B GIO DC V O TO B Y T TRNG I HC Y H NI NGUYN C NAM đánh giá KếT QUả ĐIềU TRị BệNH VõNG MạC ĐáI THáO ĐƯờNG BằNG TIÊM AVASTIN NộI NHãN KếT HợP LASER QUANG ĐÔNG CNG LUN VN THC S Y HC H NI - 2015 B GIO DC V O TO B Y T TRNG I HC Y H NI NGUYN C NAM đánh giá KếT QUả ĐIềU TRị BệNH VõNG MạC ĐáI THáO ĐƯờNG BằNG TIÊM AVASTIN NộI NHãN KếT HợP LASER QUANG ĐÔNG Chuyờn ngnh: Nhón khoa Mó s : CNG LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Hong Th Phỳc H NI - 2015 MC LC DANH MC BNG Bng 3.1 Tỡnh hỡnh bnh nhõn theo tui v gii .32 Phõn b th lc trc iu tr 32 Bng 3.2 Phõn b th lc trc iu tr ca nhúm tin tng sinh 32 Bng 3.3 Phõn b th lc trc iu tr ca nhúm tng sinh .32 Bng 3.4 Tỡnh trng nhón ỏp nhúm tin tng sinh 33 Bng 3.5 Tỡnh trng nhón ỏp nhúm tng sinh 33 Bng 3.6 Tỡnh trng huyt ỏp nhúm tin tng sinh 34 Bng 3.7 Tỡnh trng huyt ỏp nhúm tng sinh 34 Bng 3.8 Tỡnh hỡnh kim soỏt ng huyt nhúm tin tng sinh 34 Bng 3.9 Tỡnh hỡnh kim soỏt ng huyt nhúm tng sinh .34 Bng 3.10 Liờn quan gia mc phự hong im v th lc nhúm tin tng sinh 36 Bng 3.11 Liờn quan gia mc phự hong im v th lc nhúm tng sinh 36 Bng 3.12: Cỏc bin chng ti mt .37 Bng 3.13 Cỏc bin chng ton thõn 38 T VN ỏi thỏo ng l mt bnh ri lon chuyn húa ngy cng ph bin Vit Nam cng nh trờn th gii v cú tc phỏt trin rt nhanh T chc Y t Th gii (WHO) c tớnh nm 2000 trờn ton th gii cú khong 171 triu ngi mc bnh ỏi thỏo ng v d oỏn n nm 2030 s ng i mc bnh ỏi thỏo ng trờn ton th gii s l 366 triu ngi [1], [8] Ti Vit Nam tỡnh hỡnh mc bnh ỏi thỏo ng cng ang cú chiu hng gia tng Theo iu tra nm 2010 ca Bnh vin Ni tit Trung ng, t l mc ỏi thỏo ng trờn c nc lờn n 8% [3] Bnh ỏi thỏo ng gõy nhiu bin chng v mch mỏu ln v vi mch ti nhiu c quan ớch nh thn, tim, mt Ti mt, bnh gõy nhiu bin chng nh sp mi, lit nhón, hay tn hi nhiu cu trỳc ni nhón nh c th thy tinh, glụcụm tõn mch, c bit l bnh vừng mc ỏi thỏo ng Bnh VMT l bnh mch mỏu vừng mc hay gp nht v l nguyờn nhõn hng u gõy mự vo tui 30-64 nc cụng nghip Bnh VMT cú hai giai on: Bnh vừng mc ỏi thỏo ng tin tng sinh v tng sinh Vic chn oỏn v iu tr Bnh VMT giai on sm rt cú hiu qu vic phc hi th lc, phũng nga gim th lc cho nhúm bnh nhõn tui lao ng, ci thin cht lng sng cho bnh nhõn Can thip kp thi cũn ngn nga tin trin ca bnh sang cỏc giai on mun, gõy gim th lc nng n nh: Xut huyt dch kớnh, rỏch vừng mc, bong vừng mc Trong lch s nhón khoa, ó cú rt nhiu cụng trỡnh nghiờn cu tỡm tũi, khỏm phỏ nhm iu tr bnh lý ny nh laser, thuc iu tr ni khoa Tuy nhiờn, cho n nay, cha cú phng cỏch no thc s cú hiu qu Vic phỏt hin yu t phỏt trin ni mụ mch mỏu (VEGF) v vai trũ ca nú iu hũa sinh tõn mch to bc ngot cho vic nghiờn cu v iu tr Bnh VMT Gn õy, cỏc cht c ch yu t phỏt trin ni mụ mch mỏu (anti VEGF) c phỏt hin nh: Pegatanib(Macugen), Bevacizumab(Avastin), Ranibizumab (Lucentis) ó bc u c ng dng trờn lõm sng v thu c nhng kt qu ht sc khớch l Bờn cnh ú, vic s dng laser quang ụng iu tr cng ó úng gúp rt ln lm gim nguy c mt th lc bnh VMT Trờn th gii, bờn cnh nhng cụng trỡnh nghiờn cu v hiu qu iu tr bnh VMT vi tng phng phỏp riờng r ó cú nhng nghiờn cu v hiu qu ca vic phi hp hai phng phỏp l tiờm Avastin ni nhón sau ú laser quang ụng ton vừng mc Vit Nam, ó cú nhiu nghiờn cu v iu tr Bnh VMT Tuy nhiờn cha cú nghiờn cu no v vic phi hp iu tr gia tiờm Avastin ni nhón v laser quang ụng ton VM iu tr bnh VMT Vỡ vy chỳng tụi thc hin nghiờn cu ny vi hai mc tiờu: Mụ t c im lõm sng Bnh VMT giai on tin tng sinh v giai on tng sinh cú ch nh iu tr ỏnh giỏ hiu qu iu tr phi hp tiờm Avastin ni nhón v laser quang ụng ton vừng mc iu tr hai th bnh VMT trờn Chng TNG QUAN 1.1 S lc gii phu v h tun hon vừng mc 1.1.1 Cu to gii phu chc nng ca vừng mc Vừng mc l mt mng sut nm gia hc mc v dch kớnh Vừng mc gm 10 lp t ngoi vo trong: - Lp biu mụ sc t, - Lp t bo cm th (TB nún/gy), 3- Mng gii hn ngoi, 4- Lp nhõn ngoi, 5- Lp ri ngoi, 6- Lp nhõn trong, 7- Lp ri trong, 8- Lp t bo hch, 9- Lp si thn kinh, 10-Lp gii hn Hỡnh 1.1: S cu trỳc vừng mc (theo Kanski [11]) 1.1.2 H tun hon vừng mc 1.1.2.1 H ng mch vừng mc H ng mch trung tõm vừng mc xut phỏt t ng mch mt, i dc phớa ngoi v di ca th thn kinh Cỏch cc sau nhón cu khong 10mm nú chui vo lũng v i dc theo trc ca th thn kinh, xuyờn qua mng sng n a th Phn ln cỏc trng hp ng mch trung tõm vừng mc n gn a th thỡ chia lm nhỏnh l nhỏnh mi v nhỏnh thỏi dng, t ú cỏc nhỏnh ny tip tc phõn chia theo kiu phõn ụi n tn vựng vừng mc chu biờn (ora - serrata) Ngi bỡnh thng, 20-25% cú ng mch mi - vừng mc, l mt hay nhiu nhỏnh ca vũng ng mch Zinn (ngun gc t h mch hc mc) i v hng hong im ng mch trung tõm vừng mc ch m bo ti mỏu cho lp t bo thn kinh cựng ca vừng mc l t bo hch v t bo hai cc Lp t bo cm th v lp biu mụ sc t cng nh vựng hong im v vựng ora serrata nhn c cht dinh dng nh s thm thu t mch mỏu hc mc qua mng Bruch ng mch vừng mc l mch tn, cỏc tiu ng mch khụng cú ni thụng v khụng b xung b tc 1.1.2.2 H mao mch vừng mc T cỏc tiu ng mch cỏc mao mch c tỏch i sõu vo lp gia ca vừng mc n lp ri ngoi phn ln vừng mc, cỏc mao mch c xp thnh lp: + Lp mao mch nụng: c xp thnh mt mng lp si thn kinh th giỏc + Lp mao mch sõu: c xp dy c hn nm gia lp ht v lp ri ngoi Gia hai mng ny cú cỏc mao mch ni chp mt s vựng vừng mc, li mao mch cú s phõn b c bit: + quanh hong im: Mnh mao mch cú lp lp mao mch nụng b tỏch thnh hai Mng mao mch th ba nm gia lp ri v lp ht trong, cỏc mng mao mch ny dng li cỏch trung tõm vừng mc mt vựng ng kớnh khong 0,4 - mm, ú l vựng vụ mch ca hong im + quanh a th cú lp mao mch, lp ging quanh hong im v mt lp na nm phn sõu ca lp si thn kinh th giỏc + vựng vừng mc chu biờn, cu trỳc hai lp mao mch nụng v sõu tr nờn ngt quóng v n vựng ora serrata ch cũn mt ỏm ri mao mch nụng Thnh ca cỏc mao mch ch gm lp mng ỏy, ngoi cú cỏc t bo quanh thnh mch (pericytes) tng cng v l lp ni mụ xp khớt 1.1.2.3 H tnh mch vừng mc phn trung tõm vừng mc, tnh mch thng i kốm theo ng i ca ng mch vừng mc, ụi bt chộo v phn ln tnh mch nụng hn ng mch Ti nhng ni ng mch v tnh mch bt chộo nhau, bao thn kinh m ca cỏc mch mỏu ny hp nht tr thnh mt bao chung Cỏc tnh mch nh ca vừng mc trung thnh nhỏnh chớnh, n gn a th thỡ hp thnh hai tnh mch a th trờn v di, cui cựng vo mt thõn chung l tnh mch trung tõm vừng mc Sau qua mng sng ca a th, tnh mch trung tõm vừng mc i theo trc th thn kinh ri qua khe bm vo xoang tnh mch hang 1.2 Bnh vừng mc ỏi thỏo ng 1.2.1 S lc v bnh ỏi thỏo ng ỏi thỏo ng (T) l mt thut ng chung dựng ch cho mt nhúm cỏc hi chng cú cỏc biu hin lõm sng v bnh cn khỏc nhau, nhng cú chung c im l khụng dung np glucose Nhúm nghiờn cu T quc gia ca vin Y t quc gia ó phõn loi T thnh hai nhúm: nhúm 1, T type 1, ph thuc Insulin Nhúm ny cú c im l phỏt t ngt, ph thuc Insulin trỡ cuc sng v phũng nga toan mỏu Khi phỏt thng t lỳc hay thiu niờn, nhng cng cú th xy bt k la tui no Nhúm 2, T type 2, khụng ph thuc Insulin Nhng bnh nhõn ny khụng khụng ph thuc Insulin, khụng b toan mỏu mc dự ụi cn dựng Insulin iu chnh ng mỏu Khi phỏt thng sau tui 40, nhng cng cú th tr hn 1.2.2 Dch t hc bnh vừng mc ỏi thỏo ng Nghiờn cu dch t hc bnh VMT, cỏc tỏc gi nhn thy cú mi liờn quan gia nng ca bnh lý vừng mc vi bnh mch mỏu ton thõn T vi bnh vừng mc tng sinh cú t l bnh thn, t qu v nhi mỏu c tim cao Cỏc nghiờn cu cho thy rng, yu t quan trng nht dn n bnh VMT l thi gian mc bnh T Nu bnh T tin trin trờn 30 nm thỡ cú 80% bnh nhõn cú bnh VMT Bnh VM tng sinh ch yu xy vi type v chim 2% bnh nhõn T Bnh nhõn T type cú bnh cnh lõm sng nhanh hn so vi T type Nghiờn cu bnh nhõn T cú bnh lý VM tin trin, Bordansky v cng s [58] thy bnh nhõn type cú t l bnh VM tng sinh cao hn phự hong im v ngc li vi type Ngoi cỏc nghiờn cu cho thy cú nhiu yu t khỏc cú nh hng n s phỏt trin bnh VMT l nng axit uric huyt thanh, gii, protein niu v cao huyt ỏp, ph thuc Insulin, trng lng c th thp, tui mc bnh tr, T kộo di Vai trũ ca kim soỏt ng mỏu tt vic d phũng bnh VMT cũn nhiu tranh cói 1.2.3 Biu hin lõm sng Bnh VMT biu hin trờn lõm sng ch yu qua nhng hỡnh thỏi sau: 38 3.5.2 Cỏc bin chng ton thõn Bng 3.13 Cỏc bin chng ton thõn Bin chng S bnh nhõn T l (%) t qu Bnh lý tim mch 39 Chng D KIN BN LUN 4.1 c im chung ca nhúm bnh nhõn nghiờn cu 4.1.1 c im nhúm bnh nhõn theo tui v gii 4.1.2 Phõn loi typ ỏi thỏo ng v thi gian b bnh ỏi thỏo ng 4.1.3 c im v th lc 4.1.4 Tỡnh hỡnh kim soỏt ng huyt 4.1.5 Tỡnh trng huyt ỏp 4.1.6 Cỏc hỡnh thỏi tng sinh 4.2 Tỡnh trng hong im 4.3 Nhn xột kt qu iu tr 4.3.1 Kt qu v gii phu 4.3.1.1 Kt qu v tõn mch nhúm tng sinh 4.3.1.2 Kt qu v hong im - Nhúm tin tng sinh - Nhúm tng sinh 4.3.2 Kt qu v th lc - Nhúm tin tng sinh - Nhúm tng sinh 4.3.3 Tai bin v bin chng 4.3.3.1 Tai bin th thut tiờm ni nhón 4.3.3.2 c tớnh ti mt cú th xy thuc 4.3.3.3 Tỏc dng ph ton thõn 4.3.3.4 Tai bin laser 40 D KIN KT LUN Kt qu iu tr Kt qu v gii phu Kt qu v th lc Bin chng Ti mt: Ton thõn: TI LIU THAM KHO Basic and clinical Science Course, Section 12 Bnh mch mỏu vừng mc, Bn dch, Nguyn c Anh (1996), tr 30-38, NXB Thanh niờn B mụn Mt Trng i hc Y Dc TP H Chớ Minh (2010) Bnh lý vừng mc ỏi thỏo ng, Nhón khoa lõm sng Nh Hn (2001), Chuyờn dch kớnh vừng mc, NXB Y hc, H Ni 2001 H Huy Tin, Nguyn c Anh: Bnh vừng mc ỏi thỏo ng, Bi ging lõm sng nhón khoa, NXB Y hc, 1994 Hong Th Phỳc (2010) 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Thilo, Sierra A et al (2006) Anti proliferativeand cytotoxic properties of bevacizumab on different ocular cells, Br J Ophthalmol 90: 1316 1321 62 Thomas A, Ciulla, Philip J, Rosenfeld (2009) Anti-Vascular endothelial growth factor therapy for neovascular ocular than agerelated macular degeneration, Current Opinion in Ophthalmology 20: 166-174 MU BNH N NGHIấN CU ỏnh giỏ kt qu iu tr bnh VMT bng laser v tiờm Avastin ni nhón I Hnh chớnh: H v tờn: .Tui Gii: Nam N Ngh nghip: a ch: T II Khỏm bnh ln u: Th lc: Ngythỏngnm MP:Cú kớnh: MT:Cú kớnh: Nhón ỏp: MP:mmHg MT:mmHg - Mt b bnh MP MT - Type T: Type Type - Thi gian b bnh T: T thỏngnm - Tỡnh hỡnh iu tr T: Thng xuyờn Khụng thng xuyờn - Thi im phỏt hin bnh VMT: T thỏng.nm - Tỡnh hỡnh iu tr bnh VMT: - Chc nng thn: Bỡnh thng Khụng bỡnh thng - Huyt ỏp: Bỡnh thng Cao - in tõm : Bỡnh thng Khụng bỡnh thng - Glucose huyt: Bỡnh thng Tng - Tỡnh trng ton thõn: Khỏm bỏn phn trc phỏt hin cỏc tn thng phi hp c th thy tinh Tõn mch mng mt Khỏm ỏy mt: - Phỏt hin cỏc tn thng ca bnh VMT: Vi phỡnh mch Xut huyt VM Xut tit VM Bt thng mch mỏu VM - Phỏt hin tõn mch VM v a th: Mc tõn mch:.din tớch a th V trớ tõn mch: Khỏc: CMHQ: Mc tõn mch:din tớch a th V trớ tõn mch: Tỡnh trng H: OCT: dy H: Th tớch H: Khỏc: III Khỏm li sau tiờm Avastin ngy Ngy.thỏngnm Th lc: MP Kớnh Nhón ỏp: MP.mmHg MT Kớnh MTmmHg Triu chng: Cú Khụng au Cm Chúi sỏng Chy nc mt Xung huyt kt mc Xut huyt kt mc Xut huyt dch kớnh Viờm MB Viờm ni nhón Khỏc: IV Khỏm li sau tiờm Avastin tun Ngy.thỏngnm Th lc: MP Kớnh Nhón ỏp: MP.mmHg MT Kớnh MTmmHg Triu chng: Cú Khụng au Cm Chúi sỏng Chy nc mt Xung huyt kt mc Xut huyt kt mc Xut huyt dch kớnh Viờm MB Viờm ni nhón Bong vừng mc Mc tõn mchdin tớch a th V trớ tõn mch: dy H: Th tớch H: Khỏc: V Khỏm li sau tiờm Laser thỏng Ngy.thỏngnm Th lc: MP Kớnh Nhón ỏp: MP.mmHg MT Kớnh Triu chng: MTmmHg Cú Khụng au Xut huyt dch kớnh Viờm MB Viờm ni nhón Bong vừng mc Mc tõn mchdin tớch a th V trớ tõn mch: dy H: Th tớch H: Khỏc: VI Khỏm li sau tiờm Laser thỏng Ngy.thỏngnm Th lc: MP Kớnh Nhón ỏp: MP.mmHg MT Kớnh MTmmHg Triu chng: Cú Khụng au Xut huyt dch kớnh Viờm MB Viờm ni nhón Bong vừng mc Mc tõn mchdin tớch a th V trớ tõn mch: dy H: Th tớch H: Khỏc: VII Khỏm li sau tiờm Laser thỏng Ngy.thỏngnm Th lc: MP Kớnh Nhón ỏp: MP.mmHg MT Kớnh MTmmHg Triu chng: Cú Khụng au Xut huyt dch kớnh Viờm MB Viờm ni nhón Bong vừng mc Mc tõn mchdin tớch a th V trớ tõn mch: dy H: Th tớch H: Khỏc: VIII Theo dừi cỏc bin chng ton thõn quỏ trỡnh iu tr: Cú Khụng Bnh lý tim mch t qu: Khỏc: