UING DUNG KY THUAT CHUP CAT L^P VONG MAC DANH GIA SlTTHAY udl CUA LOTP son THAN KINH QUANH DfA THj GIAC M A T GLdCOM NGUYEN PHAT
D 6 H O A N G HA, NGUYEN Qu6c VJONG, DAOTHjLAlVIHUdNG.
B^nh vi^n Mat trung trong
TOIW T A T
Muc tieu: 1. Dinh gii ton thuung Idp sgl thin kinh quanh dia thj giic(RNFL) mat gidcdm nguyin phit bing phuung phip chup dt lap vdng mac (OCT). 2. Nhin xit vi vai trd cua OCT trong chin doin s&m bgnh gidcdm Doi twg/ng- Nhom 1- 190 mit gidcdm cua 117 ngwdi binh gidcdm, nhdm chung: 110 mit binh thw&ng cOa 55 nguui Vi$t Nam tnjung thanh. Phuung phip: quan sit md ta cat ngang, cd doi chOng. Kit qui: mit binh thuung cd do diy trung binh cOa RNFL bing 114,74±
10,93 pm, a cic vj tn cic gdc phin tw trin: 137,89±
17,51; duui: 147,54± 16.59; trong: 91.49± 13,31 vi ngoii. 81.82± 19.81 Dg day tmng binh cua RNFL qua cac giai do^n binh gidcdm tir tiim ting den sa phit, tiin triin, gin mu vi mO giam lin luut li 17,7%, 18.4%;
22,7%; 19,8%. Trong dd RNFL gdc phin tw phia dwin giam sdm, nhanh vi nhliu nhit, thO- hai din RNFL gdc phan tw phia trin,r6i phia thii dwang va phia mOi. Kit iuin.l. Giai dbgn binh gidcdm dng bin triin trim trgng thi dg day cua RNFL cing giam nhiiu 2.0CT li mgt phuung phip can lam sing cd the phit bi$n dwgc nhOng bien doi sam cue RNFL a gidcdm giai doan dau
Til- khoi: Gidcdm. lop sgi than kinh quanh dia thj giic (RNFL), chup cat lap vong mac (OCT)
EVALUATION THE CHANGE OF NERVE FIBER LAYER THICKNESS OF OPTIC DIGS IN PRIMARY GLAUCOMATOUS EYES BY USING OPTICAL COHERENCE TOMOGRAPHY
SUMMARY
Objectives: To evaluate the RNFL thickness thoughout different Glaucoma stages
To evaluate the role of OCT in diagnosis of Glaucoma
Subjects: Two gmups; 1.Study group: 190 eyes of 117 Glaucoma patients; 2 Control group: 110 eyes of 55 normal subjects
Method: Descnptive cross-sectional case control study
Results: Normal eyes have overall mean RNFL thickness of 114.74±10.93 pm. Mean thickness in each quadrant: superior 137.89±17.51 pm, inferior: 147.54
±16.59, nasal: 91.49±13.31and temporal: 81.82±19.81.
The reduction of the overall mean RNFL thickness throughout suspected, early, progressive, nearly blind and blind stages of Glaucoma is 17.7%; 18 4%; 22.7%;
19 8% respectively. RNFL in inferior quandrant is damaged the most, the fastest and the earliest followed by superior, temporal and nasal quadrant
Conclusion: I.The more advanced the Glaucoma stage is the more decrease of RNFL thickness will be.
2.0CT Is important paraclinical test which can help to detect eariy RNFL damages in Glaucoma.
Keywords- Glaucoma, RNFL, OCT
DAT V A N D ^
Gidcdm Id mdt trong nhOng nguydn nhdn hdng diu gdy mil vinh viln. Tuy nhidn ed t h i phdng trdnh mii Ida do gidcdm nlu bdnh dupe phdt hidn sdm vd dilu trj kjp thdi.Tin hgi chii-e ndng thj gide trong gidcdm Id hdu qua cua sy t i n hgi d i n d i n cdc Idp spi thin kinh vdng mgc.
Phyang phdp chyp d t Idp vdng mgc bing mdy Stratus OCT (OCT) mdi dype dya vdo su dyng d Vipt nam d l phdt hidn nh&ng t i n hgi thye t h i cua vdng mgc, dTa thj gidc trong d e bdnh mit. Mdc dCi d mdt s l ca sd nhan khoa trong nu'dc da quan tdm nghidn cdu yng dyng OCT d l ehin dodn d e b$nh t i n Uiyang vdng mgc nhu'ng cho d i n nay chya thIy cd mpt cdng trinh khoa hpe ndo d n g b i ve kit qua nghien cuu sy thay doi cua Idp spi thin kinh quanh dTa thj gide (RNFL) trSn mat ngudi bpnh gidcdm d Viet nam.Vi vgy chiing tdi tiln hdnh nghign cau nay vdi myc tieu: I.Danh gid t i n thu'ang Idp spi than kinh quanh dfa thi gidc mat gidcdm bdng phuang phdp chyp d t Idp vong mac. 2. Nhgn xet v l vai trd eiia OCT trong chan doan sdm bpnh gidcdm.
D 6 | TU'P'NG VA PHIJ-CNG P H A P NGHIEN ClJU 1. Ddi tu'p'ng nghien cii'u
1.1 Nhdm bpnh nhan gidcdm
Tieu chuin lya chpn: nhiJng ngydi bpnh gidcdm nguyen phat dieu trj tgi khoa Gidcdm Bpnh vipn Mat Trung aang tu' thdng 12/2007 d i n thdng 9/2010.
Tieu chuan logi tm-: nhUng ngudi bpnh gidcdm cd nhijng t i n hgi kem theo ciia vdng mgc, dTa thj gidc, cd ede mdi trydng trong suit bj dye nhilu nhu phii, spo giac mac, dye t h i thuy tinh, van dye djch kinh, xuat huylt dich kinh.
1.2. Nhdm chung: nhCrng ngydi Vipt Nam tnj'dng thdnh binh thydng, khdng ed tien sir bpnh mat.
2. Phyang phap nghien ciru* Quan sat md ta d t ngang, d dii chiing,
2.1.Phuang tipn
Chung tdi su dyng may chyp d t Idp vdng mgc (OCTl STRATUS O C T " t h i h# ba cua Bpnh vidn Mit Tnjng yang
2.2. Cdch thii'C tiln hdnh
Bpnh nhdn dupe dilu trj hg nhdn dp trudc khi chyp.
Tra td b l mdt nhan d u bdng Dicain 1%. Chyp OCT Chinh tieu dilm nim diing dTa thj gidc. D l nghj ngydi bdnh nhin vdo vgt tieu trong mdy. D l i vdi nhu'ng trydng hpp bpnh nhdn chi d n chire nang mpt mat, n l u chyp mdt mil thi hydng d i n bpnh nhdn i^nh thj vdo vdt tiiu ngodi mdy bing mat kia. Ghi nhdn cdc cht so ve dp day cua RNFL: Dd dly trung binh, dp day theo d c gdc phan ty {tren, dudi, mui, thai du'ang).
2.3. Ddnh gid k i t qua: Ket qua dupe trinh bay d
Y HOC THirC HANH (810) - s 6 3/2012
dgng dd thj va bang s i lipu cy t h i theo cde gdc phln ty vd theo mill gid So sdnh kit qua vdi thang chuIn mdu dd dupe mdc djnh trong mdy: 100% trydng hpp thang mdu trlng cd RNFL binh thydng. 95% tru'dng hpp mdu xanh ed RNFL binh thudng, chl cd 5% trydng hpp mdu vang binh thu'dng. Nlu dd dly RNFL nim trong khodng thang mdu do thi 99% Id bit thydng
2.4 Xu li s i lidu bdng thudt todn so sdnh trung binh, siK dyng phln mIm SPSS 10,0.
K t T QUA NGHIEN CU'U
Trong s i 117 b$nh nhdn gidcdm (190 mit) cd 64 nD' vd 53 nam Dd tuii trin 40 Id 82 ngydi, chilm da s i (70,1%) 50% s l b$nh nhdn dudi 40 tuli cd tiln si> tra Ihulc corticoid kdo ddi, Gidcdm gdc md chilm 80% (152 mdt), gdc ddng chilm 20% (38 mit) 103 mit cd nhdn dp cao > 25 mmHg (ehilm 86,8%) 25 m i t nhdn dp khdng cao Cdn Igi Id nhOng m i t nhdn dp dd ty dilu chinh ho$c dd dupe dilu chinh bing thuie. S i mit d giai dogn mudn eua bdnh (trim trpng, g i n mil vd mil) chilm tl 1$ khd cao 39,4% (75 mdt). 30 mit (15,8%) d giai dogn tilm tdng 45 mdt (23,7%) d giai dogn sa phdt 40 mit (21.1%) d giai dogn tiln triln. 50 mdt (26,3%) d giai dogn trim trpng. 25 mit (13,1%) d giai dogn cuii g i n mil vd mu. Nhdm chiing g i m 55 ngudi binh thydng khdng miccdcbdnh ve mit (110 mdt) tir 18 din 71 tuli, tuii tnjng binh 46,85±11,77; trong dd 28 ny, 27 nam.
Bang 1. Chilu dly RNFL d mdt ngu'di binh thudng vd d d c giai dogn gidcdm
(x ± s,pm)
Qua ede giai dogn b§nh sy biln d l i ciJa NRFL d c^c gdc phln ty khdng ding d i u . NRFL biln d l i nhilu vd nhanh d gdc phln ty dydi, sau dd d gdc phln tu trfin, r i i din gdc phln ty phia miji, cuii eOng Id gdc phln tu- phia thdi dyang. Cf giai dogn sa phdt, khi chua ph^t hi§n cd t i n thyang thj trydng, RNFL trung binh dd giam so vdi giai dogn t i l m tdng Id 17,7%.
Bdng 3. Sy biln d i i RNFL d cdc giai dogn gidcdm dya theo thang chuIn mdu
Giai do^n MStbinh thu'O'ng Ti6m ISng Scr phat Ti§n tnen
Tram trpng can mil.mil
Trung binh 114,7 +10,9 113,9 ±
7.0 93,7 ±
7.7 76,5
±13,9 59,1 +12,6 47,4 + 7.1
Tren 137,9 +17,5 141,6±
13,0 114,8±
14,1 93.6
±22,5 71,0 +18,4 55,2 ± 11.8
Du'di 147,5
±16,6 147,1±
13,7 114,7 +16,3 64,1
±23,3 58,7
±15,8 46,0 ±
7,2 Mui 91,5 +13,3 91,2
±15,4 73,7
±11,2 64,9
±15,3 56,8
±13,8 48,9
±10,2 Thdi du-ong
81,8 +19,8 75,4
±13,8 71.4
±11,9 62,9
±14,1 49,7
±14,4 39.5 ± 9.7 K i t qua do cho thIy ehilu day RNFL cua mit ngydi Vipt nam trydng thdnh binh thydng va mdt chaa bj bpnh eua ngydi bpnh gidcdm Id tyang dyang nhau.
RNFL giam d i n qua d e giai dogn giddm, sy khde bi$t nay cd y nghTa thing ke vdi p< 0,001.
Bang 2. Mirc dp gidm RNFL qua cac giai dogn bdnh
Giai do^n Ti6m tSng
^ sa phSt S a p h i t - * ti^n t r i l n Tien tri^n - » l r ^ m
trpng Tr^m trpng - t gan mij.
RNFL (ym Trung
binh 20,2 (17,7%)
17,2 (18,4%)
17.4 (22,7%)
11,7 (19,6%)
Trfin 26,8 (19,2%)
21,2 (18,5%)
22,6 (24,1%)
15,8 (22,3%)
Du'di 32,4 (22%) 30,6 (26,7%)
25,4 (30,2%)
12,7 (21,6%)
MDi 17,5 (18,6%)
8,8 (11,9%)
8,1 (12,5%)
7,9 (13,9%)
Thdi d u c n q
4,0 (5.3%)
8,5 (11,9%)
13,2 (21%) 10,2 (20,5%)
Giai dogn Mat binh t h u d n g TiSm tdng (n = 30) S o phSt (n = 45) Tidn tridn (n = 40) TrSm trpnq (n = 50) Gdn mil, mil (n = 24)
T i n q
RNFL bdtthLFdnfl (vdn TrSn
0 0 3 27 48 24 102
D u d i 0 0 7 33 50 24 114
MDi 0 0 1 9 22 17 49
g.d6) ThSi dircna 0 0 , 0 7 30 21 58 RNFL CLia m i t ngydi Vi§t nam trydng thdnh binh thydng vd ciia m i t d giai dogn tilm tdng (ehya bj gidcdm) d i u n i m d thang mdu xanh (dd tin edy 95%) ho$c mdu trlng. Cf giai dogn sa phdt (chya phdt hi^n c6 t i n thyang thj trydng) d d d 11 m i t (11/45 mit chilm ty 1$ 24,4%) d RNFL b i t thydng, ndm d thang mdu vdng ( d i tin edy 95%) hodc do ( d i tin cgy 99%). Trong s l 109 mit d biln d l i RNFL:114 mit (71,7%) c6 tin thaang gdc phln t y phia dodi, 102 m i t (64,2%) d ton thyang gdc phln t y trdn, s i mdt d ton thyang d hai gdc phln ty phia mui va thdi dyang chilm ty Ip it han
B A N LUAN
Trong ca quan thj gidc d a ngu'di t l bdo hgch la naron dan truyen trong eung ptidn xg than kinh. Mdi mat ed khoang han mpt tridu te bdo hgch. Cac spi tnje cIJa t l bdo hach dupe cdc spi Muiler bao boc, tgo thdnh bo spi. Cde bd spi tgo nen Idp spi t h i n kinh (RNFL). Tgi dTa thj gidc d e bd spi'tgp trung thanh ddy than kinh thj gidc, di qua la sang ra ngodi nhdn d u . Dp dly RNFL tdng dan khi d i n g i n dia thj. Quanh dTa thj dp day cua RNFL khdng deu nhau, d phia tren vd phia dudi day han, d phia mui vd phia thai dyang mdng han, cho mdng nhlt ehi bing 1/4 dp day RNFL d phia thdi daang trdn vd dudi. Theo k i t qua nghidn ciru d a cac tde gia nydc ngodi d mdt ngydi binh thydng dp dly RNFLtrungbinhnlmtrongkhoang tir 110-128 pm [71, dd dly RNFL phia trdn tif 140,4 ± 10,5 pm din 153,6 i 20,7 pm, phia dydi tir 140,4 ± 9,7 pm d i n 150,1 ± 19,1 pm, phia mui tic 85,2 ± 14,0 pm d i n 106,1± 24,7pm, phia thai dyang Or 90,1 ± 10,8 pm den 103,6 ± 19,5 pm [7]. K i t qua nghidn eiru cua ehung tdi tren nhdm ngudi binh thydng cho thIy dd d l y eua RNFL trung binh va d i dly RNFL d cac gdc phan tu- tren, dydi. phia mQi va phia thdi dyang eua ngydi Vipt Nam cung nam trong d e khoang kich thydc trdn. Nhy v§y khong d sy khdc bipt v l kich thydc dd day RNFL d mit ngudi binh thydng giira d c viing, chung t i c khde nhau. Dilu d6 cho phdp sy dyng tharig bang mdu ehuin da dypc mgc djnh s i n trong may de danh gia mu-c dp ton thuang cGa RNFL quanh dTa th| giac cua bpnh nhdn gidcdm if Vi^t Nam.
Y HOC THirC HANH (810) - s 6 3/2012
Nhdn d u Id mpt c l u triic kin. Ap lye n i l nhan tdc dpng len thdnh nhan d u vdi mpt lye nhy nhau Idm cho Idp vd cdng ra, giii cho nhan d u d hinh dgng nhat dinh. Khi dp lye npi nhan tang cao, phln y l u nhlt cua nhan d u Id Id sdng se bj tac ding nhilu nhlt. Cdc tam m i IJdn k i t cua Id sdng bj dp dpp xuing vd bj day ra sau. Sy bien doi cua la sdng d i n d i n t i n thuang than kinh ddm, mgch mau vd bd spi thin kinh, gdy t i n thyang Idm teo dTa th[ vd Idp spi thin kinh quanh dTa thj rat dde tryng cua gidcdm [5] Mgch mdu bj ehdn dp, bien dang, doi hydng, gap khiic Idm giam lyu lypng mdu nudi duang vong mgc. Sy roi logn luing bao tyang trong spi tryc d Id sdng Idm r i i logn dinh dudng giij'a spi tryc vd thdn t l bao, lam tac nghen sy din toiyln qua spi tryc. T i t d nhu'ng yeu to dd Idm eho t l bdo hgch chit tif tir. Te bdo hgch vd spi tn,ie eua nd khdng cd kha ndng sinh san, chung chit di 1dm d o s i lypng spi tnjc giam vTnh vien. Vi vgy t i n hgi thin kinh thj gidc trong bpnh gidcdm la ton thyang khdng cd khd ndng h i i phye.
Kit qua nghien cuu cua chiing t i i eho thIy RNFL quanh dTa thj trung binh va d cac v| tri trSn, dydi, trong, ngodi cua nhdm bpnh nhdn gidcdm bj giam han so vdi nhdm ngu'di binh thydng, sy khdc bipt ndy cd y nghTa thing ke (p< 0,001) Kit qua nghign eiru eua chiing tdi cung tu'ang ty nhu' kit qua cua d e tde gia Bowd C, Viviane Guedes, Kanamori, Liu X, Ling Y, Nouri-Mahdavi [1, 3, 4, 6, 7], dp d l y RNFL giam dan theo d e giai dogn gidcdm Nam 2005 Hess DB va d n g sy nghidn ciru tren hai nhdm bpnh nhan tre em binh thydng va gidcdm cung thu dapc kit qua RNFL tren tre gidcdm d ca 4 gdc phln ta d i u giam so vdi tre binh thydng. Dp d l y vong mgc trung tdm d tre gIddm eung bj gidm han [2]. Cung do dde dilm d u tnje giai phau eua RNFL d ede gde phln ta quanh gai thj khdng giing nhau nen t i n thyang RNFL d 4 gdc phan t y eung xay ra khdng deu nhu nhau. Dp day RNFL phia tren vd phia dydi day han, phia mui vd phia thai du'ang mdng han. Sy phan bo cac spi tryc trong bd spi cung khdng giong nhau: d phia tren vd phia dudi mit bd sal chua vai sai tryc, d phia mui va phia thdi dyang hau h i t moi bd chi chua mpt spi tryc.
Trong moi bd spi cdc spi tnje dypc bao bpc, bao vp bdng t l chuc thin kinh d$m, Nhirng bd spi chua nhilu spi tryc, cd it t i ehue than kinh dpm han d l bj ton thaang han dydi tac ddng cua nhdn dp eao. Do dd d c spi tryc d eye tren va cyc dadi cua gai thj thudng bj ton thyang tn/de va nhanh. nhilu han trong bpnh glddm.
Ket qua nghien eifu d a chung tdi cung tyang ty ket qua cua Nouri-Mahdavi va d n g sy. Trong bpnh gidcdm RNFL gdc phan ty du'di bi giam sdm vd nhanh nhat, sau dd Id RNFL gde phan ty tren roi mdi din phia mui vd phia thdi dyang [6]
Tren thyc t l Idm sang chan dodn gidcdm d n dya vao tam chyng chinh Id nhan dp, ton thyang d i u day than kinh thj giac (gai thj, RNFL) vd t i n thyang thj trydng. Tnj-dc kia d Vipt nam ndi chung, d Bpnh vipn mdt Trung yang ndi rieng, d l ddnh gid ton thyang dau ddy than kinh thj gidc thydng phai diing mdy soi ddy mit. Tuy nhien vdi phaang phdp ndy k i t qua eh? la ddnh gid ydc lupng, bj phy thupc nhilu y l u t i ehCi quan nhy
kinh nghi$m cua bdc sT. dp khiic xg mit eua bdc sT va eua bdnh nhdn.... Soi ddy mit khd phdt hi§n dapc nhirng t i n thuang nhd d giai dogn sdm. Trong khi dd nhilu tdc gia nude ngodi nhdn thIy t i n hgi thin kinh xay ra tryde t i n thyang thj tru-dng. Theo Quigley H A. vd d n g sy (1982) Idp spi thin kinh cd t h i bj mat tdi 40%
trong khi thj trydng van chua phdt hi$n cd t i n thyang.
Trong nghifin ciru cua chiing tdi 24,4% mit gidcdm sa phdt (chya cd bilu hidn t i n thuang thj tradng) dd cd t i n thu-ang RNFL quanh dTa thj. Phuang phdp chyp c i t Idp vdng mgc (OCT) cho phdp do kich thudc ehilu d l y RNFL ir d e gdc phln ta vd theo miii gid quanh gai thj, lyu giCf kit qud trdn mdy hodc in ra gily mdu bing hinh anh, sa d i , d l thj vd bdng mdu chuIn d l ddnh gid so sdnh k i t qua. Vi vdy OCT ddng vai trd quan trpng trong ehIn dodn xdc djnh gidcdm d giat dogn sdm. dgc bi$t khi dao ding nhdn dp chua rd rdng hodc bpnh nhan bj hinh thdi gidcdm khdng cd nhdn dp cao.
K^T LUAN
Trong b$nh glddm kich thydc chilu d l y RNFL quanh gai thj giam din theo tiln triln qua cde giai dogn b§nh, giam sdm, nhanh vd nhilu d gdc phln ty phia trdn gai thj, sau dd d gdc phln ta phia dudi roi mdi d i n gdc phln ty phia miji vd phia thdi dyang.
Do chilu day RNFL bang phuang phdp chyp d t Idp vdng mgc (OCT) la mpt phyang phdp d n Idm sdng quan trpng, cho phep chan dodn xde i^nh bpnh glddm dgiai dogn sdm.
TAI LI$U THAM K H A O
1. BowdC, ZangwillLM. et al (2001)." Detecting early glaucoma by assessment of retinal nerve fiber layer thickness and visual function". Invest Ophthalmol Vis Sci; Vol 42: p 1993-2003.
2. HessDB, SanjayG, et al (2005), " Macular and retinal nerve fiber l.ayer analysis of normal and glaucomatous eyes in children using Optical Coherence Tomography". Am J Opthalmol; Vol 139: p 509-517.
3. KanamoriA, NakamuraM, EseanoMF, SeyaR, MaedaH, NegiA (2003), " Evaluation of the glaucomatous damage on retinal nerve fiber layer thickness measured by optical coherence tomography".Am J Ophthalmol; Vol 135: p 513-520.
4. Liu X, Ling Y. Luo R. Ge J. Zheng X (2001), "
Optical Coherence Tomography in measuring retinal nen/e fiber layer thickness in normal subjects and patients with open- angle glaucoma". Chin Med J (Engl);
Vol 114: p 524-529.
5. NeufieldAH. HemandezMR. GonzalezM (1997), "
Nitric oxide synthase in the human glaucomatous optic nerve head",Areh Ophthalmol;Vol 115: p 497-503,
6. Nouri-MahdaviK, HoffmanD, TannenbaumDP, LawSK, CaprioliJ (2004), " Identifying early glaucoma with optical coherence tomography".Am J Ophthalmol;
Vol 137: p 228-235.
7. Viviane Guedes, SchumanJS, et al (2003), Optical coherence Tomography measurement of macular and nerve fiber layer thickness in nomial and glaucomatous human eyes". Ophthalmology; Vol 110: p 177-189.
Y HOC THirC H A N H (810) - S6 3/2012
