Trnh Th H

BAO V LUN VN THAC SY

HA NI - 2013

TRNG I HC Y H NI

Trnh Th HNGHIN CU MT S THAY I CA GIC MC SAU M LASIK IU TR CN TH

Ngi hng dn khoa hc: TS. NGUYN XUN HIP

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T VN PT LASIK ang ph bin v tnh an ton v hiu qu. PT LASIK tc ng trc tip ln GMsau m GM c nhiu thay i: dy GM, Cng sut khc x, cong, nh hng n TL v KX C nhiu tc gi nc ngoi nghin cu v s thay i ca GM sau PT LASIK v c nhiu tranh ci v vn ny. Vit Nam cn t nghin cu v vn ny.

3C tc gi cho rng sau PT LASIK, GM n nh nhng cng c tc gi cho rng sau PT, Gm cn c s thay i 2 nm thm ch l 10 nm

MC TIU1. M t s thay i ca dy, cong v cng sut khc x gic mc sau m LASIK iu tr cn th.2. nh gi 1 s yu t lin quan n s bin i gic mc sau m LASIK.

TNG QUANMt trc GM: hnh cu, mt sau: bu dc. BKC mt trc: 7,8mm, mt sau: 6,6mm.K ngang: 11-12 mm, dc: 9-11 mm.CSKX: 43 D. dy GM trung tm: 0,5mm, ra khong 0,74mm.

-Cc kch thc ca bn phn trc nhn cu

TNG QUANQu trnh lin vt thng GM sau PT LASIK:T ngy th 2 tr i, cc TB biu m bt u gin phn v hn gn vt thng theo gi thit XYZ ca Thoft. C hin tng tng sn ca biu m GM, cao nht thi im 1 thng.T tun th nht tr i, t collagen mi xut hin, nhiu nht vo thi im 1 thng v n nh sau 6 thng.Sau PT LASIK c hin tng GM bo kch hot, hot ng mnh nht thi im 1 thng sau PT, sau gim dn.

Cc phng php o cc ch s gic mc

1.o dy gic mc Siu m.OCTPP iu chnh quang hc.PP quang hc kp.2.o cng sut khc x GM v bn knh cong GMGic mc k Javal-Schiotz .Gic mc k t ng.Keratotoscopy hoc Videokeratoscopy.My chp bn khc x gic mc.

S thay i gic mc sau phu thut LASIK

PT LASIK iu tr cn th l dng tia laser Excimer bo mn GM gim cong ca gic mc.Jay C (2002): Sau PT 1 thng dy BM tng 22%, nhu m thay i gia 1 thng v 12 thng sau PT khng ng k.Avunduk AM (2004): Sau PT 1 tun DGM gim, tng sau 1 thng, sau thay i khng ng k nhng vn cao hn 1 tun.Anders Ivarsen (2009): Sau PT 1 tun v 1 thng, dy biu m tng 15-20%. DGM sau 3 nm tng so vi thi im 1 tun. S tng DGM tng quan vi thay i KXC tng ng.

MT S YU T LIN QUAN N S THAY I GIC MC Khc x iu chnh. Th lc. cn tn d. Lin quan gia DGM v CSKXGM.Lin quan gia DGM v thay i khc x.

I TNG V PP NGHIN CUi tng nghin cu:BN cn th m bng LASIK ti Bnh vin Mt TW t thng 3/2013 10/2013.Tiu chun la chn BN: BN cn th c C m LASIK.Chp nhn tham gia nghin cu.Tiu chun loi tr:Cc trng hp c b/c trong v sau m.Cc trng hp khng ti khm ng hn.

I TNG V PP NGHIN CUThit k nghin cu: Nghin cu dc.Tin cu.M t lm sng.Khng c nhm chng.C mu nghin cu:

Trong : n: S mt ti thiu cn nghin cu s: lch chun: chn s =1 = 5. : mc ngha thng k ( = 0,05). : Xc sut ca vic phm phi sai lm loi II. Chn = 0.1. Z: h s tin cy, tra bng = 10.5.Tnh ton ra n =101,64; nh vy phi ly c mu t nht l 102 mt.

Vy n = 102 mt

n: S mt ti thiu cn nghin cu s: lch chun: Cc nghin cu trc t 10.03-12.05; chn s =11: S khc bit v dy gic mc trung tm gia cc mc thi gian nghin cu theo mong mun, chn = 5. : mc ngha thng k ( = 0,05). : Xc sut ca vic phm phi sai lm loi II. Chn = 0.1. Z: h s tin cy, tra bng = 10.5.11

I TNG V PP NGHIN CUPhng tin thm khm:Bng TL v hp knh.Nhn p k Maclakov.My SHV khm bnh.My SA: BMy o khc x t ngMy SA Pachymeter SP 3000 TOMEYMy chp bn KX GM OPD Scan Nidek

Hnh 2. My chp bn GM OPD Scan NidekHnh 3. My Pachymeter SP 3000 TOMEY

I TNG V PP NGHIN CUPhng tin PT:H thng laser Excimer EC 5000 Nidek.Dao ct vt GM MK 2000Phng tin thu thp s liu.Bnh n.Phiu nghin cu.

HT laser Excimer EC 5000 Nidek

Dao ct vt GM MK 2000

PHNG PHP TIN HNHKhm LS trc m.Th lc v khc x.Nhn p. dy GM, CSKXGM v BKCGMCc XN khc.Phu thut.Theo di sau PTTh lc v khc x. dy GM, CSKXGM v BKCGM

Cc bc PT LASIK

CC TIU CH V PP NH GIBin s nghin cu: Nhm bin s v bnh nhn trc m. nh gi s thay i gic mc.Cc yu t lin quan n s thay i ca gic mc sau phu thut.X l s liu: Phn mm ton hc SPSS 16.0 Test T- student, test One Way ANOVA, test Paired Sample T-Test, T- student, test 2. Gi tr p, t l % so snh, xc nh s khc bit v tm mi lin quan.

KT QU V BN LUN Phn b BN theo gii

Jay C. Erie (2002): 49% n v 51% nam.Nguyn Xun Hip (2008): 47,7% n v 52,3% nam

Nghin cu c thc hin trn 73 BN vi 143 mt, trong c 35 nam (47.95%) v 38 n (52.05%). KQ tng t cc tc gi trong v ngoi nc: Jay C (2002), Avunduk (2004), Nguyn Xun Hip (2009). iu ny chng t nhu cu v vic b knh gng nam v n ngang nhau, cho d bt c l do g: Thm m, ngh nghip hay kh chu khi eo knh.

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KT QU V BN LUNPhn b BN theo tui

Jay C (2002): 33 10T, Avunduk (2004): 35,4 8,7TNguyn Xun Hip (2008): 23,04 5,77T

Tui trung bnh l 22,27 5,01T, min 18, max 50. BN m LASIK ch yu l nhng bnh nhn tr tui t 18-24T, nm trong tui hc sinh, sinh vin l chnh, chim 80,82%, > 40 tui ch c 1 bnh nhn chim 1,37 % v tui 25-40T chim 17,81%. tui trong nghin cu ca chng ti tng ng cc tc gi trong nc ( Nguyn X Hip 2009) nhng thp hn so vi cc tc gi nc ngoi Jay C (2002), Avunduk (2004),V vy cn c nhng nghin cu c th a ra gii hn tui trong C m LASIK.

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KT QU V BN LUNTh lc v khc xTh lc: Th lc trung bnh l 0,12 0,12, cao nht l 0,63 (20/30), thp nht l 0,01 (NT 0,5m).Khc x: Bng 3.3. Mc TKX trc m

Jay C. Erie (2002): -6,64 2,39D, Nguyn Xun Hip (2008): -5,09 2,32 D.Nhm nghin cuS mt (%)-1 -3D45 (31,5%)- 3,25D - 6D64 (44,7%)- 6,25D - 9D25 (17,5%)- 9D9 (6,3%)Tng143 (100%)

-Trong nghin cu ca chng ti, KXC trc m l -4,65D 2,44D, trong max -11,75D v min -1,00D. TL 0,12 0,12, max 0,63 (20/30), min 0,01 (NT 0,5m). Tng ng vi cc tc gi Jay C. Erie (2002), Nguyn Xun Hip (2008)-Theo nhm cn th thy tp trung ch yu nhm cn nh (31,5%) v va (44,7%). nhm cn nng ch chim 17,5% v nhm cn rt nng chim 6,3%. Khc vi cc n/c trc y thng tp trung ch yu nhm cn nng, v n/c ca chng em trong thi gian m c nhiu phng php khc dnh cho ngi cn nng khng DGM: Phakic

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DY GIC MC TI CC THI IM NGHIN CUBiu 3.3. dy gic mc trung tm ti cc thi im theo diJay C. Erie (2002), Avunduk A.M (2004), Hjortdal J. O (2005), Hjortdal J. O (2009), Nguyn Mng Linh (2009), Nguyn Vn Sanh (2009)

Biu 3.3. DGMTT ti cc thi im nghin cu

DGMTT trc PT 546,1231,01m, max 620m, min 490m. Kt qu tng ng vi cc tc gi Jay C, Avunduk A.M, Anders Ivarsen, Nguyn Mng Linh, Nguyn Vn Sanh.19

KT QU V BN LUN

Tc giTrc mSau m1 tun1 thng3 thng6 thngJay C. Erie (2002)551 37483 45493 44489 42494 44Avunduk A.M (2004)483,15 28,72515,8238,77511,35 39,24526,51 39,83Hjortdal J. O (2005)556,648485,649481,646487,645Anders Ivarsen (2009)52949,4460,347,0477,343,3Nguyn Mng Linh (2009)552,41 39,25438,5056,79451,91 53,26457,92 52,88Nguyn Vn Sanh (2009)539,02 26,37462,16 48,09465,86 47,31467,86 46,18467,16 46,18Trnh Th H (2013)546,1231,01454,9550,65467,6750,15464,69 50,19467,28 49,47

Sau PT, DGMTT gim ng k so vi trc PT, sau 1 thng tng, sau 3 thng gim hn v sau 6 thng tng. Nhng u tng hn ti thi im 1 tun.Jay C: Do c s tng sn biu m, nhiu nht Avunduk: Bng knh hin vi ng tiu pht hin ra c gic mc bo kch hot sau PT LASIK, mt nhiu thi im 1 tun v cao nht 1 thng n 3 thng sau gim dn. iu ny c tc gi gii thch s lm tng dy lp m nhu m GM.Trn Mng Linh: do dng c o DDGM: ORBCAN khc vi chng em (SA): DDGM o bng Orbscan dy hn so vi my siu m trc m v ngc li mng hn so vi my siu m sau m.Sau phu thut LASIK cn phi theo di nhn p cn thn v DDGM gim v sau thay i theo thi gian. V bnh nhn cn th thng c nguy c glocom gc m.20

KT QU V BN LUNCng sut khc x gic mc ti cc thi im theo di

Biu 3.4. CSKXGM ti cc thi im theo di

Ng Nh Ho: 43D Hjortdal J. O (2004), Ng Ngc Chu (2009)

Sau PT c s gim CSKXGM ng k, nhng chng ti thy c hin tng tip tc tng CSKXGM theo thi gian t 43.68 1.36D gim xung 39.881.81D ti thi im 1 tun, 40.051.91D ti thi im 1 thng, 40.011.80D ti thi im 3 thng v 40.101.81 ti thi im 6 thng

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KT QU V BN LUN

CSKXGM sau PT gim, nhng sau 1 thng, 3 thng v 6 thng tng ln so vi 1 tun. Gi thuyt Dierick v Missotten: biu m sau phu thut LASIK c gng pht trin khi phc li cong ban u ca gic mc . Do CSKXGM thay i nn s c kh khn trong vic tnh ton cng sut thu tinh th cho nhng BN ny trong tng lai.Trc m cng sut khc x gic mc trung bnh sau m (D)1 tun1 thng3 thng6 thngHjortdal J. O (2004)49.461.3644.041.8844.561.8744.571.82Ng Ngc Chu (2009)43,85,3738,0810,538,549,4738,599,49Trnh Th H (2013)43.681.3639.881.8140.051.9140.011.8040.101.81

BN KNH CONG GIC MC TI CC THI IM NGHIN CU

Nguyn Vn Sanh (2009): 7,660,24mm

BKCGM trc m: 7,730,25mm, max 8,83mm; min 6,97mm. Kt qu ny tng t kt qu ca Nguyn Vn Sanh. Sau PT, BKCGM tng nhng theo thi gian sau m c hin tng gim, gim nhiu 1 thng sau th khng ng k.

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BIN I BN KHC X GIC MCNhm cn th nh

BKXGM A trc PT, B sau PT 1 tun , C: sau PT 6 thng, CSKXGM trc PT 43,5D ; 1 tun 35,5D; 6 thng 36D. Trn BKXGM chuyn t mu xanh l cy sang mu xanh da tri. So snh A v C chnh lch 9D, gia B v C l 0D.24

BIN I BN KHC X GIC MCNhm cn th va

A : 48D B: 43,5D ; C: 43,5D, A-C =4,5D , C-B =0D25

BIN I BN KHC X GIC MCNhm cn nng

A: 50D ; B= 45,5D ; C= 45D; A- C=5D, C-B= -0,5D26

BIN I BN KHC X GIC MCNhm cn rt nng

Bn khc x gic mc ti 3 thi im: Trc m), 1 tun (B) v 6 thng (C). CSKXGM trc PT: 52,5D; sau PT 1 tun: 43,5D; sau 6 thng: 42,75D. So snh gia trc PT v sau PT 6 thng (A-C) chnh lch khc x = 9D, Tng ng chuyn mu trn bn t mu sang mu xanh da tri.So snh gia 1 tun v 6 thng (B-C) Chnh lch khc x = 0D. Trn bn khc x GM vn gi mu xanh da tri. Chng t c s n nh v CSKXGM sau 6 thng PT. Khng tm thy du hiu gic mc hnh chp sau PT. 27

MI LIN QUAN GIA DY GIC MC V CC NHM CNSau PT , DDGM ca cc nhm cn cng nng cng gim nhiu, ng thi cng tng nhiu hn theo thi gian.

Nhm cnDGM TT-1D -3D- 3,25D 6D- 6,25D - 9D> -9DTrc m544,1830,09547,3134,03549,4029,01538,2217,14Sau m 1 tun497,8431,43455,3435,55410,4434,87381,339,85Sau m 1 thng509,6932,01468,3635,45425,9233,94399,7822,12Sau m 3 thng504,9133,41464,4937,27423,4032,9040439,58Sau m 6 thng508,8733,90465,6936,8843033,8542033,78

Nhng BN cn cng nng th trc PT cn phi gi thch v tin lng.Sau PT phi theo di lu di v theo Randleman: nhng yu t nguy c gy gin phnh gic mc sau phu thut LASIK l cn trc m -8D v dy gic mc nn 250 m.28

MI LIN QUAN GIA DY GIC MC V CC NHM CNKhc x ti cc thi im nghin cu theo mc cn

cn tn d sau m ca nhm cn cng cao ln hn v tng nhiu hn theo thi gian sau PT .DDGM ca cc nhm cn cng nng tng nhiu hn sau PT theo thi gian.V vy s tng dy gic mc sau phu thut theo thi gian cng lm cho nguy c ti cn nhm cn rt nng cao hn cc nhm khc

Mc cnKhc x cu tng ng (D)Trc mSau m1 tun1 thng3 thng6 thng-1D -3D-2,41-0,42-0,33-0,37-0,51- 3,25D -6D-4,90-0,37-0,34-0,42-0,46- 6,25D - 9D-7,70-0,52-0,63-0,54-0,58> -9D-10,85-0,92-1,42-1,36-1,28

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MI LIN QUAN GIA DGM V CN TN D dy gic mc theo khc x tn d

DGM ca nhm cn tn d cng cao th cng mng nhng tng theo thi gian nhiu hn. Chng t s tng DGM c vai tr trong s ti cn sau PT LASIK. Kt qu ny tng t ca Eric JC v Andvunk.

Khc x tn d sau m dy gic mc sau m (m)1 tun1 thng3 thng6 thng< -0,5D462,4246,92476,9944.36481,2847,41483,2147,18-0,5D -1D451,4452,63467,6450,29460,4546,71462,5245,73-1,25-2D436,6052.47416,5042,28425,1839,87434,9455,43> -2D418,50101,12405,2047,13401,4950,19447,0045,24

MI LIN QUAN GiA DGM V CSKXGMMi lin quan gia thay i DGMTT v thay i CSKXGM trc v sau phu thut c tng quan tuyn tnh vi nhau, vi R = 0,82 ; p = 0,000. Phng trnh tng quan: Y = -11,45 * X 21,03 Vi Y: thay i DGMTT trc v sau phu thut 1 tun. X l thay i CSKXGM trc v sau phu thut 1 tun Nh vy c ngha l nu mun gim i 1D cng sut khc x gic mc th dy gic mc phi bo mn i 11,45 m

MI LIN QUAN GIA DGMTT V KHC XMi lin quan gia thay i DGMTTv thay i khc x trc v sau phu thut 1 tun c tng quan tuyn tnh vi nhau, vi R = 0,91; p = 0,000. Phng trnh tng quan: Y = 12,17 * X 15,96. Vi Y: thay i DGMTT sau m 1 tun so vi trc m. X: khc x c iu chnh.Nh vy c ngha l nu mun iu chnh gim i 1D khc x th dy gic mc phi bo mn i 12,17 m.

T c th gii hn cn cn iu chnh trc phu thut hn ch bin chng dn phnh gic mc sau phu thut v c th a ra phng php iu tr phu thut khc x ph hp cho tng bnh nhn.

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MI LIN QUAN GIA CSKXGM V NHM CN

nhm cn th cng nng th CSKXGM cng gim nhiuCSKXGM ca nhm cn rt nng mc d gim nhiu nhng cng nm trong gii hn an ton sau phu thut l > 35D.

Mc cnCng sut khc x gic mc (D)Trc mSau m1 tun1 thng3 thng6 thng-1D -3D43,3441,0741,3340,2241,42- 3,25D -6D42,8340,0540,1440,1640,22- 6,25D - 9D43,738,3838,5538,5538,54> -9D44,2236,8637,0837,0337,08

MI LIN QUAN GIA CSKXGM V KHC X TN D

Nhm > -2D th tng ln theo thi gian c bit l sau phu thut 6thng so vi 1 tun.Nhm -2D thay i khng ng k theo thi gian

Khc x tn dsau m Cng sut khc x gic mc trung bnh sau m (D)1 tun1 thng3 thng6 thng< - 0,5D39,96 1,4240,48 1,5440,07 1,4340,22 1,49- 0,5D - 1D40,02 2,2239,79 2,2340,09 2,0740,12 1,89- 1,25 - 2D39,25 1,6338,87 1,1339,68 1,9439,83 2,42> - 2D37,62 2,2939,20 2,4639,58 3,3039,45 2,39

MI LIN QUAN GIA CSKXGM V KHC X THAY I KHC X

Cheri Leng (2009): -1 -2D l 0,9; T -2,25 -3D l 0,87; t -3,25 -4D l 0,85 v > -4D l 0,84.Xc nh c mi lin quan gia thay i CSKXGM v lng khc x iu chnh, c th gii hn cn th cn iu chnh GM sau PT khng phng qu (< 35D) v ng dng trong tnh CS IOL chnh xc hn.Mc cnT l K / SE-1D -3D0,91- 3,25D -6D0,83- 6,25D - 9D0,74> -9D0,70

Kt qu nghin cu ca chng em: S thay i CSKXGM cn thit iu chnh 1D khc x khng phi l mt hng s, m gim khi lng iu chnh cao, tng khi lng iu chnh thp. Tng t kt qu ca Cheri Leng: T l thay t -1 -2D l 0,9; T -2,25 -3D l 0,87; t -3,25 -4D l 0,85 v > -4D l 0,84.Xc nh c mi lin quan gia thay i CSKXGM v lng khc x iu chnh, c th gii hn cn th cn iu chnh GM sau PT khng phng qu (< 35D) v ng dng trong tnh CS IOL chnh xc hn.35

MI LIN QUAN GIA BKCGM V NHM CN TH

cc nhm cn th khc nhau bn knh cong gic mc trung bnh thay i khc nhau, cc nhm cn th cng cao th bn knh cong gic mc trung bnh cng cao.Mc d s thay i BKCGM theo thi gian khng c ngha thng k, nhng chng em vn nhn thy c s thay i sau PT , v vy cn c s theo di lu di cho BN sau PT.

Mc cnBn knh cong gic mc mt trc gic mc(mm)Trc mSau m1 tun1 thng3 thng6 thng-1D -3D7,798,238,188,218,16- 3,25D -6D7,718,438,428,418,40- 6,25D - 9D7,708,808,768,768,76> -9D7,649,189,129,149,13

MI LIN QUAN GIA BKCGM V NHM CN TN D

BKCGM ca cc mc khc x tn d cng cao th cng ln v gim nhiu hn theo thi gian n/c. Cn phi theo di BN lu di hn v GM vn cn tip tc cong hn na.Khc x tn d sau mBn knh cong gic mc sau m (mm)1 tun1 thng3 thng6 thng< - 0,5D8,458,358,438,40-0,5D -1D8,468,518,448,43-1,25-2D8,618,688,548,51> -2D8,968,648,578,58

KT LUN1. S thay i gic mc sau phu thut LASIK iu tr cn thDGMTT gim r rt sau khi pt LASIK, c bit trong tun u , sau tng ln sau 1 thng, 3 thng v 6 thng nhng s thay i ny khng lin quan n s thay i khc x sau phu thut 6 thng.CSKXGM gim r rt sau PT ti cc thi im. Ch s ny tng ln thi im 1 thng so vi 1 tun sau phu thut v n nh sau .BKCGM tng r rt ti cc thi im sau phu thut. Ch s ny gim i sau 1 thng so vi 1 tun sau phu thut v sau khng thay i nhng vn gim hn so vi sau phu thut 1 tun.

KT LUN2. Cc yu t lin quan n s thay i cc ch s gic mc. cn th iu chnh cng cao th DGM v cn tn d sau phu thut tng nhiu hn theo thi gian . C mi tng quan tuyn tnh gia s thay i DGMTT vi cn . C mi tng quan gia s thay i ca DGMTT v s thay i CSKXGM. cn cng cao th CSKXGM cng gim nhiu. S thay i CSKXGM cho mi Diop khc x iu chnh tng nu lng khc x iu chnh thp v ngc liBKCGM sau PT tng nhiu nu mc cn th iu chnh tng.

KIN NGHCn c nghin cu vi thi gian theo di di hn v c mu ln hn.Cn c nhng nghin cu nh gi s thay i ca dy, cng sut khc x v cong ca gic mc trn nhng phng tin khc nh OCT, knh sinh hin vi ng tiu nghin cu su vo chi tit ca cc lp gic mc.Cn c nhng nghin cu nh gi s thay i ca c mt trc v mt sau GM trc v sau PT LASIK.

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Em xin chn thnh cm n !

Em xin trn trng cm n !

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Chart10.52050.4795

Sales

Sheet1SalesNam52.05%N47.95%To resize chart data range, drag lower right corner of range.

Chart10.80820.17810.0137

Sales

Sheet1Sales18-24 T80.82%25-40 T17.81%>40 T1.37%To resize chart data range, drag lower right corner of range.

Chart1546.12454.95467.67464.69467.28

Series 1

Sheet1Series 1Trc m546.12Sau m 1 tun454.95Sau m 1 thng467.67Sau m 3 thng464.69Sau m 6 thng467.28To resize chart data range, drag lower right corner of range.

Sheet2

Chart1Trc m43.68Trc mSau m 1 tun39.88Sau m 1 tunSau m 1 thng40.05Sau m 1 thngSau m 3 thng40.01Sau m 3 thngSau m 6 thng40.1Sau m 6 thng

Column1Series 2Column2

Sheet1Column1Series 2Column2Trc m43.68Sau m 1 tun39.88Sau m 1 thng40.05Sau m 3 thng40.01Sau m 6 thng40.1To resize chart data range, drag lower right corner of range.