JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 8 - N°1 /2013^
Nghien ciiu dac digm lam sang va ket qua phau thuat ck mong ghep kSt mac ria ty than
The Clinical Characteristics and Evaluation of Limbal - Conjunctival Autograft in Primary Pterygium Surgery
Phiing Long ^''"" ^^'' ^'^" Quany !3
T o m t a t
Muc dich nghien cUu eua chung tdi n h I m d i n h g i l dac diem 13m s i n g v3 ket q u i phau thuat elt mpng nguyen phat theo phuong phap ghep ket mac ria t u than. 65 mong nguyen p h i t tren 36 benh nhan dUOc tien hanh phau thuat va theo ddi ket qua sau 6 t h i n g tU t h i n g 3 nam 2011 den 12 nam 2012.
LUa tudi thudng gap ciia BN ed mpng tren 40. Thj luc <0,05, 0,05 - 0,3 va tren 0,3 tUong Ung la 6,2%, 37,5%va56,3%.Ty le m i t cd ket q u i phau thuat tdt sau 1 t h i n g vdi mdng do II, III v l IV la 93,7%, 86,1%, 76,9% v i d e ket q u i phau thuat tuang Ung sau 6 t h i n g I I 81,8%, 80,6% v l 66,6%. Cd mdi lien quan cdy nghia thdng ke (p<0,05) giUa do mpng va ket qua phau thuat e l t mdng theo phuong phap ghep ket mac ria t u t h a n .
TL//c/ido; mong nguyen p h i t , ghep k e t m a e t u t h i n S u m m a r y
The purpose of this study was to determine clinical characteristics and evaluation of limbal- conjunctival autograft in primary pterygium. 65 eyes with primary pterygiums in 36 patients were underwent limbal-conjunetival autografts and 6-month post-surgical follow-up from March 2011 to December 2012. The patients with primary pterygium were mostly at aged over 40. Reduction in vision under 0.05, 0.05 - 0 3 and over 0 3 were 6.2%, 37.5% and 56.3% in pterygium eyes, respectively. T^e good surgical outcomes for pterygium of grade 2 ,3 and 4 were 93.7%, 86.1%, 76.9% at post-operative first month and 81,8 %, 80.6 %, 66.6 % at 6th month. There was a significant relationship between pterygium grading and surgical outcomes.
Keywords: primary pterygium, limbal-conjunetival autograft
I . D a t v a n d e phia nep gap h i n h b i n nguyet. Nhin chung, mpng M d n g I I qua trinh thoai hda nguyen p h i t va t h u d n g tien trien rat cham qua nhieu nam, cdnhi/ng t i n g s i n cua ket mac vdi viec hinh thanh t d chdc xa 9 ' ^ ' ^ ° ^ " ' ^ '^"^9 ^^^ ^^ v ^ ' t ^ ^ ' ^^ P^^^ ^ " ^ " "^
mach nhd len tren be mat ket mac, phat trien vao ^^^^^ ^^^^ ^^° '^ ^° ' ' ^ " ^^^^ ^ ^ " V^^ ^° ^'^"^' t r o n g v l tham nhiem xudng nhu md g i l c mac. "^''^^S " " = ^^"^^"9 h o p nay, m d n g phat trien hddng Thong t h u d n g , m p n g cd hinh tam g i l c vdi dinh "^^^ ^'^^^ ^^^ 9 ' ^ ^ ""^^ 9ay kich thich chay nUdc hudng v i o t r u n g tam g i l c mac, mat day quay ve ^ ^ ^ ' ^ ^ ' " ^ ^ ^ ° ^^ ^^°- 9ay 'o^n thj h o l e che lap
true quang hpc.
Phan bicn khoa hoc: TS LETH] DONG PHUONG
TAP CHi Y DU'O'C LAM S A N G 108 Tap 8 - S o 1/2013
Mdng thUOng gap d nhUng v u n g cd khi hau jl ndng am, t h d i luong n d n g cao t r o n g n g i y cung n h u trong nam vdi t y le dao d d n g tU 2% - 6%. d Viet Nam, theo t h d n g ke eua Benh vien M i t t r u n g uong, ty le mac benh m p n g la 5,24%, t r o n g d d v u n g ven bien mien Trung cd t ^ le benh cao hon. Tinh Binh Dinh la m d t d l l dat ven bien mien trung, vdi dac diem dja ly v l khi h l u ven bien tao thuan loi cho . viec phat tnen benh ly nay. Vi vay, m p n g I I m d t benh ly nhan khoa d dja phUOng va can duoc quan t i m va dupc dieu trj m d t c i c h bai b i n de giam thieu benh t i l phat. Trong t h d i gian qua, chung tdi da tien phau t h u i t cat m d n g ghep ket mac ria t u than ddi vdi c l e trUOng h p p m p n g nguyen phat. Muc dieh nghien cUu nay n h I m n h i n xet 6ac diem l i m sang v l d i n h g i l ket q u i dieu tri e l t m o n g theo p h u o n g phap ghep ket mac ria t u t h i n va theo doi ket q u i sau 6 t h i n g phau t h u a t tai Vien quan y 13, quan khuV.
3. Doi tuong va phuong phap
3.1. Doi tdang nghien cdu: g d m 65 m i t tren 36 benh n h i n (BN) dUOc ehan d o i n m d n g nguyen p h i t . Cle m i t deu dUOc phau t h u a t e l t m p n g theo phuang phap ghep ket mac ria t u than va duoc theo ddi sau 6 t h i n g tai khoa Mat - Vien quan y 13, quan khu V t r o n g giai doan t u thang 3/2011 den 12/2012,
Tieu chuan lUa c h p n : nhUng BN cd m p n g
^ nguyen p h i t t U dp II t r d len.
-Tieu chuan loai trU:
-1- BN cd viem nhiem m i n t i n h d be mat n h i n cau,di ehUng khd m a t d o d j Ung thuoc, b d n g m i t . . .
+ BN cd benh li cap tinh d m i t n h u viem ket mac ' • cap, viem mang bd dao, viem tui le mu, gloeom .,.
-t- BN cd ele benh toan than khdng eho phep
•'• phau thuat.
-I- BN khdng d d n g y t h a m gia phau thuat hoac cd dieu kien theo ddi.
3.2. Phddng phap nghien cdu:
- Nghien eUu tien cUu, thU nghiem lam sang khdng cd ddi ehUng.
- Phuong p h i p phau thuat: cat m p n g ghep ket mac ria t u t h i n .
• Phan loai do m p n g : theo p h i n loai eua Benh vien mat Trung UOng:
+ D d II: dau m d n g x i m lan ehua qua V2 ban kinh giac mac.
-•- Op III: dau m d n g x i m lan v u o t qua Vi b i n kinh giac mac.
+ Op IV: dau m d n g x i m lan tdi trung t i m giac mac.
- Cac mat duoc d i n h g i l thi luc, g i l l phau tai t h d i diem trudc va 1,3 va 6 t h i n g sau phau thuat
- Oanh gia t i n h trang thj lUc (TL) theo phan loai eua WHO (1977): TL < 0,05 (dem ngdn tay 3m); TL tU 0,05-0,3; T L > 0,3.
- O i n h gia ket q u i phau t h u i t ve mat g i l l phau:
theo 3 m U c d p
+ Tdt: g i l c mac vung got mpng trong, phang, khong ed t i n mach x i m lan. M i n h ghep ket mac phang, bam tot, khdng cd xo mach x i m lan.
+ Trung binh: g i l c mac viJng gpt mdng xo nhe, bieu md khdng phang, cd t i n mach nhung chi gidi han d vung ria. Manh ghep eo xo mach x i m lan nhung chua qua ria g i l c mac.
+ Xau: giac mac vung gpt xo, nhieu, tan mach xam lan qua ria, Manh ghep ket mac bien mat hoae bi t d chUe xo mach x i m lan hoan toan,.
Cac bien chUng:
-I- Bien chUng trong phau thuat: r i c h ket mac than mong, t o n t h u o n g co trUe
+ Bien ehUng sau phau thuat: xuat huyet dudi m i n h ghep, phu, co, hoai manh ghep. viem giac mac cham ndng, u hat.
3.3. Xd li so lieu: cac sd lieu duoc xCr ly theo p h u o n g phap t h d n g ke y hpc
L OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 8 - N°172013
3, Ket qua
Bang 1, So liTong benh nhan, so mSt va so mong nghien cufu
" -——.^^^^ Loai mpng So luong ^^ —-—_____^
So benh nhan So mat So mong
Mpng don Imdt
13 13 13
2milt 9 18 18
Mong kep
/mA
n
11 22
2 mdt 3 6 12
Tdng so 36 48 65
36 BN ditoc phau thuat c5t vnong ghep ket mac ria tU than. 18 BN co mong don 2 nnat va 6 BN cd mpng kep 2 mat va 11 BN mong kep mat. NhU vay, tong so gom 65 mong tren 48 mSt duoc phau thuat.
B^ng 2, Phan bo do mong va tuoi, gidi cija benh nhan
^~"~""""~--~...,^^^ Do mong
Tuoi va gidi ---...^
Na (n = 16)
5 40 41 -60
>60 Cong
Nam (n = 20)
<40 41 -60
>60 Cong
Doll
1 5 3 9 1 3 3 16
0 6 III
0 9 3 12 0 17
7 36
Dp IV
0 3 2 i 0 3 5 13
Tong so
1 (3,8%) 17(65,4%
8 (30,8%) 26(100%) 1 (2,5%) (59%) 15(38,5%) 39(100%)
Tdng SO 36 BN CO 16 nUvl 20 nam. BN nhd tudi nhat II 38 va cao tudi nhat la 76 tudi. Ty le BN nam va nUtuong dUong , LUa tudi BN cd mdng dBN tren 40gap nhieu nhat d e l 2 gidi so vdi nhdm BN dUdi40tuoi {p<0,05).
Bang 3. Tmh trang thi lUc trUcrc va sau mo
~~~~—---______^ Thi luc Thdi gian ~~~~~--~.._____^
TrUdc mo Khi cat chi Sau PT 1 thang Sau PT 3 thang Sau PT 6 thang
<0,05 3 (6,2%) 2 (4.2%) 1 (2,2%) 1 (2,3%) 1 (3,0%)
0,05 - 0,3 18(37,5%) 19(39,6%) 21 (45,6%) 21 (47,7%) 15(45,5%)
>0,3 27 (56,3%) 27 (56,2%) 24 (52,2%) 22 (50%) 17(51,5%)
Tong so mat 48 48 46 44 33
Tyle mat CO thj luc (TL) < 0,05 giam tif 6,2% trudc mo xuong con 4,2% d thdi diem sau mo 1 thang w
tiep tuc giam cho den 3 thang (2,3%) va 6 thang (3,0%). Nhu vay, thi lijc da cai thien dan cho den sau pMu
TAP CHi Y DLfOC L^M S A N G 108 Tjp 8 - S 6 1/2013
thuat 3 t h a n g . TUOng tU n h u vay t y le so mSt co TL 0,05 - 0,3 tang tU 27,5% trUdc mo len 45,6% sau mo 1 thang va cOng on d i n h cho den 3 - 6 t h a n g .
Bang 4. IVloi
~ ~ ^ ^ ^ ^ _ ^ ^ ^ Ket q u i 06 mong ^ ^ " ^ ^ ^ ^ ^ ^
Op II Do III Op IV
en quan giCra do Tpt
15(93,7%) 31 (86,1%) 10(76,9%)
n o n g va l<et qua 1 Trung binh
1 (6,3%) 4(11,1%) 2(15,4%)
thang sau p h i u thuat Xau
0 (0%) 1(2,8%) 1(7,7%)
P
<0,05
Tai thdi diem 1 thang sau phau thuat, m o n g dp III va IV co ket quJ xau t u o n g i l n g la 2,8% va 7,7%. B o i vcfi mpng do II, t y l e ket qua xau la 0%. TUOng tij" n h u vay, ty le ket qua t o t d mpng dp II, III va IV tuong ci'ng la la 93,7%, 86,1% va 76,9% (p<0,05).
B i n g 5. Moi lien quan giura do mong va ket qua 6 thang sau phau thuat
^ ^ " ^ ^ • ^ ^ ^ ^ Ket qua Oo ^ ^ ~ ~ - - - , . . _ ^ 0611(0=11)
06lll(n=31) e6IV(n=12)
Tdt 9f8r,8%J 25 (80,6%;
8 (66,6%)
Trung binh 2 (8,2%) 4 112,9%) 2 (16,7%)
Xiu 0(0%) 2 (6,5%) 2 06,7%)
P
<0,05
Tai thdi diem 6 t h i n g sau p h l u thuat, k e t q u i xau ddi vdi mdng do II, III v l IV lan luot la 0%, 6,5%,16,7%.
Trong khi d d , ty le ket q u i phau t h u a t t d t g i l m dan tU 81,8% xudng 80,6% va 66,6% theo do mdng dp II, III v l tV vdi SU k h i c biet cd y nghia t h d n g ke (p<0,05).
Bang 6, Cac bien chOTng phau thuat Bien chdng
Rach ket mac than mpng Phu manh ghep ket mac Xuat huyet dudi manh ghep Hoai tU manh ghep Viem giac mac cham Uhat
Soluong 11 15 6 2 3 2
Ty le(%) 16,9 23,1 9,2 3,1 4,6 3.1 Bien ehUng hay gap nhat I I phu m i n h ghep ket mac 23,1%, r i c h ket mac than mdng 16,9 m i n h ghep v l u hat ch! g i p d 2 BN (3,1%).
, hoai t d
4. Ban luan
Trong sd 36 BN nghien cUu eua chung t d i , t y le nam/nU la t u o n g d u o n g nhau (nam 55,6% v l nU 44,4%). Theo nghien cUu cCia Nguyen Oinh A n h , ty le
n i y I I 52,3% va 47,7%. Nghien cUu k h i c eua Nguyen Thi Ngoc Han lai thay BN nU chiem tdi 78%. Ket q u i eua e h u n g t d i e h o t h a y BNdlUa tudi t d 4 0 - 6 0 l a e h u yeu, ket q u i nay cung phu hop vdi ket qua nghien eUu eua c l 2 t i e g i l tren. Trong so BN cua chung tdi.
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 8 - N°1 /2013
m d n g gap chu yeu d e l e ddi tUOng ed nghe nghiep ndng dan va n g u d i n , p h l i t h u d n g xuyen tiep xuc vdi cac yeu to nguy co cho sU hinh t h a n h va p h i t trien cua m d n g n h u tiep xuc vdi gid, bui, I n h sang m i t trdi ... Moi lien quan cua e l e yeu t d n i y cung duoc de cap t r o n g m d t so nghien eUu cua cac tac g i l k h i c .
Ket qua nghien eUu ( b i n g 3) cho thi'y sd BN cd TL <0,05 I I thI'p nhat, chi chiem 6,2% v l BN eo thj luc TL > 0,3 la cao nhat (56,3%). TrUdc m d , so m^t cd TL<0,05 ehiem ty le la 6,2% va da g i l m x u d n g eon 2,2%, 2,3% va 3% v I p cac t h d i diem sau m d 1 t h i n g , 3 t h i n g va 6 t h i n g vdi su khac biet cd y nghTa t h d n g ke (p<0,05). N h u vay, TL tang b i t dau tU sau m d 1 thang v l dn d j n h qua 6 t h i n g theo ddi sau phau thuat. Ket q u i n i y cung phu h p p vdi ket q u i nghien cUu cua Nguyen Oinh Anh vdi ty le tUOng t u trUde m d la 1 1 % v l sau m d tai ele thdi diem 6,9%, 4,6% va 4,9%. Nghien eUu cua Nguyen Thj Ngoc H I n ty le thj lue thap trudc m d dUdi 0,05 la k h i cao (15%), sau mo thi luc cai thien khdng rd ret tai cac t h d i diem tUOng dng la 13%, 13%, 14%. Nhin chung, eae nghien eUu deu cho thay tinh trang thi lUc t h u d n g dn d i n h hoac cd e l l thien nhUng khdng nhieu vi m p n g ehi la 1 t r o n g nhieu nguyen n h i n g i l m thj lUe d cac benh n h i n trU cac t r u d n g hop m p n g q u i t o , dp IV, ehe khul't dien d d n g tU h o l e m d n g co keo, x o l n van g i y hien t u a n g loan thi.
Trong nghien eUu cua Nguyen Oinh Anh, sd m i t cd TL >0,3% trudc md la 45% va sau m d 1 t h i n g , 3 t h i n g v l 6 t h i n g 52,8%, 53,4% va 54,1%. Ket q u i eua Nguyen Thi Ngoc H I n eho thay cac ty le tUOng dng trudc m d la 5 1 % va sau m d tai eic t h d i diem la 62%, 62%, 62%. Trong n h d m BN eua chung toi, ddi vdi m d n g dp II, ket q u i ve m i t g i i i phau sau m d t h u d n g tdt, vi v i y 6a khdng den kham lai ke tU khi cat ehi. Do vay, sd BN co ty le TL d mUc cao nay khong duoc thdng ke tai thdi diem sau m d 1 t h i n g den 6 t h i n g
Trong nghien eUu cua chung tdi tai t h d i d i e m 1 t h i n g sau phau thuat, ket q u i phau thuat khdng t o t ddi vdi m d n g do III v l IV la 2,8% va 7,7% so vdi 0% 6 cac m o n g do II (p<0,05). Ty le ket q u i t d t d m d n g dp
II, III va IV t u a n g d n g la 93,7%, 8 6 , 1 % va 76,9% vdi sir k h i c biet ed y nghTa t h o n g ke (p<0,05). Ket qua nghien curu cua c h u n g tdi kha p h u h p p vdi nghien cu'u cua Nguyen D i n h Anh vdi cac ty le tuong iJng lan luot la 93,3%, 70,3%, 20,0%. Nguyen Thj Ngoc Han c u n g bao cao cac ket q u i n g h i e n cdu tuongtii.
Tuy nhien, co sU khac biet d nhUng mpng do IV nhieu k h i nang do sd BN m d n g d p IV trong nghien eUu CLia c h u n g t o i nhieu hon so vdi m p t sd nghien CLfu k h i c . Vl vay, de so sanh m d t c i c h chinh xac hon thi p h l i can nghien cUu vdi sd l u o n g Idn hon.
Tai t h d i d i e m 6 t h i n g sau phau thuat, ket qua phau t h u a t k h d n g t d t cd m o i lien quan den ^6 m d n g t d d d II, d p III len den d d IV vdi ty le tuong iJng la 0%, 6,5% 16,7%. Ty le p h a u t h u a t cd ket qua tot g i l m dan t u o n g Ung tU 81,8% xudng 80,6% va 66,6% vdi SU k h i c biet co y nghTa t h d n g ke (p<0,05). I N h u vay, m d n g c I n g be thi ket q u i phau t h u i t cang tdt. Chung tdi cho rang ket qua n i y cung tuong ufng vdi nhan d i n h t r o n g n g h i e n cUu cua Nguyen Till Ngpc Han vdi ty le ket q u i phau t h u i t tdt theo dp m p n g I I 91,5%, 86,6% v l 100%, ket qua xau la 0%, 3,6% va 6,7% tUOng Ung voi m p n g dp II, III, IV.
Nghien eUu cua Nguyen Oinh Anh da eho thay tyle t o t 88%, 5 1 , 1 % va 0%, ket q u i xau tUOng Ung vdi do m d n g la 0%, 9,2% va 33,3%.
5. Ket l u a n
LUa t u d i t h u d n g g a p cua BN cd mpng d BN tren 40 Thj luc <0,05, 0,05 - 0,3 va tren 0,3 la 6,2%, 37,5%
va 56,3%. Ket q u i phau t h u a t t d t sau 1 thang vdi m d n g d p II, III va IV t u o n g Ung la la 93,7%, 86,1% va 76,9% v l sau 6 t h i n g I I 81,8%; 80,6% va 66,6%. Co m d i lien q u a n ed y nghTa t h d n g ke giUa do mong va ket qua phau t h u a t cat m p n g t h e o phuong phap ghep ket mac ria t u t h a n .
Tai l i e u t h a m k h a o
1. Le Oinh Anh (2009), Nghien eUu Ung dung phau thuat ghep ket mac t h i n mdng dieu trj nnong nguyen p h i t . Ludn vdn bdc sy chuyin khoa cap I Hpc vien q u i n y .
TAP CHi Y DU'O'C LAM S A N G 108 Tgp 8 - S6 1 /2013
2. Nguyen Thj Ngpc Han (2007), Oanh g i l ket q u i t . Cern Kucukerdonmez et al. (2007). Comparision of phau thuat e l t mpng ghep ket mac ria t u t h i n tai conjunctival autograft autograft w/ith amniotic tinh Vinh Phue. Ludn vdn thacsyy hgc, Oai hoc y membrane transplantation for pterygium surgery khoa Ha ndi. and cosmetic outcome. Cornea; 26; pp 407 - 413.
3. Cu Nhan Nai, H o I n g Thj Luy, Ha Huy Tien (1996), 5. Eric Frau, Marc Labetoulle et al (2004), Corneo- Oieu tra djch te hpc mu Ida va mdt so benh ve conjunctival autograft transplantation for m i t . Cdng trinh nghien cdu cap bd, Vien M i t - pterygium surgery. Acta Ophthalmol, Scand: 82;
BdYte. p p 5 9 63.