I NGHIEN CUU KHOA HOC
DANH GIA BIEN CHUl^G TRONG PHAU THUAT TAN NHUYEN THE THUY TINH TAI KHOA MAT
BENH VIEN VIET TIEP HAI PHONG
Khdc ThiNhiin*
TOM TAT
Muc tieu: tim hieu cdc bien chi'mg trong md cua phdu thugt tdn nhuyen the thuy tinh (TNTTT) vddua ra cdc gidi phdp nhdm hgn che cdc bien chi'mg ndy.
Doi tugng vd phuong phdp: chung tdi nghien cuv nhiing bien chimg trong md ciia phdu thudt tdn nhuyen the thuy tinh tren 232 mdt md TNTTT tgi Khoa Mdt B^nh vi4n Vi?t Ti4p Hdi Phdng tir 1-2001 den 10-2003.
Ket qua.- thung bao sau ggp d 3 mdt (1,29%), chan thuang mdng mdt a 3 mdt (1.29%), rach mdng Descemet a 6 mat (2.58%). bdng vet mod 4 mdt (1,72%), rdch bao trudc a 5 mdt (2.15%).
Ket luan: nhin chung bien chimg trong md TNTTT la khdng nhieu, khong ngng. hdi phyc tot khi dieu tri vd ti le bien chujjg gidm ddn khi muc do kheo leo. thudn thuc cua phdu thugt vien tdng len.
Tir khda: tdn nhuyen the thuy tinh. bien chimg trong phdu thudt.
I. DAT VAN DE
Nam 1967 Kelman phdt minh ra phau thugt TNTTT bang sieu dm. Day la mgt budc ngodt lich su trong phau thuat due the thiiy tinh (TTT): vdi vet md nhd, lien seo nhanh, it bien chiing phdu thudt TNTTT Idm giam cdng chdm sdc, thj lyc hdi phyc nhanh va sdm sau phau thugt. CJ Viet Nam phau thugt TNTTT dugc dp dyng tir nam 1995, tai khoa Mdt Benh vien Vi^t Tiep, phau thugt ndy dugc dp dung tir thdng 01/2001. Chiing tdi tien hdnh nghien cihi de tdi ndy nham myc tieu: tim hieu cdc bien chung trong md cua phdu thudt TNTTT vd dua ra cdc gidi phdp nhdm hgn che cdc bien chung ndy.
IL DOITirONG VA PmrONG PHAP NGHIEN ClTU 1. Doi tuong nghien ciru
Benh nhdn dye TTT tir 18 tuoi trd len dugc mo bdng phdu thudt TNTTT phdi hgp dgt TTT nhdn
tgo mem Acrysof qua dudng rach giac mac phia thdi duang 3,2mm tir thdng 01/2001 - 10/2003 tai Khoa Mdt Benh vi?n Vi?t Ti?p Hdi Phong.
Tieu chuan loai trir: s^o gidc mgc, mgng tii dg II trd len, rdch bao sau do chan thuang, benh nhan cd b^nh toan thdn va tgi mat dnh hudng den ket qud phau thudt.
2. Phuong phap nghien cihi: nghien cuu md ta cdt ngang.
Phuang phdp phdu thugt: phau thugt TNTTT qua dudng rgch gidc mgc phia thai duong 3,2mm, d§t TTT nhdn tgo Acrysof trong bao.
Khdm theo doi sau phdu thugt: bang mat 1 ngay sau phdu thugt, thay bang sau md 1 ngdy, kham Igi b?nh nhdn sau I tuan, 1 thdng, 3 thang, 6 thdng va 1 nam.
Chi tieu theo dot: cdc bien chiing trong phau thugt.
* Benh vien Mdt Hdi Phong
24 I Nhan khoa Viet Nam (So 29 - 2012)
[HIEN COU KHOA HOC I
m . KET QUA NGHIEN CUtJ
1. Mot so dac diem ve benh nhan trud'c phau thu^t Tdng so mat dugc md: 232 mdt; s6 lugng benh nhan mo: 207; tudi trung binh: 68, 16 12, 63; gidi: nam: 73 (35,26%), nu': 134 (64,73%);
mdt phdu thudt: mdt phdi: 123 (53,01%), mdt trdi:
109 (46,09%); true nhan cEiu trung binh: 23,44
± 2,16mm; cdng suat TTT nhdn tgo trung binh 20,27dp ± 5,17, dg ciing trung binh ciia nhan TTT la 3,146,
2. Bien chiing trong phau thuat TNTTT Chiing tdi gdp mdt so bien chung rach bao trudc, thiing bao sau, bdng vet mo... nhieu nhat la bien chiing bong mdng Descemet:
Bdng 1. Bien chung trong md Bien chirng trong md
Thung bao sau thoSt djch kfnh Thiing bao sau khong thoSt dich ktnh Chan thuong mong mat Bong vet m6 Mch bao truac Bong mtUig Descemet
Tong so
So mat 2 1 3 4 5 6 21
Ttls(%) 0,86 0,43 1,29 1,72 2,15 2,58 9,05 IV. BAN LUAN
1. Bien chirng thung bao sau
Chiing tdi gap biSn chiing thung bao sau d 3 mat vdi ti le 1,29%. Trong dd thiing bao sau d mire do nhe (thimg bao sau khdng thodt
dich kinh) d 1 mat: 0,43%; thung bao sau trung binh (thiing bao sau thodt djch kinh) d 2 mdt:
0,86%; khdng cd mat ndo thiing bao sau nang (kem nhan hoac mdnh nhdn roi vao trong budng kinh) (bdng 1).
Bdng 2. So sdnh vdi cdc tdc gid khdc Tac gia
Esmenjaud E. [3]
Martin K.R. [4]
Thai Th^nh Nam TrinTP. Thu[l]
Zheng D. [7]
Khiic Thi Nhun
^amNC 1994 2001 2000 2001 1998 2006
So mat
3000 300 ca dau tien 300 ca cuoi ciing
200 233 ca mo dau tien
232
Thijng bao sau c6 va khong tho^t DK (%)
4,33 1,7
4 0,7 0,00
1,5 8,6 1,25 Nghien ciiu cua cac tac gid trong vd ngodi
nude eho thay ti le bien chiing thiing bao sau thudng gap nhi6u d thdi ky chuy8n giao kT thudt tir phau thuat md ngodi bao sang phau thugt TNTTT.
Ti le ndy cdng gidm khi mire do kheo leo, thudn thyc cua phdu thudt vien tang len. Ngodi cac yeu td nhu do Cling nhan TTT, tudi, miic do gian ciia ddng tu va logi may sii dyng cung gdp phdn quan
Nhan khoa Viet Nam (So 29 - 2012) I 25
E I G H I E N CUtJ KHOA HOC
trgng trong vivc hg thap ti li; bien chiing. Mgl phau thugt vien mdi chuyen song phSu thugt 1 N f 1 1' Ih) nen bdt dau vdi nhdn cung dg 11-111, dong tii glSn tdt, lien phdng sdu trung binh \;i mgl mdy TNTTT logi bam nhu dgng (pcrislallic): bom cd Ihdi gian dap ling tang dp lyc chain de dgt dugc sy tang dp lyc can thiel doi vdi mgl bam nhu dgng hi 10 - 15 giay trong khi dd doi vdi bam Venlury chi cd lit 1 - 2 giay \ a \ di bom kieu mdng Id 3 - 4 giay [4].
Su dap ling tang dp lyc chgm giup cho phau thuiil
\ len mdi chua cd dii sy nhanh nh^n. kheo \6o trong timg dgng tdc trdnh dugc nguy co lining bao sau, dac bi^t la khi muon hiil dua nhiing mau than mem nam dudi bao trudc, sat xi'ch dgo TTT vao trung tam bao de tdn nhuyen.
2. Bien chung bong mang Descemet Ld bien chung hay gap va thudng nh^ khdng de Igi di chiing n^u chi bong 1 vgt Descemet nhd.
Monnes gap d 43% cdc ca trong mgt nghien cu:u soi gdc tien phdng mgt each he thdng; Wong W.
nghien ciiu tren 2.250 mdt gap bien chii-ng bong mdng Descemet vai ti le 0,2%; Nguyen Thu Huang [1]: 6,25%; Popiela G. [5]: 4%. Trong nhdm nghien ciiu ciia chiing tdi bien chiing nay gap d 6 mdt (2,58%), trong dd bong nhe d viing mep mo ggp d 4 mat (1,72%) vd bong vdi mire dg trung binh d 2 mdt (0,86%). Xii ly khi gdp bien chirng bong mdng Descemet: trong liic mo neu phdt hi?n thay bong mang Descemet thi phai thao tdc thgl Ihgn trgng trdnh Idm rach them, khi ddng vet mo trong khi bom nude khep vet md phdi bom bdng hai tien phdng chii y sao cho vat Descemet bong dp Igi vj tri cu. Kiem tra sau ngay md dau lien, neu mdng Descemet ap tdt, gidc mgc se trong trd Igi.
3. Bien chung rach bao trudc
Chiing tdi gap vdi ti le 2,15% (5 mdt). Trong do ed 3 mdt (1,29%) Id do dudng \ e bao lien tyc chgy ra ngoai vi gap tren 3 mdt dye TTT nhdn truang, dp lyc trong bao Idn, 01 mdt (0,43%) rdch bao trudc Id do dau phaco tip khi thyc hi?n thao tdc chop da di qua ra phia chu vi, lam rach bd Id xd bao
d kinh tuydn 6h vd 01 mdt (0,43%) rdch bao tmi do cdt phdi bd iS \i bao, khi thyc hi?n kt thugt ci bd d6ng tCr bdng kt£o nhd (sau khi dd x6 bao trudc trong trudng hgp dong tii kdm gidn.
Martin K.R. vd cs [4] nghien ciiu tren 300 ca mo dau liiin gOp bien chiing rdch bao Irudc d
\6 bao ra ngogi vi: 20% trong 100 ca mo dau tie, vd 2,0% trong 2000 ca mo liep theo. Vajpayee R,l li 1$ x^ bao ra ngogi vi Id 8,00% tren nhihtg mi dye TTT chin trdng. Ng. D.T. vd cgng sy g$p biei ehung rdch bao Irudc vdi li 1^ 3,8% trong 1000 c;
m6 dau tian: irong dd ti 1? ndy Id 9,3% trong 15(
ca mo dau lien vd 0,9% trong 850 ca mo tiep theo.
Nguyen Thj Thu Huong gdp bien chiing racl bao trudc d 8,33% so mdt. Theo cdc tdc gia li It bien chirng rdch bao trudc tdng d nhiJug mat dgc dg IV, V, nhiing mdt dye I I I chin trdng va d$c bi^l d giai dogn dau mdi chuyen giao ki thugt. Theo ehung Idi tl 1^ x^ bao ra ngogi vi chii > eu ggp tren nhOng mdt nhdn tnrcmg, dp luc trong bao Idn. (i nhiing mdt nay dii dd hg nhan dp tdt trudc md, bom nhieu chat nhay vao tien phdng de de bao TTT xuong, nhimg dudng xe bao rat de chgy ra ngoai vi, tham chi bao rat de bj rdch doc ra ngogi vi ngay khi vira dung kim chgc thiing trung tdm bao. Vi vgy d nhiing mdt ndy can nhugm bao TTT bdng xanli trypan irudc khi .\c bao dd ki6m soal tot dudng xe, cdn xe bao thgt (hgn trgng vd ngay tir dau khong nen xe bao qud rgng, ludn hudng dudng \e bao ve phia trung tdm.
4. Bdng vet mo
Chiing tdi g$p d 5 mdt (2,15%). Cd 5 mdt nay bdng \ ct mo Id do thdi gian phaco keo ddi hen mdt nhan cung dg IV, V. Thdi Thdnh Nam gap bien chiing bdng giac mgc vdi ti I? 2%. Sugar A.
vd cs gidi thi?u 3 mdt bdng vet md giac mac sau phau thugt TNTTT. Tdc gia thay rdng cd 3 mat bdng ndy deu cd dg logn thi sau md cao tir +7D den +150 d tryc ciia vet mo va bfnh nhdn thii 3 da gay mgt phii gidc mgc mat bi bugc phai phau thu?t gh^o gidc mgc.
26 I Nhan khoa Viet Nam (So 29 - 2012)
NGHIEN CUU KMOA
"^
5. Chan thir<mg mong mat
Trong qud trinh phau thuat mdng mdt cd th6 bj tdn thuong do dau phaco hiit vao mong mdt trong trudng hgp ddng hi co nhd hogc do phdi mong mat qua mep md khi dudng ham ciing giac mgc ngdn. Theo Burato ti 16 bien chiing mong mdt Id khoang 1%. Herbert E.N. gap bien chiing ndy vdi ti le 0,26%; Wang W: 1%; Zeng D. [7]: 5,6%; Thdi Thanh Nam; 1,88% (do ddu phaco chgm vdo mong mat); Chakrabarti A. va cs: 0.9%. Trong nhdm benh nhan nghien ciiu, chiing tdi gap chan thuang mong mdt d 3 mdt (1,25%). Ca 3 mdt ndy deu do ddu
phaco hut vdo mong mdt trong thi TNTTT d nhfl-ng mat nhdn ciing, ddng tir co nhd md khdng ed mdt ca ndo chan thuong mong mat Id do phdi mdng mat qua vet mo do dudng ham gidc mgc ngan. Theo Savini G. thi tot nhat nen tgo mgt du'dng ham ddi 1,75mm, chimg tdi cung thong nhat vdi quan diem nay ciia tac gid.
V. KET LUAN
Qua thong ke tren ta thay nhu'ng bien chirng cua phdu thuat TNTTT la khdng nhieu, khdng nghiem trgng va dieu trj dem Igi kel qua tot.
TAI LI5U THAM KHAO
1. NGUYEN THU HUONG (2002) " Nghien eiiu mdt sd bien chiing cua phdu thudt tdn huyk nhuyen the thdy tinh vd cdch xii tri", Ludn vdn Thgc sTYhoc, TrudngDgihgc YHdNgi.
2. TRAN THI PHUONG THU (2001)" Lugng gia phdu thudt phaco stop, chop, chop and stuff tren benh nhdn due thiiy tinh the nhdn ciing" Yhoc thuc hdnh, 7, tr.57-60.
3. ESMENJAUD E., FRAIMOUTT.L. (1994),
"Phacoemulsification, les 300 premiers cas", Bull.
Soc. Opht. France. 6-7, XCIV, pp.633 - 637.
4. MARTIN K.R., BURTON R.L. (2000), "The phacoemulsification learning curve: per - operative complications in the first 3000 cases of an experienced
surgeon'". Eye, Apr. 14 (Pt2). pp. 190 - 5.
5. POPIELA G., MARKUSZEWSKA J., CHELSTOWSKA J., SZALINSKI M. (2004)
"Analysis of phacoemulsification complications during mastering of the method", Klin Oczna, 106 (l-2).pp23-7.
6. WANG W., JIA L., YANG G. (2001),
"Analysis, prospect and treatment of causes of phacoemulsification complications" Zhonghua Yan Ke Za Shi, Sep 37(5), pp. 325 - 327.
7. ZHENG D.,.LIU Y, (1998) "Observation of complications at the operative and early postoperative stages of phacoemulsification", Yan KeXueBao, Jun, 14(2), pp. 105-7. 104.
SUMMARY
Aim: to evalute the intraoperative complication of phacoemulsification and to indicate the solution to repaire them.
Methods: We study the intraoperative complication of phacoemulsification in 232 eyes in eye department, Viet Tiep hospital from Jan 2001 to Oct 2003.
Results: The rate of posterior capsular rupture without vistreous loss was 1.29%, descemet membrane tear in was 2.58%, incision burn was 1.72%, interior capsular tear was 2.15%.
Conclusions: The rate of surgical complications is acceptably low, not severe, and well recovered after treatment. Better outcome was achieved with more experience and adopting better techniques.
Key words; complication of phacoemulsification.
Nhan khoa Viet Nam (So 29 - 2012)
