VIETNAM MEDICAL JOURNAL N°1 - MAY - 2017
DAC DIEM LAM S A N G VA KET QUA DIEU TRI VIEM LOET GlAC MAC TAI KHOA MAT BENH VIEN DA KHOA SaN LA
TRONG 5 NAM ( 2 0 1 1 - 2 0 1 5 )
Tran Thi Khuygn', Ludtig Thi Tuyet lVIai^ D6 Van Dung^
corneal ulcers in ophthalmology hospital in Son La 5 years (2011-2015). Research method: cross-sectional description, prospecbve and retrospective. Results:
The incidence of the disease in a majority eye, eye disease in two patients and only 1 in the group having other causes. Trauma is the leading risk factors accounted for 92.9%, the majority of mjunes carried vat. Ton agents are common corneal ulcer forms (bacteria and virus) accounted for 95.2%. Visual acuity on admission mostJy met witti 57.1% under the CSF 3m. 5.7% corneal perforation. With groups suppurative corneal ulceration by bacteria treatment duration of 4.3 ± 7.56 average day, the longest time is 14 days, the shortest time is 6 days. Have 4 untreatKl eye consen/abon, met in causes bacterial groups and causes. Group studied 70 eyes of 53 eyes observed post- treatment visual acuity of vision increased the most in the grciup caused by the virus.
Keywords: suppurative corneal ulceration, ophthalmology. Son La
T O M TAT
Nghien cffu "Dac diem lam sang va ket qua dieu tri viem loet giac mac tai khoa mat benh vien Da khoa son La trong 5 nam (2011-2015) vdi 2 muc tiSu: (1) Mo ta mot so dac diem lam sang ciia benh viem ioet giac mac tai khoa Mat Benh vien Oa khoa Sdn La trong 5 nam (2011-2015) va (2) Nhan xet ket qua dieu tri benh viem loet giac mac (VLGM) tai dia ban nghien ctfu. Doi tffdng nghien ciru: toan bp benh an CLia benh nhan dtfdc chan doan va dieu tri viem loet giac mac tai khoa Mat Benh vien da khao SOn La trong 5 nam "(2011-2015). Phu'cfng jihap nghien culi: Mo ta cat ngang ket hdp hoi CU\J va tien cffu ho sO benh an.
Ket qua: Ty le bj benh d mgt mat chiem dai da so, b;
benh 6 hai mat chi co 1 benh nhan va gap d nhom nguyen nhan khac. Chan thtfdng la yeu to nguy cd hang dau chiem 92,9%, trong do phan ldn chan thtfdng do tac nhan thtfc vat. Ton thtfdn_^ giac mac hay gap la hinh thai viem loet (do vi khuan va virus) chiem 95,2%. Thj Itfc khi vao vien gap chii yeu la dtfdi DNT 3m_ vdi 57,1 %. Thiing giac mac chiem 5,7%. Vdi nhom ton thtfdng giac mac do vi khuan, thdi gian dieu tri trung binh la 7,56 ± 4,3 ngay, nbieu nhat la 14 ngay, it nhat la 6 ngay. Co 4 mat khong dieu tri bao ton dtfdc, g3p d nhom nguyen nhan do vi khuan va nhom nguyen nhan khac. Trong 70 mat nghien cffu co 53 mat ghi nhan dtfdc thi Itfc sau dieu trj thj Itfc tang nhieu nhat d nhom nguyen nhan do virus.
T&khoa:M\e.m loet giac mac, Khoa mat, Sdn La SUMMARY
CLINICAL FEATURES AND TREATMENT RESULTS CORNEAL ULCERS DEPARTMENT OF OPHTHLMOLOGY, SON LA HOSPITAL I N
5 YEARS ( 2 0 1 1 - 2 0 1 5 ) Research in the clinical features and treatment results suppurative corneal ulceration in ophthalmology hospital in Son La 5 years (2011- 2015) include two objectives: (1) Describe some clinical characteristics of corneal ulcers in Ophthalmology Hospital Son La for 5 years (2011- 2015) and (2) Comments results of treatment of corneal ulcers at study. Research subjects include 70 medical records of patients diagnosed and treated
'Tnj'ng Dai hgc YDddc Thai Binh
^Khoa mk Benh vien da khoa Sdn La
^Lien hiep cac hoi Khoa hgc va ky thuit Ninh Binh Chiu trach nhiem chinh: Do Van Dung Email: [email protected] Ngay nhan bai: 27.01.2017 Ngay phan bien khoa hgc: 27.3.2017 Ngay duyet bai: 10.4.2017
I. BAT VAN OE
Viem loet giac mac la mpt benh rat pho bien d cac ntfdc dang phat trien, cd the de lai hau qua nghiem trong gay md due giac mac, giam th|
Itfc tram trpng, neu khdng dtfdc chan doan va dieu tri kip thdi cd the dan den mii Ida, tham chi phai bd mat, anh htfdng nang ne den cudc sdng ciia ngffdi benh.
6 ntfdc ta do dac diem khi hau ndng am, thuan ldl cho stf phat trien ciia vi sinh vat, dieu kien ve sinh mdi trtfdng kem, mffc sdng ciia phan ldn ngffdi dan cdn thap, ban che ve dan bi, viec cham sdc sffc khde ndi chung cijng nhU cham sdc mat ndi rieng chffa dffdc quan tam diing mffc, thdi quen va kien thffc phdng benli trong lao ddng cung nhff trong sinh hoat chu^
dffdc pho bien ap dung rdng trong nhan dan, ben canh dd la viec tff y diing thudc (dac biet la corticoid), khdng di kham, chffa kip thdl khi benh dang cdn d gial doan sdm cang lam cho ty le mac cung nhff mffc dp benh cang them tram trpng. Chinh vi vay chiing toi tien hanh de tai nham muc tieu:
1. i^o ta mpt sddac diem lam sang ctia benh viem ioet giac mac iai khoa l^at Benh vien Da khoa Sdn La trong 5 nam (2011-2015).
2. Nhan xet ket qua dieu tri benh viem loet giac mac tai dia ban nghien OOJ.
46
TijiP CHi Y HOC VlgT NAM TAP 454 - THANG 5 - SO 1 - 2017
11. DOI TU'OWG VA PHU'OTMG PHAP NGHIEN CUTJ 2 . 1 . Ooi tu'dng nghiin citu: Toan bd benh an ciia benh nhan dudc chan doan va dieu trj viem ioet giac mac tai khoa l*1at Benh vien da khao Sdn La trong thdi gian 5 nam tff 2011 d§n 2015.
- Tieu chuan chgn doi tu'dng nghien cuV + Ho sd cua benh nhan dffdc chan doan va dieu trj viem loet giac mac.
+ Ho sd ciia benh nlian phai cd dii thdng tin de khai thac trong nghien cffu.
+ Neu mpt benh nhan co hdn mdt benh an trong mdt lieu trinh dieu tri thi cac thdng tin khai thac dffdc du^ vao tat ca cac benh an do.
- Tieu chua'n loai trii': Cac ho sd khdng cd dii cac thdng tin can thiet.
2.2. Thiet ke nghien cu'u: Phffdng phap nghien cffU dich te hpc md ta vdi dieu tra cat ngang ket hdp vdi nghien ctfu hdi cffu va tien cffu hd sd benh an.
2.3. Mau va chon mau:
*Cdmau nghien cift/.'Toan bd benh an ciia benh nhan dtfdc chan doan va dieu tri viem loet giac mac tai klioa l^at Benh vien da kiiao Sdn La trong thdi gian 5 nam tff 2011 den 2015.
*Chgn mau. Chii dpng chon tat ca cac benh
an ciia benh nhan dffdc chan doan va dieu trj benh viem loet giac mac tai khoa Mat Benh vien da khoa Sdn La trong 5 nam 2011-2015. Thffc te da nghien ciitf tren 70 ho sd benh an ciia benh nhan dffdc dieu tri viem loet giac mac ndi tru.
2.4. ky thuat va cong cu thu thap thong tin Thu thap thdng tin cd sin ve benh nhan qua khai thac trong hd sd benh an. Cac can bd tham gia thu thap sd lieu nghien cirtj: la cac bac sT chuyen khoa Mat dang cdng tac tai khoa Mat ciia benh vien tinh Sdn La. Cac can bd dffdc tap huan de thdng nhat each thu thap sd lieu.
- Xifly va phan tich sdlieu: Ket qua thu dffdc xff ly thd sau dd nhap dii' lieu sff dung phan mem Epidata, sff dung phan mem Stat Transfer xuat dff lieu tff Epidata sang SPSS, phan tich va xff ly dff lieu sff dung phan mem SPSS 18.0, ve bieu do sff dung phan mem excell. Sff dung cac thdng ke md ta, phffOng phap phan tich de xac djnh cac tan sd, t^ le. Cac sd lieu dffdc bieu dien dtfdl dang ty le phan tram va trinh bay bang cac bang va bieu do.
III. KET QUA
3.1. Oac diem lam sang viem loet giac mac Bang 3.1. Hinh thai ton
tiinh thai 11 Nguyen nhan
Vi khuan Virus Khac Tonci so
tht/dng 'nat theo nguyen nhan Viem ioet
SL 27 13 2 4 2
TL»/o 64,3 30,9 4,8 60,0
A p x e SL 17 5 6 28
TLVo 60,7 17,9 21,4 40,0
Tong so SL 44 18 8 70
TLVo 62,9 25,7 11,4 100,0
p
< 0 , 0 5
Hmh thai ton thtfdng viem loet giac mac gap nhieu hdn ap xe giac mac, viem loet giac mac chiem 60% va ap xe giac mac chiem 40%, stf kiiac biet giffa cd y nghla thdng ke vdi p<0,05. Phan tich cac tac nhan gay ton thffdng giac mac chiing tdi thay tac nhan vi khuan gay viem loet giac mac chiem ty le cao nhat vdi 62,9%, tiep do la do virus chiem 25,7%. Tac nhan vi khuan va virus gay viem loet giac mac nhieu hdn la gay ap xe giac mac; do cac nguyen nhan khac gay ap xe giac mac chiem ty le cao hdn viem loet giac mac (ap xe giac mac la 21,4%, viem loet giac mac 4,8%), sff khac biet cd ^ nghTa thdng ke vdi p<0,05.
Bang 3.2. Thi l&c ciia benh nhan khi nhap viin
Thi Iu'c Sd lu'dng T L %
s r ( - )
ST ( -1-) - < DNT 3m
4,3 4 0
> DNT 3m - 1/10
22,9
1/10
-3/10
1115,7
Tong so
100,0
Ket qua bang 2 cho thay, thi Iffc ciia benh nhan khi vao vien phan ldn b| anh htfdng nghiem trpng, chi cd 15,7% sd benh nhan la^cdn duy tri dtfdc thi iffc tff 1/10 - 3/10.
Bang 3.3. Kich th&dc ton th&dng theo nguyin nhan gay viem loet giac mac Nguyen nhan
Vi Ichuan Virus Khac Tong so
> 2 - SL 41 18 4 63
6 mm T L % 65,1 28,6 6,4 90,0
> 6 SL
3 0 4 7
mm TL»/o 42,9
0 57,1 10,0
Tonq so SL 44 18 8 70
TL»/o 62,9 25,7 11,4 100,0
p
<0,01
VIETNAM MEPICAL JOURHAL N°1 - MAV 2017
Cac benh nhan co kich thuSc 6 loet tCr > 2 - 6mm do vl khuan chiem ty le cao nhat 65,1%, tiep do la do virus 28,6%. Cac ton thu'dng loet tren 6mm chii yeu do nguyen nhan khac gay nen chiem ty le 57,1%.
Bang 3.4. Dau hieu viem trong tien phong Nguyen nhan
Vi khuan Virus Khac Tong so
Tyndali-f Xuat tiet SL
33 15 4 5 2
TLo/o 63,5 28,8 7,7 100,0
Mil SL
8 3 4 15
TL»/o 53,3 20,0 26,7 1 0 0 , 0
Tong SL 44 18 8 70
T L % 62,9 25,7 11,4 100,0 Trong 70 mat nghien CIJ'U, co 52 mat ghi nhan co dau hieu viem trong tien phdng, trong do co 8 tru'cfng hdp co mu tien phdng do vi khuan. SlT khac biet co y nghTa thong ke vdi p < 0.01.
3.2. Ket qua di'eu trj viem ioet giac mac
Bang 3.5. Thay ddi thi itfc ciia benh nhan sau dieu tri Nguyen nhan
VI khuan Virus Khac Tdng so
So di'eu tra
44 18 8 70
Khong doi SL
8 1 4 13
T L % 18,2 5,6 5 0 £ 18,6
Tang SL 36 17 '
0 53
TL»/o . 81,8 94,4 0,0 75,7
Giam SL
^ 0 0 4 4
T L % 0,0 0,0 50,0
5,7 Trong 70 mat nghien cu'u co 53 mat ghi nhan du'dc thi li/c sau dieu tri tang hdn so vdi tru'dc dieu tri chiem ty le 75,7%, trong dd d nhdm nguyen nhan do virus chiem ^ le cao nhat (94,4%). Cac nguyen nhan khac khong cd tru'dng hdp nao tang thi IUc.
Bang 3.6. Ketqua di'eu tri Nguyen nhan
VIkhuan Virus Khac 1 Tong so
So dieu tra
44 18 8 70
Khoi SL 38 17 4 59
TL«/o 86,4 9 4 , 4 50,0 84,3
Khong giam SL
6 1 3 10
T L % 13,6 5,6 37,5 14,3
Bo mat SL
0 0 1 1
T L % 0,0 0,0 12,5 1,4 Qua ket qua bang 6 cho thay, phan ldn benh nhan viem loet giac mac dieu tri khdi chiem t / le 84,3%; cd 1 trffdng hdp chiem ty le 1,4% phai bd mat; 14,3% benh nhan dieu t n khdng giam. Khdng cd trffdng hdp nao phai bd mat nguyen nhan do vi khuan va virus, cd 1 trtfdng hdp phai bd mat do nhdm nguyen nhan khac. Ty le benh khdng giam khi ra vien gap nhieu nhat d nhdm nguyen nhan khac 37,5%.
IV. BAN LUAN
4 . 1 . Oac diem lam sang cua vi§m loet giac mac: Oieu trj viem loet giac mac nhieu khi rat khd khan, ket qua dieu trj phu thudc vao nhieu yeu t d nhtf dieu kien khdi phat, nguyen nhan gay benh, hinh thai lam sang, tien sff viem loet tai mat cung nhff tinh trang toan than, thudc dieu tri trffdc do... cd khi Ithdng bao tdn dffdc nhan cau neu benh nhan den mupn, da dieu tri trtfdc do bang nhffng phtfdng phap phan khoa hpc, benh qua nang khdng dap ffng vdi dieu trj.
4.1.1 Dac diem cua benh nhan Nguyen nhan gay benh: Trong nghien culi, sd benh ntian VLGM do vi Wiuan ma yeu to nguy cd tff chan thuOng la thffc vat (92,9%) chiem nhieu nhat.
Theo y van ttie gidi, nguyen nhan VLGI^ chu yeu do vi khuan. Ty le mdi mac ciia VLGM do nam la 6 - 20%, thap hdn nhieu so vdi VLGM do vi khuan [ 3 ] .
Ve thdigian bi benh tru'dc khi vao vien: Trong
ket qua nghien cilli cua chung tdi, sd benh nhan vao vien sau khi bj benh tff 10 den 20 ngay chiem ty le cao nhat (64,3%).
Phan ldn benh nhan thtfdng den vien mupn, trtfdc do hau het da tff dieu tri, dieu trj d y te tff nhan hoac dieu trj d cac cd sd y te tuyen trtfdc khdng ktidi hoac benh nang ten mdi chuyen vien va day cung la yeu t d lam cho mffc do benh cang them nang ne, khd khan cho dieu trj.
- Ty ie mac benh d t&ng mat:
Ty ie mac benh d mat phai va mat trai gSn nhff nhau. Chi cd 1 benh nhan bj benh d 2 mat do nhdm nguyen nhan khac. Nhff vay trong cac nhdm nguyen nhan, benh phan ldn tij d mpt mat vdi ty le tffdng dffdng nhau, ty le bj benh d hai mat khdng nhieu, chu yeu gap trong nhdm nguyen nhan khac. Oay la nhdm benh co cd cii^
lien quan den yeu to toan than, trong khi do cac nhdm nguyen nhan khac la do tac nhan tff ben ngoai gay nen.
TAP CHl Y HOC VIET NAM TAP 454 - THANG 5 - SO 1 • 2017
-VS yoj to nguy cd: Trong 70 ho sd cua benh nhan VLGM dutfc nghien culj chiing tei thay chii yeu cac trffdng hdp deu cd yeu td nguy od. Phan ldn trong so dd la chan thtfdng tff thffc vat chian 92,9%
Chan thffdng giac mac van la yeu t d nguy cd hang dau gay VLGM, chan thtfdng lam mat dl sff toan ven ciia bieu md giac mac tao dffdng vao cho vi sinh vat gay benh.
Trong sd 771 trffdng hdp cd yeu t d nguy cd la chan thffdng thi tac nhan thffc vat gay chan thtfdng gap nhieu nhat chiem 37,9%. Ket qua nghien ciiij ciia Hoang Nang Trpng (2002) trong tong so 112 tac nhan gay chan thtfdng giac mac, tac nhan cd nguon goc thtfc vat thtfdng gap ntiat chiem 75,9% (cac tac nhan bao gom; hat thdc, la liia, canh cay, rdm ra, que lat tre...) [5].
4.1.2. Triiu ch&ng lim sang - Thi itfc khi vao vien: Nghien cirtj ciia Vu Thj Tue Khanh va cdng stf (2006) trong so 640 mat bj VLGM do nam thi 577 mat cd thj Itfc liic vao vien dtfdi BNT 3m chiem 9 0 . 1 % [ 1 ] , chi cd 362 mat cd thj itfc tren ONT 3m chiem 11.26%.
Trong mdt nghien cffu khac ciia Tran Vu Thd (2005) thi Iffc khi vao vien ciia 45 mat bj VLGM do amip thi cd 92% so mat cd thj Iffc dtfdi ONT 3m [4]. Trong nghien ciili ciia chiing tdi cd thj Itfc dffdi DNT 3m chiem 5 7 , 1 % .
- Hinh dial ton thddng: Hinh thai tdn thffdng viem ioet giac mac gap nhieu hdn ap xe giac mac. Phan ti'ch cac tac nhan gay ton thffdng giac mac chung tdi thay tac nhan vi khuan gay viem giac mac chiem ty le cao nhat vdi 62,9%. Tac nhan vi khuan va virus gay viem loet giac mac nhieu hdn la gay ap xe giac mac.
Ton thffdng giac mac phan ldn la viem loet lam tieu md. anh htfdng ldn den stf toan ven ve mat giai phau ciia giac m?c, do dd dii dieu trj tdt, bao ton dtfdc nhan cau cung gay de dpa den thj Itfc cua benh nhan va dd la ly do lam cho mirc dp tram trpng ciia benh tang ten.
- I(kh th&dc ton thudng: Cac benh nhan cd kich thffdc d loet tff 3 - 6mm do vi khuan chiem ty le cao nhat: 6 5 , 1 % . Cac tdn thffdng loet >
6mm chii yeu do nguyen nhan khac gay nen.
Qua dd thay rang phan ldn benh nhan thffdng den vien trong tinh trang tdn^ thtfdng giac mac da lan rdng, co trtfdng hdp tdn thffdng toan bp be mat giac mac the hien mffc dp tdn hai t d chffc ciia giac mac tram trpng. Kich thffdc tdn thffdng giac mac rpng cd the do benh nhan den vien qua muon, dac biet neu tac nhan la trffc khuan mii xanh thi qua trinh tieu hiiy t d chffc dien ra rat
nhanh do vi khuan nay tiet ra enzym collagenase hoac trffdc dd benh nhan da sff dung cac che pham cd corticoid lam cho qua trinh viem loet giac mac cang them nang ne hdn.
- Do sau l€n th&dng: Trong nghien cffu cua chung tdi thay ty le thiing giac mac chiem 5,7%, khdng thiing giac mac chiem 94,3%.
- Dau hieu viem trong tien phong: Trong 70 mat nghien cffu, cd 52 mat ghi nhan cd dau hieu viem trong tien phdng, trong dd cd 8 trffdng hdp cd mu tien phdng do vi khuan.
4.2. Ket qua dieu tri: Cd 4 mat khong dieu trj bao ton dffdc, gap d nhdm nguyen nhan do vi khuan va nhdm nguyen nhan khac.Trong 70 mat nghien ciTu co 53 mat ghi nhan dffdc thj Iffc sau dieu tn thi Iffc tang nhieu nhat d nhdm nguyen nhan do virus.
V. KET LUiSkN
5 . 1 . Dac diem lam sang: Ty ie bj benh d mdt mat chiem dai da sd, bj benh d hai mat chi cd 1 benh nhan va gap d nhdm nguyen nhan khac. Chan thffdng la yeu t d nguy cd hang dau chiem 92,9%, trong dd phan Idn chan thffdng do tac nhan thffc vat. Ton thffdng giac mac hay gap la hinh thai viem loet (do vi khuan+virus) ctiiem 95,2%. Thj Iffc khi vao vien gap chu yeu la dudi DNT 3m vdi 57,1%. Thiing giac mac chiem 5,7%.
5.2. Ket qua dieu trj: Cd 4 mat khdng dieu tn bao ton dffdc, gap d nhdm nguyen nhan do vi khuan va nhdm nguyen nhan khac. Trong 70 mat nghien cffu cd 53 mat ghi nhan dffdc thj Iffc sau dieu tn thj Iffc tang nhieu nhat d nhdm nguyen nhan do virus.
TAI Ll|U T H A M KHAO
1. Nguyen Hihi Le (2002), "Nghien cull phubng ph^p gliep mang oi dieu tri loet piac mac kho han p n " , Luan v§n Thac sy y hoc, Trudng Dai hoc Y Hn.
2. Hoi nhan ktioa My (1995),_ "Viem let giac m^c do Acanthamoeba", Benli hoc ciia mi mSt, ket mac va giac mac, Nha xuat ban Y hoc, b- 60 - 61 va 90 - 91.
3. Hoang Thi Phuc, Hoang Nang Trong (1996),
"Nhan xet tinh hinh viem loet giac mac do vi khuan dieu tri tai vien Mat TW", Noi san nhan khoa so 2, b-. 44-48.
4. Tran Vu Thtf (2005J, "Nhan xet dSc diem lam sang xet nghiem va dieu tn viem loet giac mac do Acanthamoeba"^ Luan van Th^c sy y hoc, Trffdng Dai hpc Y Ha Noi.
5. HoSng Nang trong (2002), "Nghien ciili h|u qua mil loa do chan thtfdng mat ndng nghi?p va hieu qua btfdc dau ciia bien phap can thiep cpng dSng tai Thai Binh", Luan an Tien sy Y hpc, Trtfdng Oai hpc Y Ha Noi.
