1 B GIO DC V O TO TRNG I HC Y H NI B Y T Lấ TH DOAN Nghiên cứu MộT Số ĐặC ĐIểM LÂM SàNG Và kết ĐIềU TRị BệNH VIÊM THị THầN KINH TRẻ EM TạI BệNH VIệN MắT TRUNG ƯƠNG TRONG NĂM (2008 2012) LUN VN THC S Y HC H NI 2013 B GIO DC V O TO TRNG I HC Y H NI B Y T Lấ TH DOAN Nghiên cứu MộT Số ĐặC ĐIểM LÂM SàNG Và kết ĐIềU TRị BệNH VIÊM THị THầN KINH TRẻ EM TạI BệNH VIệN MắT TRUNG ƯƠNG TRONG NĂM (2008 2012) Chuyờn nghnh Mó s : Nhón khoa : 60.72.56 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Lờ Th Kim Xuõn H NI 2013 LI CM N Tụi xin chõn thnh cm n Ban Giỏm hiu, Phũng o to Sau hc, B mụn mt Trng i hc Y H Ni, Ban Lónh o Bnh vin Mt trung ng ó to mi iu kin thun li giỳp tụi quỏ trỡnh hc v hon thnh lun Tụi xin c by t lũng bit n sõu sc PGS TS Lờ Th Kim Xuõn, ngi thy kớnh mn tn tõm ó trc tip hng dn, ht lũng giỳp , dy bo, dỡu dt tụi nhng bc u tiờn trờn ng nghiờn cu khoa hc, ó ng viờn, úng gúp cho tụi nhng ý kin quý bỏu chuyờn mụn cng nh cuc sng, to mi iu kin thun li cho tụi sut quỏ trỡnh hc v hon thnh lun ny Tụi xin chõn thnh cm n PGS TS Hong Th Phỳc ngi thy ó ch bo, úng gúp nhng ý kin quý bỏu giỳp tụi xõy dng v hon chnh lun ny Tụi xin chõn thnh cm n PGS TS V Bớch Thy ó giỳp tụi quỏ trỡnh hc v hon thnh lun ny Tụi xin chõn thnh cm n ti cỏc anh ch, cỏc bn ng nghip khoa Mt tr em, Phũng K hoch tng hp, th vin Bnh vin Mt trung ng ó nhit tỡnh giỳp tụi quỏ trỡnh hc tp, thu thp s liu, ti liu, thc hin cỏc k thut quỏ trỡnh nghiờn cu v hon thnh lun ny Xin gi li cm n n bn bố, ng nghip, ngi thõn ó luụn ng viờn, khớch l v sỏt cỏnh bờn tụi sut quỏ trỡnh hc v nghiờn cu Cui cựng, tụi xin dnh tt c tỡnh thng yờu, lũng bit n sõu sc ti b m ó nuụi dng, dy d, dỡu dt nõng tụi t nhng bc chp chng i ngi, tụi cú c ngy hụm Li cm n c bit ny tụi xin dnh cho chng v gỏi bng ca tụi, ó luụn ng viờn, chia s mi gỏnh nng, l ch da vng chc, l sc mnh giỳp tụi vt qua mi khú khn cuc sng, quỏ trỡnh hc tp,v hon thnh lun ny H Ni, ngy 20 thỏng nm 2013 Lờ Th Doan LI CAM OAN T i xin m o n yl n u lu n v n n y l trung th ng tr nh nghi n v h t ng u ri ng t i C s li u v k t qu ng t t i li u n o Hc viờn Lờ Th Doan DANH MC CH VIT TT DTKTG : Dõy thn kinh th gi VTTKHNC : Vi m th thn kinh h u nhón u CNC : Cnh nhón u VM : Vừng m MRI : Chp ng h ng t CT-Scanner : Chp t lp vi tớnh OCT : Chp gi o tho NT : m ngún t y BBT : Búng bn tay nh s ng MC LC T VN Chng 1: TNG QUAN 14 1.1 Gii phu dõy thn kinh th giỏc 14 1 Gi i phu 14 1 Tun ho n d y thn kinh th gi 15 1.2 Bnh viờm th thn kinh tr em 16 nh ngh 16 2 Ph n loi 16 Sinh lý nh vi m th thn kinh 17 Nguy n nh n g y vi m th thn kinh 18 125 C im vi m th thn kinh tr em 21 Tri u h ng l m s ng 23 C n l m s ng 24 1.2.8 Cỏc hỡnh thỏi lõm sng 27 iu tr 31 10 Ti n trin v ti n l ng 34 1.3 Tỡnh hỡnh nghiờn cu v viờm th thn kinh ca cỏc tỏc gi khỏc Vit Nam v trờn th gii 34 Chng 2: I TNG V PHNG PHP NGHIấN CU 37 2.1 i tng nghiờn cu 37 1 Ti u hun hn nh nh n 37 2 Ti u hun loi tr 37 2.2 Phng phỏp nghiờn cu 37 2 Loi h nh nghi n 2 Thi gi n, im nghi n 2 Ph ng ti n nghi n 224 C u 37 u 38 u 38 ti n h nh nghi n u 39 225 C h s nghi n u 40 2 X lý s li u 44 2 V n o nghi n u 44 Chng 3: KT QU NGHIấN CU 45 3.1 c im ca nhúm bnh nhõn nghiờn cu 45 1 Ph n nh nh n theo tui 45 Ph n nh nh n theo gii 46 3 im v lý 46 Tin s Ph n nh 47 mt nh tr n mi nh nh n 47 Thi gi n t xu t hi n tri u h ng u ti n 3.1 Tri u h ng h qu n n v o vi n 48 vi m th thn kinh 48 3.1.8 Hỡnh thỏi lõm sng 49 3.2 c im lõm sng v cn lõm sng 50 321 C tri u h ng to n th n 50 2 Th l , nhón p lỳ v o vi n v r vi n 50 323 C 324 C d u hi u tn th ng im y mt 52 n l m s ng vi m th thn kinh 53 3.3 Kt qu iu tr 56 3 T nh h nh iu tr tr v o vi n 56 3 iu tr ti kho Mt tr em 57 3 K t qu s u iu tr ti thi im kh m li 58 3 Mt s y u t li n qu n n k t qu th l 60 Chng 4: BN LUN 65 4.1 Nhn xột v c im ca nhúm bnh nhõn 65 4.1.1 Nh n xột v tui 65 Nh n xột v gii tớnh 65 Nh n xột 4 im v lý 66 im v tin s nh 66 Nh n xột v mt nh 67 Thi gi n ph t hi n nh 68 Nh n xột v tri u h ng h qu n nh vi m th thn kinh 68 4.1.8 Nh n xột v h nh th i l m s ng 70 4.2 c im lõm sng v cn lõm sng ca viờm th thn kinh 70 Th l , nhón p lỳ v o v r vi n 70 2 Kh m mt 71 Nh n xột v im n l m s ng 73 4.3 Nhn xột kt qu iu tr v mt s yu t liờn quan n kt qu th lc cui cựng 74 Nh n xột v t nh h nh iu tr 74 K t qu s u iu tr ti thi im kh m li 77 3 Nh n xột v y u t li n qu n n k t qu th l u i ựng 78 KT LUN 82 TI LIU THAM KHO PH LC DANH MC BNG B ng 1: Ph n B ng 2: nh theo tui 45 im v tin s B ng 3: Ph n mt nh 47 nh 47 B ng 4: Thi gi n xu t hi n tri u h ng u ti n B ng 5: Tri u h ng h qu n B ng 6: C n v o vi n 48 vi m th thn kinh 48 tri u h ng to n th n 50 B ng 7: Th l lỳ v o vi n 50 B ng 8: T nh trng th l r vi n 51 B ng 9: Tn th ng g i th 52 B ng 10: Tn th ng vừng m 52 B ng 11: Tn th ng m h m u vừng m 53 B ng 12: Tn th ng th tr ng 53 B ng 13: Tn th ng tr n CT S nner s nóo - h mt 54 B ng 14: Tn th ng OCT 55 B ng 15: Tn th ng MRI 55 B ng 16: C s iu tr tr v o vi n 56 B ng 17: iu tr thu B ng 18: C thu kh ng sinh 57 ti m nh nhón u 58 B ng 19: K t qu th l 59 B ng 20: Tn th ng tr n OCT 60 B ng 21: So s nh m th l 60 B ng 22: Li n qu n gi gii tớnh v k t qu th l B ng 23: Li n qu n gi tui v k t qu th l B ng 24: Li n qu n gi mt u i ựng 61 62 nh vi k t qu th l 63 B ng 25: Li n qu n gi tn th ng g i th v k t qu th l 63 10 B ng 1: T l nh mt mt h i mt theo B ng 2: Tri u h ng u theo t B ng 4.3: T l vi m g i th theo B ng 5: K t qu th l B ng 6: So s nh m theo th l gi 70 t t gi 68 gi 69 t B ng 4: Tn th ng g i th theo t gi 72 gi 77 >20/50 nhúm d i 11 tui vi mt s t gi 79 80 nh ó qu l u ri mi h tớ h trung ng n vi n, v mt lý n l hỳng t n s, v v y dự iu tr tớ h th th l nh nh n ng kh ng iu tr n B nh vi n Mt i thi n nhiu 4.3.3.3 Liờn quan gia mt b bnh v kt qu th lc cui cựng Theo k t qu nh n nhúm nghi n nh mt mt hi m 36 8%, ú 43 hi m 63 2% Qu ph n tớ h nh n nh nh n (16 3%) ú th l l m > 20/50 nhúm nh nh n gi h i nhúm nhúm nh h i mt nh m t 20/200 20/50, cú nh nh n nh h i mt cú m t 20/200 20/50, cú < 20/200 Nh v y t l nh nh n ph hi th nh h i mt l 67 4%, ũn nh mt mt l 52 0% Tuy v y kh ng ú s kh nh nh n > m nh nh n i t nh mt mt v h i mt vi p > 05 T l n y hỳng t i th p hn so vi t th l nh nh nh n (67 4%) ú k t qu th l nh nh n (16 3%) ú k t qu th l nhúm nh nh n ú th l < 20/200 nhúm nh nh n ú ú 29 >20/50, ú nh nh n nh nh n (52 0%) ú k t qu th l nh nh n (28 0%) nh nh n (20%) ú th l nh nh n ú 25 ng 26 hỳng t i th y rng 25 nh mt mt ú 13 20/25, ú 43 u 68 gi MH Sun (2011) ó nh h i mt l 85 7%, nhúm r t l ph hi nh mt mt l 80% [6] 4.3.3.4 Liờn quan gia tn thng gai th v kt qu th lc cui cựng Theo k t qu nghi n u hỳng t i 111 mt ú 68 mt ú phự g i th (61 3%), ú 36 mt ú g i th nh th ng (32 4%), ú mt ú h nh nh g i th m u (6 3%) Trong 68 mt ú phự g i th ú 47 mt (69 2%) ú k t qu ph hi th l m m t 20/200 20/50, ú mt (13 2%) ú k t qu th l mt ú h nh nh g i th m > 20/50, ú 12 mt (17 6%) ú k t qu th l < 20/200 36 nh th ng ú 22 mt (61 1%) ú k t qu th l > 20/50, ú mt (22 2%) ú k t qu th l t 20/200 20/50, ú mt (16 7%) ú th l 20/50, ú mt th l l 20/100, ú mt ú th l 81 < 20/200 Nh v y kh n ng ph hi th l o hn nhúm g i th ú s kh mt ú g i th phự l 69 2% nh th ng v nhúm g i th m u Tuy nhi n kh ng i t v k t qu th l gi nhúm th phự v th ng, nh ng vi nhúm th m u ú s kh 05, iu n y h ng t rng t l hi ph th l kộm hn so vi nhúm th phự K t qu kột qu l t gi MH Sun (2011), t i t vi m gi gi n y ó nh th ng ú k t qu th l th m u kh ng ú mt n o ú th l h nh nh tn th ng th n k t qu th l g i th ý ngh p < hỳng t i ng gn t ng t r k t qu hi ph th ú 83 3% mt nhúm th phự ú th l 81 8% mt nhúm th nh nhúm th m u l nhúm th m u kộm hn so vi nhúm th phự v th ng, theo t th th nh 20/40, ú 20/40, v nhúm 20/40 [6] K t qu n y ho th y th ti mt ng l mt y u t qu n trng nh h ng u i ựng nh nh n Nhng nh th ng ho phự ú k t qu hi ph th l nh n ú h nh nh g i th m u ho teo g i th nh nh n v o vi n ú t t hn nhng nh 82 KT LUN Qu qu tr nh nghi n u, hỳng t i r mt s k t lu n: c im lõm sng ca viờm th thn kinh tr em 1.1 Lõm sng - Vi m th thn kinh tr em gp n nhiu hn n m, t l n/n m l 5/1 B nh nh n l tui d i 11 tui hi m 61 8%, tui trung nh nh l 9.84 3.91 - B nh nh n vựng n ng th n hi m 79.4% - Vi m th thn kinh h i mt hi m 63 2% H nh th i vi m g i th hi m 61 3%, ú 58 6% mt ú phự g i th, 30 6% ú phự vừng m - B nh ph t s u s t l 16 2%, - Cú 100% v o vi n ú th l nh nh n ú tin s vi m xo ng l 4% nh nh n v o vi n vi tri u h ng nh n m, 85 6% mt < 20/200 ; au nh mt cú 30.6% 1.2 Cn lõm sng - Xột nghi m h u m u t ng o l 45 6%, thi gi n m u lng kộo d i hi m 45 2% - Th tr ng : m im trung t m l 23 3%, m im nh trung t m l 20 5% v thu hp th tr ng l 16 4% - Chp CT-S nner s nóo h mt: h ú 11 6% mt d y TKTG to > 5mm, 36 2% d y TKTG < 5mm nh ng nh m nh, 3% ú hi n t l n ng d y v tenon, 10 1% ú tn th ng xo ng - Chp ng h ng t h ú 28 1% ú t ng kớ h th d y TKTG - Chp OCT s mt phự g i th hi m 52 9%, gi m d y lp s i thn kinh hi m 8%, teo g i th hi m 9% 83 Kt qu iu tr 2.1 Tỡnh hỡnh iu tr v kt qu sau iu tr - B nh nh n t mu thu iu tr ti nh l 20 6%, t l nh nh n n thng B nh vi n Mt trung ng l 25% - Ti kho Mt tr em t t nh nh n u iu tr ng corticoid v khỏng sinh ton thõn - Ti thi im kh m li: ú 64% mt ú th l >20/50, t l g i th mu l 35.1%, teo g i th l 1%, t l gi m d y lp s i thn kinh trờn OCT l 24.3% 2.2 Mt s yu t liờn quan n kt qu th lc cui cựng - nhúm < tui ú k t qu th l nh n n ú k t qu th l l m o nh t 84 6% Cú 65 9% > 20/50, h ú 55 6% nh nh nh n n m ú th > 20/50 - T l ph hi th l nh nh n tn th ng h i mt t 67.4% cao hn so vi tn th ng mt mt l 52% nhúm ú g i th m u v teo g i t l ph hi th l l kộm nh t 84 HNG NGHIấN CU TIP S u qu tr nh nghi n v u, hỳng t i th y ũn mt s v n ũn tn ti r mt s h ng nghi n -Nghi n u theo dừi vi thi gi n d i hn l u d i v ti n trin - Nghi n hn v u ti p theo: nh gi k t qu nh u vi s l im l m s ng, ng nh nh n ng hn n l m s ng v k t qu nh gi iu tr hớnh xỏc TI LIU THAM KHO Pula, J H.,Macdonald, C J (2012), "Current options for the treatment of optic neuritis" Clin Ophthalmol 6: p 1211-23 Morales, D S., Siatkowski, R M., Howard, C W., Warman, R (2000), "Optic neuritis in children" J Pediatr Ophthalmol Strabismus 37(5): p 254-9 Lana-Peixoto, M 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Lấ TH DOAN Nghiên cứu MộT Số ĐặC ĐIểM LÂM SàNG Và kết ĐIềU TRị BệNH VIÊM THị THầN KINH TRẻ EM TạI BệNH VIệN MắT TRUNG ƯƠNG TRONG NĂM (2008 2012) Chuyờn nghnh Mó s : Nhón khoa : 60.72 .56 LUN VN... 52 n l m s ng vi m th thn kinh 53 3.3 Kt qu iu tr 56 3 T nh h nh iu tr tr v o vi n 56 3 iu tr ti kho Mt tr em 57 3 K t qu s u iu tr ti thi im kh m li 58 3... u vừng m 53 B ng 12: Tn th ng th tr ng 53 B ng 13: Tn th ng tr n CT S nner s nóo - h mt 54 B ng 14: Tn th ng OCT 55 B ng 15: Tn th ng MRI 55 B ng 16: C s iu