NGHIEN CLfu PHAU THUAT CAT DICH KINH DIEU TRI TO CHU'C HOA DICH KINH SAU VIEM MANG BO DAO
r Bd Nhu Hon *, Cung Hong San *, Nguyin Trgng Kiidi** J
TOM T A T
Muc tieu: ddnh gid kit qud cdt dich kinh (CDK) dieu tri to chiec hod dich kinh (TCHDK) sau viem mdng bo dao (VMBD) vd iflgt so yiu to lien quan.
Doi tuong va phuong phap: nghiin cieu mo td, tien ciru khong co nhom chimg, gom 40 mdt (40 binh nhdn) dugc phdu thudt CDK diiu tri TCHDK sau VMBD tai Binh viin Mdt Trung leang tie thdng 9/2008 din thdng 7/2009.
Ket qua: tai thdi diem 03 thdng sau phdu thudt, kit qud gidi phdu theo miec do due dich kinh dgt kit qud tot Id 82,5%; trung binh 7,5%); xdu 10%). Kit qud thi luc tdng 80%>; giie nguyen 12,5%; gidm 7,5%.
Ket luan: kit qud phdu thudt khd quan, da cdi thien ddng ki cd vi gidi phdu vd chiic ndng thi gidc cho ngudi binh.
Tir khoa: viim mdng bo dao, cdt dich kinh
I. DAT VAN DE
Viem mang bd dao la benh thudng gap trong lam sang. Benh dien bien phuc tap duai nhieu hinh thai va de lai nhieu biln chiing. TCHDK la bien chiing it gap hon so vdi mot sd bien chung khac nhung la bien chiing nang, neu khdng dugc xii tri kjp thdi thi do la nguyen nhan gay eo keo va bong vong mac. Cach day khoang 30 nam, khi chua cd phuong phap phau thuat CDK thi nhung benh nhan TCHDK sau VMBD kit qua dieu trj rat han che. Tuy nhien, trong khoang 2 thap ky gan day nhd nhung tien bp ve khoa hpe, ky thuat va cong nghe da tao ra mgt budc tien mdi trong dieu trj cac benh djch kinh - vong mac ndi chung, dilu trj TCHDK sau VMBD ndi rieng. Tren the gidi, cd nhieu nghien cuu v l phlu
*Binh vien Mdt Trung uomg,
**Benh viin Mdt tinh Hd Nam . . . .
thuat CDK de chan doan, dieu trj va dieu trj cac bien chiing ciia benh VMBD, trong do cd bien chiing TCHDK. O Viet Nam, cho den nay chua cd nghien ciiu day dii ve CDK dilu trj TCHDK sau VMBD. Vi vay, chiing tdi tien hanh d l tai nay vdi 2 muc tieu:
1. Ddnh gid kit qud phdu thudt CDK diiu tri TCHDK sau VMBD.
2. Niidn xet mgt so yiu to liin quan din kit qud dieu tri.
II. DOI TirONG VA PHirOOVG PHAP 1. Doi tuong nghien ciiu
La cae benh nhan phau thuat CDK dilu trj TCHDK sau VMBD tai Benh vien Mit Trung uong til' thang 9/2008 din thang 7/2009.
Nhan khoa Viet Nam (So 19 - 2010) 13
1.1. Tiiu citudn ciion binh nhdn
- Mit TCHDK tren benh nhan VMBD da on djnh.
- Nhirng mit bj TCHDK day dac khdng soi ro day mat.
- Mat TCHDK khu trii trung tam.
- Nhirng mit TCHDK gay co keo de doa bong vong mac.
1.2. Tiiu citudn loai trie
- Mat CO seo giac mac day, the thuy tinh due nhieu, bong vong mac.
- Nhirng mat teo nhan cau, mat chuc nang.
- Cd benh toan than nang khdng cho phep phau thuat.
- Benh nhan khdng dong y tham gia nghien ciiu.
2. Phuong phap nghien cuu 2.1. Thiit ki nghiin cieu
* Loai nghiin cieu: md ta, tien ciiu khdng cd nhdm chumg.
* Cd indu: n = 40
* Phuang phap mo cdt djch kinh:
- Vo cam: gay te hoac gay me tuy theo tudi benh nhan.
- Cd djnh nhan cau bang vanh mi.
- cat ket mac sat ria 180° cam mau.
- Chpc Cling mac each ria 3,5 - 4,0 mm; dat dinh nude, den npi soi va dau cat vao buong djch kinh.
- Tien hanh cat djch kinh td chiic hoa.
- Laser npi nhan trong mgt so truong hgp.
- Khau ciing mac bang chi 7/0, miii chir X.
- Khau ket mac.
* Bdnh gid kit qud - Kit qud ve gidiphdu
+ Ket qua tdt: djch kinh trong, soi ro day mat tii trudc xich dao din vdng mac trung tam, vong mac ap.
-I- Ket qua trung binh: djch kinh due khu trii,
day mat soi ro qua nhung viing djch kinh cdn trong, vdng mac ap.
-I- Kit qua xiu: djch kinh due nhilu, khong soi ro day mat hoac bong vong mac.
- Kit qud thi luc: theo danh gia bang bang do thj lire vdng hd Landoh cd chinh kinh. Biln ddi thj ,.Iuc coi la cd y nghTa khi:
+ Vdi thj luc DNT > 5m: bien ddi it nhat 1 hang theo bang thj luc vdng hd Landolt.
+ Vdi thj lire < DNT 5m: bat cu mgt bien ddi thj lire nao so vdi trudc md.
- Ddnh gid vi nhdn dp: do nhan ap bang nhan ap ke Maclakov qua can lOgam. Doi vdi trudng hgp khdng do dugc chiing toi udc lugng bang tay.
+ Nhan ap binh thudng: tii 16mmHg - 24mmHg.
+ Nhan ap thap: dudi 16mmHg.
+ Nhan ap cao: tu 25mmHg trd len.
- Ddnh gid vi biin chimg: bien chiing trong phau thuat, bien chung sdm va bien chiing mugn sau phau thuat.
3. Xuly so lieu
Sd lieu dugc ghi nhan trong ho sa nghien ciiu, xii Iy theo phuong phap thong ke y hpe.
in.KETQUA
1. Dac diem benh nhan truo'c mo
1.1. Bac diim benh nhdn theo tuoi vd gidi Cd 40 mat d 40 benh nhan dugc phau thuat CDK, Uong do cd 55% (22/40) BN nam, 45%
(18/40) BN nij. Tudi dudi 18 la 4/40 BN (10%), tir 18-60 tudi la 34/40 BN (85%), tren 60 tudi cd 2 BN (5,0%). Benh nhan nhilu tudi nhit la 77 tudi, benh nhan it tudi nhat la 10 tudi. Tudi trung binh ciia nam la 41,4 ± 16,2; nu 36,0 ± 18,7; chung 2 gidi 40,0 ± 17,3.
1.2. Cdc itinh titdi Idm sdng TCHBKsau viimMBB
Bdng 1. Cdc Itinh thdi idm sdng TCHBKsau viim MBB Hinh thai lam sang
Khu trii Toa Ian Mang the mi
Co keo mang djch kinh Tong
n 29
II 0 0 40
% 72,5 27,5 0,0 0,0 100,0 Trong cac hinh thai Iam sang, hinh thai khu trii thudng gap nhat 29/34 (72,5%)).
2. Ket qua phau thuat 2.1. Kit qud gidiphdu
Bdng 2. Kit qud gidiphdu theo miic do due dicit kinh Djch kinh
Ra vien Sau 2 tuan Sau 1 thang Sau 3 thang
Tot n 28 30 33 33
% 70,0 75,0 82,5 82,5
Trung binh
It
11 9 5 3
% 27,5 22,5 12,5 7,5
Xau n
1 1 2 4
% 2,5 2,5 5,0 10,0
Tong 40 40 40 40 - 0 thdi dilm ra vien 70% (28/40 BN) DK-VM tdt, 27,5% trung binh va 2,5% xau.
- Tai thdi diem 1 thang ty Ie BN cd DK-VM tot tang len (82,5%)), trung binh giam di cdn 12,5%), xau tang len 5%).
- 6 thdi dilm 3 thang ty Ie BN cd DK-VM tdt la 82,5%, trung binh giam cdn 7,5%, xau tang len 10%.
2.2. Kit qud thi luc
2.2.1. Kit qud thi liec trudc vd sau mo tai cdc thdi diim theo ddi Bdng 3. Kit qud thi luc trudc vd sau diiu tri Thi luc
ST (+) din DNT <3m
DNT>3m din 3/10
>3/10
Vao vien n (%)
29 72,5
11 27,5
0
Ra vien
n (%•)
12 30,0
25 62,5
3 7,5
Sau 2 tuan 8 20,0
24 60,0
8 20,0
1thang n (%)
5 12,5
22 55,0
13 32,5
3 thang n (%)
4 10,0
22 55,0
14 35,0 Sau phlu thuat 3 thang ty le BN cd thi luc tii' ST(+) - DNT < 3m giam di tir 72,5% trudc mo xudng cdn 10%). 0 muc thj luc tu DNT > 3m din 3/10 tang len tir 2,75% tm'dc mo len 55%o. Mire thj lue > 3/10 tang len tir 0% Uudc md len 35%.
Nhan khoa Viet Nam (So 19 - 2010) 15
2.2.2. Biin doi thi luc sau mo
Bdng 4. Biin doi thi luc sau md
Thi luc Ra vien
Sau 2 tuan Sau 1 thang Sau 3 thang
Tang
It
30 31 32 32
% 75,0 77,5 80,0 80,0
Giir nguyen n
8 7 5 5
% 20,0 17,5 12,5 12,5
Giam n
2 2 3 3
% 5,0 5,0 7,5 7,5 Sau md 3 thang cd 80%i thj luc tang, 12,5%o giu nguyen va 7,5%) giam.
2.3. Kit qud nhdn dp sau phdu thudt
Bdng 5. Kit qud nhdn dp trudc vd sau diiu tri tai cdc titdi diim titeo doi Nhan ap
<16 mmHg 16-24 mmHg
> 25 mmHg
Vao vien
n (%)•
0 40(100,0)
0
Ra vien
n (%•)
0 40(100,0)
0
2tuan n (%)
0 40(100,0)
0
1thang n (%)
0 39 (97,5)
1 (2,5)
3 thang n (%) 2 (5,0) 38 (95,0)
0
KH.St
- Trudc phau thuat 100%) sd BN cd nhan ap d gidi han binh thudng.
- Thdi diem 01 thang sau phau thuat cd 01 BN tang nhan ap.
- Thdi diem 03 thang ed 02 BN cd nhan ap thap do bong vong mac.
2.4. Biin chung phdu thudt
- Bien chung trong mo: xuat huyet djch kinh 5°/o; due the thuy tinh 2,5%); raeh vong mac 2,5%).
- Bien chung sau mo: phu djch kinh 7,5%; viem giac mac khia 12,5%); phan ung viem mang bd dao 10%, due thi thuy tinh 10%; tang nhan ap 2,5%; bong vdng mac 5%; TCHDK tai phat 5%.
3. Mot so yeu to lien quan den ket qua diiu tri
3.1. Lien quan giira itinh thdi khu trd vd tda ian vdi thf iuc ra viin
Bdng 6. Liin quan giua itinh thdi khu tru vd toa ian vdi tiii lire ra vien
^~^^--^^^ Thj luc Hinh thai^^""^^-.^^^
Khu trii Toa Ian
St(-t-) din DNT <3m n (%) 6 (20,7) 6 (54,5)
DNT >3m den 3/10 n (%) 20 (69,0)
5 (45,5)
>3/10 n (%) 3(10,3)
0
T6ng 29
11 - Thj lire khi ra vien miie DNT > 3m din 3/10 d hinh thai toa lan ehi chiem 45,5%o, trong khi d hinh thai khu trii ty le cao hon 69% (20/29 BN).
- Thj lire d muc DNT < 3m thi ngugc lai, hinh thai khu trii chilm ty Ie 20,7% thip hon so vai hinh thai toa Ian 54,5%).
- Thj luc > 3/10 CO 3BN (100%) gap trong hinh thai khu trii.
3.2. Liin quan thdi gian iir khi viim MBB idn cudi ciing din khi phdu thudt vdi bien chteng sdm sau phdu thudt
Bdng 7. Liin quan titdi gian tie khi viim MBB ldn cuoi ciing den khi pita u tit udt vdi biin citieng
sdm sau phdu tituat.
Thoi gian viem
< 12 thang
>12 thang
Co bien chiing n = 16 (%)
3 18,8
13 81,2
Khong bien chung n = 24 (%>)
15 62,5
9 37,5 Sd BN md trudc 12 thang ke tir khi VMBD lan cuoi cung cd bien chiing sdm la 18,8%), khdng bien chiing 62,5%). Sd BN md sau 12 thang cd bien chiing la 81,2%o, khdng cd bien chung la 37,5%).
IV. BAN LUAN
1. Dac diem benh nhan truo'c mo
Trong nhdm nghien cuu ciia chiing toi, ty Ie mac benh chii yeu d Iiia tuoi lao dgng tii' 18-60 tudi (85%). Chinh vi vay, viec phat hien sdm, dieu trj kjp thdi nham cai thien thj luc cho BN la luc Iugng lao dpng chinh trong xa hoi.
Ty Ie BN nam mac benh dugc phau thuat (55%)) nhieu hon BN nu' (45%)). Ty Ie nam/nu la 1,2/1.
Hinh thai lam sang TCHDK sau viem MBD thudng gap d hinh thai khu trii 72,5%), hinh thai tda Ian chi chiem 27,5%. Hinh thai mang the mi va co keo mang djch kinh khong gap trudng hgp nao.
Da sd BN cd thj luc trudc phlu thuat d muc tu ST (+) din DNT 3m (72,5%). Muc thj luc tir DNT > 3m din 3/10 la 27,5%. Khdng BN nao cd thj luc > 3/10.
Nhan ap trudc phau thuat: 100%o so BN cd nhan ap d gidi han binh thuong.
2. Ket qua phau thuat 2.1. Kit qud gidi phdu
Theo thdi gian, chiing toi thay ket qua ve giai phau theo muc dp due djch kinh: ket qua tdt tang len, ket qua trung binh giam di, ket qua xau cung tang len.
Nhung trudng hop cd ket qua xau do la nhung BN bj bien chung bong vong mac, due djch kinh.
Kit qud gidi phdu cua mgt so tdc gid sau mo 3 thdng
Bdng 8. Kit qud gidiphdu cua mpi so tdc gid
~—-~-_,_^^ Djch kinh Tac gia ^^~"^--^.__
Yu. HG, Chung H (1994)
Li J va cdng su (2002) Do Nhu Hon; Nguyen Trpng Khai (2009)
Tot 70,2%
85,7%
82,5%
Trung binh 19,8%
10,8%
7,5%
Xau 10%
3,5%
10%
2.2. Kit qud thi iiec
Qua theo ddi chiing tdi nhan thay, thj luc tang so vdi liic vao vien. Tai thdi diem 3 thang sau phau thuat, CO 80% so BN ed thj lire tang, 12,5%) thj lire giii' nguyen, 7,5%) thj luc giam.
Kit qud thi luc ciia mgt so tdc gid sau mo 3 thdng
Bang 9. Kit qud thi iuc cua mgt so tdc gid
Tac gia
Heligenhan A va cong su (1994).
YuHG, Chung H (1994).
Bovey EH, Herbort CP (2000).
Li J va cdng su (2002).
Do Nhu Hon, Nguyen Trpng Khai (2009)
Thi luc (ty le %) Tdng
82,8 69,2 80,4 72,5 80,0
Giie nguyin
12,3 20,8 5,8 15,0 12,5
Gidm 4,9 10,0 13,8 12,5 7,5
Nhan khoa Viet Nam (So 19 - 2010) 17
2.3. Bdn ludn vi kit qud nhdn dp
Nhan ap ha dang ke so vdi trudc phau thuat, nhan ap ha nhung van d gidi han binh thudng.
Sau phau thuat 1 thang cd 1 BN tang nhan ap. Nhan ap dieu chinh bang dung djch Timolol tra mat.
Chung'tdi gap 2 BN ha. nhan ap do bong vong mac. Khdng gap trudng hgp nao nhan ap ha keo dai.
2.4. Bdn luan vi biin citieng phdu thudt
Xuat huyet djch kinh trong phau thuat: chiing tdi gap xuat huyet dich kinh nhe, chi can nang cao chai djch truyen la ngimg chay mau, sau do diing dien dong de cam mau.
Mot sd bien chung nhu phu djch kinh, viem giac mac khia, phan ung VMBD dieu trj ngi khoa ket qua tdt.
Bien chiing Iam giam thj Iuc thudng gap la due the thiiy tinh, bong vong mac, due djch kinh.
Tuy nhien, bien chiing due the thiiy tinh thuong gap do trudc md the thuy tinh da due, sau mo due tang nhanh. Sau mo lay the thiiy tinh due ket hpp dat lOL thi Iuc cai thien tdt.
3. Ban luan ve mot so yeu to lien quan den ket qua dieu trj
3.1. Liin quan giiea Itinh thdi khu trd vd toa lan vdi thi iuc ra viin
0 hinh thai khu tru ket qua phau thuat tot hon hinh thai tda Ian. Theo chiing tdi d hinh thai khu trii TAI LIEU THAM KHAO
1. TRAN AN (2003), "Nghien ciin phau thuat cat djch kinh trong viem npi nhan d tre em". Tap chi Nghien dm Yhgc, Bp Y te - Dai hoc Y Ha Npi.
2. DO NHU' HON (1996), "Nghien ciiu cit djch kinh trong phau thuat bong vong mac", Luan an phd tien sT khoa hoc y - dupe.
3. TON THI KIM THANH va CS (1991),
viec thuc hien phau thuat se thuan lgi han hinh thai tda lan. Hon nua nhirng VMBD nang thudng gay TCHDK hinh thai tda Ian, nhung VMBD nhe hon thudng gay TCHDK khu tru.
3.2. Liin quan titdi gian tie khi viim MBB ldn cudi ciing den khipitdu thudt vdi biin chu'ng sdm sau phdu thudt
Chung toi thay rang, nhirng benh nhan dugc phau thuat trudc 12 thang thi ty le cd bien chiing sdm (18,8%) it hon sd benh nhan dugc phau thuat sau 12 thang (81,2%)). Theo ehung tdi, nhirng benh nhan cd thdi gian tii' khi viem MBD Ian cudi cung den khi phau thuat cang dai thi su co keo djch kinh vong mac cang lau, qua trinh tang sinh djch kinh vong mac cang phat trien. Vi vay, viec phat hien sdm, dieu tri kjp thdi, chi djnh phau thuat dung, tien Iugng chinh xac se han che bien chiing sdm sau phau thuat.
V KET LUAN , ..
cat djch kinh theo 3 dudng qua pars plana (dudng nude vao, duong npi soi va dudng de cho dau may CDK) la phuong phap cd hieu qua trong dilu trj TCHDK sau VMBD.
Ket qua phau thuat kha quan, da cai thien dang ke ca ve giai phau va chiic nang thj giac cho ngudi benh, giam nguy ca mu Ida.
Viec phat hien sdm, dieu trj kjp thdi, chi djnh phau thuat dung, tien Iugng chinh xac se han che bien chiing som sau phau thuat. ., . ^ , ,,|.
"Nhung ket qua budc dau ve su dung may cat djch kinh de cat thuy tinh the va djch kinh", Ky yeu hoi nghi khoa hgc ky thudt nganh mdt; Itr
102-107. ,, ,;-, ,.;:,,,, :.,..!. , : ,:, :^ ;,,,,;
4, BOVEY E.H; HERBORT C P (2000),
"Vitrectomy in the management of uveitis". Ocul.
Immunol lnflammS(4):2S5-29\
5. HELIGENHANS A; BORNFELD N, FOEVSTER MH, WESSING A (1994), Long - term results of pars - plana vitrectomy in the management of complicated uveitis. Br. J. Ophthalmol (78,7):
549-554.
6. LI J, TANG S, LU L, ZHANG S, LIM
(2002), "Therapeutic, vitrectomy for severe uveitis and its complications", Zhonghua Yan Kezazhi, 38 (4).
7. YU HG, CHUNG H (1994), "Results of vitreous surgery for posterior complications of chronic uveitis", Korean J. Ophthalmol; 8 (1): 20 - 25.
SUMMARY
STUDYING OF TREATMENT OF VITREOUS ORGANIZASION AFTER POSTERIOR UVEITIS USING VITRECTOMY
Objectives: to evaluate the result ofvitrectomy and some other related factors for vitreous organizasion after posterior uveitis.
Methods: prospective, descriptive non controlled study based on 40 eyes of 40 patients those were vitrectornised to treat the post uveitis vitreous organizasion in VNIO from 9/2008 to 7/2009.
Results: Anatomical result: good: 82.5%, moderate: 7.5%, bad: 10%. Visual acuity increase 80%, unchanged: 12.5%, redusced 7.5%.
Conclusion: the result are promising, anatomy and function are improved.
Key words: vitreous organizasion, uveitis
Nhan khoa Viet Nam (So 19 - 2010) 19
