sau ciia bao gay nen due bao TTT [ 1 , 3 ] .
Phan tieh sd lieu ehiing tdi nhan thay d hai nhdm kich thude 16 md bao trUde da giam di ro ret theo thdi gian. Ty le DBT cd sff khae biet cd y nghTa giffa hai nhdm. Tai eae thdi diem theo doi sau phau thuat chiing toi gap DBT vdi cac mffe dp khac nhau d nhom I nhieu gan gap ba fan 6 nhdm I I . NgUdc lai, cung tai cac thdi diem nay, DBS d nhdm I ft hdn gan 2 lan so
vdi nhdm I I . SU khac biet nay giffa hai nhdm ed y nghTa vdi P < 0,05. Qua do, ehiing tdi cho rang DBT ty le nghjch vdi kfch thude xe bao, edn DBS lai ty le thuan vdi kfch thude xe bao. DBT xay ra nhieu hdn va sdm hdn so vdi DBS va tien trien cham lai d thang thff 6 sau phau thuat. Mae dii vay DBT khdng anh hffdng den thi lUe ciing thdi diem 1 thang sau phau thuat thj Iffc d nhdm I va nhdm I I la nhU nhau. Tham ehi, sau 6 thang nhdm I ed 100% bj DBT nhUng thj Iffe trung binh van cao hdn nhdm I I cd y nghTa P<0,05.
Mat khae, chiing tdi eung nhan thay DBT vin phat trien eho dii cd xe bao rpng hay nhd, bdi vi sff tang sinh va di cU ciia te bao bieu md cdn lai van eo the nay mam tff viing xfeh dao. Quan sat tren lam sang chiing tdi nhan thay qua trinh DBTxay ra qua 4 giai doan: 1) xd hda hoac due bd xe bao d vai cho; 2) toan bp bd xe bao tiep xiie vdi optic cffa TTTNT trd nen due tien trien; 3) hinh thanh nhffng nep nhan bao;4) xd hda tien trien qua mffc hoae khdng can ddi lam bao eo lai, ed the dan den bien chffng co that lo md bao trffdc, lech tam 16 md bao va di lech TTTNT.
4.2. Co rut bao tru'dc *
Co riit bao trUdc ds phan nao lam nan Idng cac PTV.Ld md bao trUdc chi't hep qua mffc ed the gay giam thi lUc,sff meo md bao cd the anh hUdng den vj trf va chffc nang eiia TTTNT. Co riit bao tien trien eo the trffc tiep dan den hau qua lam dirt day chang Zinn,vi the ed the bien chffng di lech phffc hdp ca bao va TTTNT [8],
Trong nghien effu chiing toi gap 2 mat co rut bao ehiem ty le 2,63% deu d nhdm I Khdng gap trffdng hdp eo rut bao nao xay ra d nhdm II.BN 75 tud'i dffdc xe bao vdi kich thUde 3,5mm cd hien tUdng eo riit bao vao thang thff 1 sau phau thuat. BN thff hai 70 tud'i, dUde phau thuat vdi kfch thUde xe bao 3,5mm va hien tUdng CO rut bao xay ra sau phau thuat Inam ed kem theo DBS gay giam thj Iffe 2 hang. Ca hai mat ed DBT d mffc 2, bd eiia 16 md bao day va xd eo lai ehi cdn khoang 3 mm nhUng chUa di lech TTTNT.
J.D.Ho [4] gap 8 mat xe bao nhd 4,5 - 5mm co riit bao gay di lech TTTNT ra trUdc va gap ngay trong tuan dau tien sau phau thuat, thj luc giam
l.I.Tsinopoulos [9] gap 3,29% vao thang thff 2 den
Tap 5 - S o 5/2010 TAP CHl Y DUOC LAM S A N G 108
thang thff 4 sau phau thuat.Tat ca deu bi DBT va dffdng kinh eiia xe bao khoang 3,5 - 4mm, thj Iffe giam trong khoang 6/60 den 6/19 nhUng chUa cd di lech TTTNT. Tudi ciia nhffng BN nam trong khoang 65 - 81 tu6'i,ed mot BN bj gia bong bao va mot BN bj gidcdm gdc md. '• - ' • ..^r.r j . ;, , . - v : i.^;:
Cae tac gia eho rang kfch thUde xe bao ban dau la yeu td quan trpng, nd dUdc cho la ed nhieu te bao bieu md di chuyen hdn gay nen hien tUdng co riit bao tiem tang [9,10]. Trong nghien effu chiing tdi da chii tam loai trff tat ea eac benh ly toan than va tai mat trffdc phau thuat. Vi vay, chiing tdi eho rang 2 mat co rut bao gap trong nghien effu cd the la do xe bao qua nhd (dffdi 3,5mm) va tuoi benh nhan cao tren 70 tuoi.
Qua nghien effu ehiing tdi xin dUa ra mot so quan diem ve dieu tri co rut bao nhU sau: \)Theo doi lam sang, nhffng BN Cd nguy cd eo riit bao trUdc d mat bj xe bao dffdi 4-5mm. 2) Xe bao vdl kfch thu'dc
rong q\hm bdt mffc dp chit hep bao,PTV nen co gang xe bao toi da bang dffdng kfnh ciia optic TTTNT de han che nguy cd tang co rut bao.3) can nhac raeh bao trUde hinh nan hoa 2 diem doi dien nhau trUde khi ket thiic phau thuat khi xe bao nhd 3,5mm de de phdng bien chffng co riit bao sau nay.
4.3. Due bao sau
DBS la mot bien chffng thudng gap nhat sau phau thuat TTT khoang tff 20% den 50% [3].DBS gay anh hudng den sffc khde, gay bat ldi ve kinh te vi vay bat cff mot nghien effu thay doi ky thuat nao eung nham mue dfch la giam ty le DBS mot each hieu qua nhat.
Nghien cffu ciia chiing t6i eung bpc 16 rd sau 1 nam ty le DBS chiem 25,57% d nhdm xe bao nhd dudi 5mm la 26,32% ft hdn so vdi nhdm xe bao rdng tren 5mm la 59,21% sff khac biet nay cd y nghTa thdng ke vdi P < 0,05.
Bang 5. Ket qua due bao sau eiia ehiing tdi va cac tac gia sau 1 nam phau thuat
Tac gia
E.J.Hollick va eong sff [5]
W.R.Meacoek va eong sff [6]
Le thj Ddng Phffdng
Nam 1999 2001 2010
Phffdng phap Xe bao theo nhdm
Xe bao 5mm Xe bao theo nhdm
Chia nhdm Xe bao 4- 5mm Xe bao 6-7mm Optic MINI famm Uptic MINI b,bmm Xe bao < 5mm Xe bao > 5,5mm
Tyle 32,7%
66,2%
1,5%
6,9%
26,32%
59,21%
N 36 39 30 30 76 76
Cae tac gia vdi cae phUdng phap khae nhau nhUxe bao vdi phan bao trUde edn lai nam ehdm len hay khdng ehdm len optic TTTNT hoac xe bao nhd hay xe bao Idn nhffng deu thffa nhan kieh thffdc xe bao nhd 4-5mm hoac nhd hdn optic TTTNT cd ty le DBS thap hdn xe bao 6-7mm hoac Idn hdn optic TTTNT. Quan sat dien bien DBS, d nhdm xe bao rpng ehiing t6i nhan thay trong thang dau phan bao trUde cdn lai sau khi xe bao dfnh vdi bao sau lam nhan bao sau 6 viing
;Chu bien, sau dd den thang thff 3 bao due xd trang vung hai la bao dinh vdi nhau tien trien dan vao trung tam gay anh hffdng den thj Iffc. Trong khi dd, d nhdm xe bao nhd chiing toi khong thay xuat hien nhan bao sau, ma thay nhffng mang dang hat Elchnig d chu
bien bao sau xuat hien mudn vao thang thff 6 va tff dd lan dan vao trung tam gay giam thj Iffe.
Cae tac gia eung img hp gia thuyet eiia chiing tdi cho rang sff tiep xuc eiia mep bao trffdc edn lai vdi bao sau la dieu kien quan trpng lam cho bao sau bj nhan [1,3,5]. Khi xe bao vdi kieh thffdc nhd, hau het eae te bao bieu md d bao trffdc dffdc giff each xa bao sau bdi phan quang hpe ciia TTTNT va vi vay hien tUdng nhan bao rat it kha nang xay ra.Khi xe bao vdi kieh thffdc rpng,mep bao trffdc kh6ng nam ehdm len tren optic eiia TTTNT, hien tffdng dfnh bao trffdc vdi bao sau khong tao nen hang rao ngan can sff di eff te bao bieu m6 trai dai dffdi optic TTTNT. Do dd, vimg DBS d nhdm xe bao rpng the hien bang ty le DBS trang sffa cao hdn so vdi nhdm xe bao nhd.
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4.4. Kich thu'dc xe bao thich hdp
Nghien effu ciia chiing tdi da bpc 16 ro kfch thudc xe bao ed anh hffdng den qua trinh due bao TTT sau phau thuat. Xe bao vdi kfch thUdc rpng thi co ty le DBS gay giam thj Iffc eao hdn nhdm xe bao vdi kich thffdc nhd. NhUng xe bao kich thUdc nhd phai ke den la hau qua hoi chffng co riit bao. Khi bao chit hep qua mffe ed the lam ehe lap viing nhin, tham chf eo keo qua mffc cd the gay tac dung khdng cd ldi. Vay kfch thu'dc xe bao nhu' the nao la thfeh hdp de la giam ty le due bao TTT?
Nhffng nghien cffu gan day cho thay ki'eh thUdc lo md bao trUde eo lai theo thdi gian sau phau thuat.
Nhu vay neu xe bao vdi kich thUde 5mm, 16 md bao trUde se co lai cdn khoang 4,4mm sau 6 thang.Tuy nhien neu xe bao vdi kfch thUdc 5,5mm thi sau 6 thang 16 md bao trUdc van cdn khoang 5mm [2,3]
Trong nghien cffu ciia chung tdi vdi xe bao kfch thUde nhd trung binh la 4,53 mm thi sau 6 thang con 4,21mm, xe bao vdi kfch thUdc rpng 5,9mm thi sau 5 thang cdn 5,62mm.
Cae tac gia eho rang khi bd ciia bao trUdc nam ehdm len optic ciia TTTNT 360° se ngan can te bao bieu md TTT tang sinh va gay ra mot hieu ffng dUdc gpi la hieu iing hang rao [3,7, 8]. Bao trUdc ehdm len TTTNT 360° la de ed djnh vi trf ciia TTTNT mot each hieu qua. Trong nghien effu eiia ehiing t6i bien ehffng di lech tam TTTNT sau 1 nam d nhdm xe bao rpng la 7,5% trong khi d nhdm xe bao nhd khdng gap trUdng hdp nao sff khae biet giffa hai nhdm la cd y nghTa vdi P < 0,05
Nhff vay, kich thUdc xe bao thfch hdp la cd dudng kfnh nhd hdn optic TTTNT la tff 0,5-lmm, nhUng theo ehiing tdi van co nhffng trUdng hdp ngoai ie. Doi vdi due TTT rat day, xe bao rpng la thfeh hdp de an toan trong khi phau thuat. Trai lai, nhffng trudng hdp xac djnh tien lUdng c6 bien chffng bao sau thi xe bao nhd hdn de ed the dat TTTNT vao khe mi khi ed bien ehffng.
5. Ketluan
Kich thffdc xe bao trUdc anh hUdng ro ret den qua trinh due bao TTT. DBT xay ra sdm hdn, nhieu
hdn so vdi DBS. DBT ty le nghjch vdi kieh thffdc xe bao, ngUpe lai DBS ty le thuan vdi kich thUde xe bao.
Xd CO tui bao ehi gap d nhdm xe bao vdi kich thUdc 3,5mm. Chiing tdi de xuat kfch thUde xe bao nhd hdn optic TTTNT 0,5-lmm va ehdm len optic TTTNT 360°
la muc tieu ed the dat dupe cho cac trUdng hdp phau thuat TTT. Tuy nhien, PTV eung can cd dUdc mot kieh thudc xe bao thfch hpp de cac bUde phau thuat tiep theo dien ra thuan ldi, an toan va dat dUde ket qua lau dai.
Tai lieu tham khao
1. Bertelmann E: Posterior capsule opacification and anterior capsule opacification.Curr Opin Ophthalmol 2001, 12: 35-40.2.
2. Fogia R: Device for Intraoperative Measurement of Capsulorhexis Dimensions. J J Cataract Refract Surg 2003; 29: August: 1643-1644.7.
3. Gimbel H.V et al: UPDATE/REVIEW: Late in-the- bag intraocular lens dislocation: Incidence, prevention, and management. J Cataract Refract Surg 2005; 3 1 : 2193-2204.6.
4. Ho J-D, et al: Early Postoperative Capsular Block Syndrome. Chang Gung Med J 2003;26:745-53,3 5. Holliek EJ et al: The effect of capsulorhexis size
on posterior capsular opacification: one-year results of a randomized prospective trial. Am J Ophthalmol 1999;128:271-279. 9.
6. Meacoek W.R et al: Effect of optic size on posterior capsule opacification: 5,5mm versus 6,0mm AcrySof intraocular lenses. J Cataract Refract Surg 2001, Aug, 27 (8), pp. 1194-8.10.
7. Nekolova J: Comparison of Posterior Capsule Opacification After Two Different Surgical Methods of Cataract Extraction. Am J Ophthalmol 2008;
145:493-498.8.
8. Park T.K, et al: Changes in the area of the anterior capsule opening after intraocular lens implantation. J Cataract Refract Surg 2002;
28:1613-1617.4.
9. Tsinopoulos I, Symeonidis C: Capsule contraction syndrome in eight eases of hydrophobic one-piece intraocular lens implantation. Clin Exp Optom 2008; 9 1 : 5: 469-472 .5
