hƯỚng dẪn chẨn ĐoÁn vÀ ĐiỀu trỊ cÁc bỆnh vỀ mẮt

1

B Y T

HNG DN CHN ON V IU TR

CC BNH V MT (ban hnh km theo Quyt nh s 40/Q-BYT ngy 12/01/2015)

H Ni, 2015

2

Ch bin

PGS. TS. Nguyn Th Xuyn

ng ch bin

PGS. TS. Nh Hn

PGS. TS. Lng Ngc Khu

Tham gia bin son

PGS. TS. Trn An

PGS.TS. Cung Hng Sn

PGS. TS. Hong Th Minh Chu

PGS. TS. Phm Khnh Vn

PGS. TS. H Huy Ti

PGS. TS V Th Bch Thy

PGS. TS. Nguyn Ch Dng

PGS. TS. Nguyn Th Thu Yn

PGS. TS. Phm Trng Vn

PGS. TS. L Kim Xun

PGS. TS. V Th Thi

PGS. TS. o Th Lm Hng

TS. Nguyn Xun Hip

TS. L Thy Qunh

TS. Nguyn Quc Anh

TS. Thm Trng Khnh Vn

TS. Hong Th Thu H

TS. L Xun Cung

TS. Phm Ngc ng

Ths. C Thanh Phng

Ths. L Th Ngc Lan

Ths. ng Th Minh Tu

Ths. H Xun Hi

Ths. Nguyn Cnh Thng

Ths. Nguyn Vn Huy

Ths. Nguyn Kin Trung

Th k bin son

Ths. Hong Minh Anh

Bs. Phan Th Thu Hng

Ths. Nguyn c Tin

Ths. Ng Th Bch H

Ths. Trng L Vn Ngc

3

MC LC Trang

1. LIT VN NHN ............................................................................................................................. 5

2. NHC TH .................................................................................................................................... 10

3. LI MT .......................................................................................................................................... 14

4. VIM T CHC HC MT .......................................................................................................... 18

5. VIM TI L ................................................................................................................................... 23

6. KH MT DO THIU VITAMIN A .............................................................................................. 27

7. BNG MT DO HA CHT ......................................................................................................... 31

8. VIM KT MC CP ..................................................................................................................... 35

9. VIM KT MC D NG CP TNH ........................................................................................... 40

10. VIM KT GIC MC MA XUN .......................................................................................... 43

11. VIM LOT GIC MC DO NM ............................................................................................. 52

12. VIM GIC MC DO HERPES ................................................................................................... 56

13. VIM LOT GIC MC DO AMIP (ACANTHAMOEBA) ....................................................... 60

14. VIM MNG B O CP TNH TR EM .......................................................................... 64

15. BNH VIM MNG B O TRC CP TNH ................................................................... 68

16. VIM MNG B O SAU CHN THNG .......................................................................... 73

17. GLCM GC NG NGUYN PHT .................................................................................... 78

18. GLCM GC M NGUYN PHT ......................................................................................... 85

19. TNG NHN P SAU CHN THNG NG DP .............................................................. 92

20. XUT HUYT NI NHN SAU CHN THNG ................................................................... 96

21. VIM M NI NHN NI SINH .............................................................................................. 101

22. VIM M NI NHN NGOI SINH ........................................................................................ 106

23. NHN VIM NG CM ......................................................................................................... 112

24. HI CHNG VOGT-KOYANAGI-HARADA ........................................................................... 116

25. BNH HC VNG MC TRUNG TM THANH DCH ......................................................... 122

26. BNH TC TNH MCH VNG MC ..................................................................................... 126

27. TC NG MCH TRUNG TM VNG MC ...................................................................... 132

28. VIM TH THN KINH .............................................................................................................. 136

29. TN THNG THN KINH TH GIC SAU CHN THNG ............................................ 140

4

CC CH VT TT

CNC: Cnh nhn cu

CT: Computed Tomography (chp ct lp vi tnh)

DK: Dch knh

KS: Khng sinh

HVMTTTD: Hc vng mc trung tm thanh dch

MB: Mng b o

MKHQ: Mch k hunh quang

MRI: Magnetic resonance imaging (chp cng hng t)

NA: Nhn p

NCVK: Nui cy vi khun

NVC: Nhn vim ng cm

PCR: Polymerase Chain Reaction (phn ng khuch i gen)

OCT: Optical coherence tomography (Chp ct lp vng mc kt quang)

TMH: Tai mi hng

RHM: Rng hm mt

ROP: Retinopathy of prematurity (Bnh vng mc tr sinh non)

ST: Sng ti (ST +: Sng ti dng tnh, ST -: Sng ti m tnh)

XQ: X- quang

XHDK: Xut huyt dch knh

XHTP: Xut huyt tin phng

UBM: My siu m sinh hin vi

WHO: World Health Organization (T chc Y t Th gii)

VMNN: Vim m ni nhn

VNN: Vim ni nhn

VTXNC: Vt thng xuyn nhn cu

5

LIT VN NHN

1. I CUNG

Lit vn nhn c biu hin lm sng a dng, phc tp v l triu chng ca

nhiu bnh l ti mt v ton thn, c th do lit mt hoc nhiu c vn nhn. Ty

theo nguyn nhn, v tr v mc tn thng m c th biu hin trn lm sng vi

cc hnh thi khc nhau, lc lit hoc lit ng tc lin hp 2 mt.

2. NGUYN NHN

a. Chn thng

Chn thng s no: thng gy lit dy thn kinh n c, hay gp lit dy VI.

Chn thng h mt: thng hay gy lit c hn lit dy thn kinh.

b. U no:

C th gy tn thng nhiu dy thn kinh

c. Tng p lc s no

Thng gy lit dy VI hai bn.

d. Bnh l mch mu

Phnh ng mch do i tho ng, phnh ng mch cnh gy lit

thn kinh III, IV, VI.

Tng huyt p, xut huyt mng no do v phnh ng mch gy lit vn nhn.

Thiu nng ng mch sng nn gy lit vn nhn ngi cao tui.

e. Bm sinh

f. Bnh l thn kinh c: Nhc c

g. Bnh ri lon chuyn ha: Bnh i tho ng

h. Cc nguyn nhn khc

Nhim khun, nm, virut

Vim: Bnh x cng ri rc, vim a r thn kinh

Ng c.

3. CHN ON

a. Lm sng

Triu chng c nng

6

+ Song th

+ Lc mt

Triu chng thc th

+ Song th

L triu chng in hnh ca lc lit nhng khng phi trng hp lc

lit no cng c song th. Song th gia tng ti a pha hot trng ca c b lit.

lc cng ln song th cng r. Triu chng ny c th mt dn do hin tng

trung ha, c ch hoc xut hin t th b tr ca u, c.

Trong lit dy III c th song th ngang n thun nu ch tn nhnh chi

phi c trc trong nhng a s l song th ng do phi hp tn thng c thng

ng hoc c cho b.

Trong lit dy IV song th ng, ti a khi nhn xung di vo trong.

Trong lit dy VI song th ngang v l triu chng c nng lm cho bnh

nhn n khm sm.

+ Lc mt

Gc lc thay i cc hng nhn khc nhau, gc lc ln nht khi nhn

v hng tc dng ca c b lit.

lc nguyn pht (D1) nh hn lc th pht (D2). y l triu

chng c bn chn on phn bit vi lc c nng.

+ Hn ch vn nhn

Hn ch vn ng hot trng ca cc c b lit.

Giai on u ca lc lit thng c biu hin hn ch vn nhn ca c

b lit v giai on sau c th biu hin qu hot ca c i vn vi c b lit.

Trn lm sng khi thm khm cn phi kim tra vn nhn theo 9 hng

nhn bao gm: nhn thng, nhn sang phi, nhn sang tri, nhn ln trn, nhn xung

di, nhn trn phi, nhn trn tri, nhn di phi, nhn di tri xc nh hn

ch vn nhn v so snh hai mt.

+ T th b tr

T th lch u vo c trnh song th bng cch u quay v pha

hot trng ca c b lit. i vi lit c thng ngang th t th b tr thng l

lch mt, lit c thng ng hoc c cho, t th b tr phc tp v thng km

theo lch u, vo c, thay i t th cm.

7

T th b tr cn chu nh hng ca nhng bin i th pht ca cc

c phi vn hay ng vn nn giai on sau ca lit vn nhn bnh cnh lm

sng khng cn in hnh nh giai on u.

Triu chng khc ti mt

+ Bnh nhn c th ri lon cm gic gic mc, gim hoc mt phn x

ng t, gin ng t, soi y mt c th c hnh nh ph gai, xut huyt. Bn

cnh cn phi lm mt s khm nghim ti mt nh o th lc, nhn p (c th

cao), th trng (thu hp, bn manh), li mt.

+ Cc khm nghim loi tr nhc c nh tets nc , test prostigmin,

tensilon.

Triu chng ton thn

Ty thuc vo nguyn nhn gy lit vn nhn c th gp cao huyt p, lit

na ngi....

b. Cn lm sng

Chp XQ s no v hc mt.

Chp CT Scan s no hoc cng hng t pht hin khi u, phnh

mch...

Chp mch no c thuc cn quang pht hin phnh mch.

Siu m nhn cu, hc mt.

Xt nghim mu, chc nng tuyn gip...

c. Chn on xc nh

Chn on lit vn nhn

Da vo 4 triu chng l song th, lc mt, hn ch vn nhn v t th lch

u vo c.

Chn on nguyn nhn,v tr lit vn nhn

Thng rt kh bn cnh vic da vo cc xt nghim cn lm sng cn

phi hp vi khm chuyn khoa thn kinh

Chn on lit dy thn kinh III, IV, VI

+ Lit dy thn kinh III:

Thng c biu hin sp mi 1 hoc 2 bn.

Lc ngoi, c th ch lc ngang n thun hoc lc ng phi hp nu c

tn thng c thng ng hoc c cho.

8

Song th c th mt trong trng hp sp mi nng, c th song th ngang

n thun nhng a s l song th ng do tn thng phi hp c thng ng

hoc cho b.

Hn ch vn nhn trn, di v trong.

C th c dn ng t do lit c co ng t.

+ Lit dy thn kinh IV:

Song th ng, song th ti a khi nhn xung di, vo trong.

Hn ch vn nhn xung di, vo trong.

T th b tr u nghing sang bn khng c c b lit, cm gp xung.

Trong lit dy IV bm sinh thy khng c s cn xng ca khun mt.

Nghim php Bielchowsky (+).

+ Lit dy thn kinh VI:

Song th ngang v l triu chng lm cho bnh nhn n sm vi thy thuc.

Hn ch vn nhn ngoi.

Lc trong.

d. Chn on Phn Bit

Trn lm sng cn phn bit lc lit vi lc c nng

Nguyn nhn ca lc c nng thng do di truyn, tt khc x khng

c chnh knh...

Trong lc c nng thng c gim th lc mt bn v c bit gc lc hng

nh mi hng nhn. Tuy nhin vi nhng trng hp lc c nng lu ngy, lc

ln rt kh phn bit vi lc lit.

4. IU TR

1. Nguyn tc chung

Tm v iu tr nguyn nhn

iu tr triu chng.

Kt hp nhiu phng php (c th iu tr ngoi khoa khi cn thit).

2. iu tr c th

p dng trong giai on lit cp tnh nhm trnh song th, ci thin vn nhn,

phng t th b tr v nhc th.

iu tr nguyn nhn v phi hp vi cc chuyn khoa khc.

9

Chm cu

iu tr ti mt:

+ Bt mt lun phin: hn ch song th

+ eo lng knh: bo tn hp th v trnh song th

+ Tp vn nhn theo cc hng

+ Tim thuc Botulium toxin type A: liu 1,5 n v - 2,5 n v/0,1ml.

Tim vo thn c i vn vi c b lit, tim mt liu duy nht, sau 6 thng tim

nhc li.

+ Vitamin liu cao.

5. TIN TRIN V BIN CHNG

Tin trin ph thuc vo nguyn nhn, v tr v mc tn thng.

30% cc trng hp c th t hi phc.

Nu iu tr mun, iu tr khng ng c th li cc bin chng lc,

sp mi, lch u vo c nh hng n chc nng v thm m.

6. PHNG BNH

Pht hin v iu tr sm cc nguyn nhn c th gy lit vn nhn.

TI LIU THAM KHO

1. Arthurl. Rosenbaum, Alvina Pauline Santiago (1999), Other paralitic

strabismus, Clinical strabismus management principles and surgical techniques, pp

249-271.

2. Edward M. Wilson (2008), General principles in the surgical treatment of

paralytic strabismus, Pediatric Ophthalmology, pp179-192.

3. Kenneth W. Wright (2003), Complex strabismus: restriction, paresis,

dissociated strabismus,and torticollis, Pediatric Ophthalmology and strabismus, pp

250-277.

4. Kenneth W. Wright (2007), Cranial nerve palsies, Color atlas of strabismus

surgery, pp.76-86.

5. Leonard B. Nelson, Scott E. Olitsky (2005), Strabismus Disorder, Harley

pediatric ophthalmology, pp 143-192.

10

NHC TH

1. NH NGHA

Nhc th l tnh trng gim th lc mt hoc hai mt hoc c s khc bit

th lc gia hai mt trn 2 dng sau khi c iu chnh knh ti u hoc iu

tr c nguyn nhn, c th l nhc th c nng hoc nhc th thc th .

2. NGUYN NHN

Cc bnh gy cn tr trc quang hc th gic: khi c s che khut trc

th gic ca mt nh sp mi, so gic mc, di chng mng ng t, c th thy

tinh bm sinh, tn hi dch knh...

Bnh lc mt

Tt khc x: Hay gp trn mt c tt khc x cao, c bit trn nhng

mt vin th v lon th cao.

Lch khc x: Khc x hai mt khng u nhau, thng chnh lch trn

2D c th gy nhc th mt c khc x cao hn .

C th do ng thi nhiu nguyn nhn phi hp.

3. CHN ON

a. Lm sng

Triu chng c nng: nhn m mt hoc hai mt, mi mt, c th km

theo lc, sp mi.

Triu chng thc th.

+ Gim th lc: mt mt hoc c hai mt sau khi chnh knh, hoc chnh

lch th lc 2 mt 2 hng th lc. tr nh khng th c th lc th da vo s

nh th ca mt v kh nng nhn theo vt.

+ Hin tng m ng: bnh nhn c tng ch tng mt ri rc d dng

hn khi c nguyn hng ch.

+ C th c lc mt, mt khng c kh nng nh th hoc nh th ngoi tm.

+ Khm c th pht hin c nguyn nhn.

b. Cn lm sng

Siu m nhn cu c th pht hin c nguyn nhn.

in vng mc gip chn on nguyn nhn.

c. Chn on xc nh

11

Chn on xc nh da vo cc du hiu gim th lc mt hoc hai mt

sau khi chnh knh th lc < 20/30 hoc chnh lch th lc hai mt 2 hng.

d. Chn on mc :

Trn lm sng da vo th lc chia lm 3 mc

Nhc th nh khi th lc t 20/40 n 20/30

Nhc th trung bnh khi th lc t 20/200 n 20/50

Nhc th nng khi th lc di 20/200

e. Chn on phn bit

Cc bnh l gy gim th lc nh

Vim th thn kinh: gim th lc mt hoc hai mt vi nhiu mc

khc nhau, c th km au trong hc mt hoc au khi vn nhn, a th c th

cng t, ph tng phn hoc ton b, chp CT scan c th thy th thn kinh to

hn bnh thng.

M v no: mt mt hon ton cm gic i vi nh sng nhng khng

c tn thng thc th no thy c, mt phn x quy t - iu tit, mt phn x

hng mt theo nh sng.

Hysteria.

4. IU TR

a. Nguyn tc chung

Hn ch s dng mt lnh

Kch thch v to iu kin cho mt nhc th c s dng c th

pht trin th gic bnh thng.

Gii quyt trit cc nguyn nhn gy nhc th.

b. iu tr c th

Hn ch s dng mt lnh:

+ Phng php bt mt

Dn bng trc tip che mt, dn bng che ln trn mt knh, s dng

knh tip xc m hoc c.

Thi gian bt mt: bt hon ton trong ngy (nhc th nng), bt hon

ton tr 1gi 1 ngy, bt 1/2 thi gian lc thc (tr di 1 tui).

12

Thi gian theo di: mt tun cho 1nm tui, v d tr 1 tui theo di sau

1 tun, tr 2 tui theo di sau 2 tun, tr 3 tui theo di sau 3 tun, t 4 tui tr ln

theo di sau 1 thng.

Phi kim tra mt lnh trnh nhc th o ngc v kim sot s ci

thin th lc ca mt b nhc th

+ Phng php gia pht: mc ch lm m hnh nh mt lnh bng cch

dng thuc hoc knh.

Dng Atropin 1% tra mt lnh mi ngy 1 git, phng php ny

thng ch dng tr nh.

Gia pht gn: dng Atropin 1% tra vo mt lnh mt git mi ngy v

khng chnh knh nu c tt khc x, trong khi cp knh s cho mt b nhc th.

Gia pht xa: thng chnh knh (thng chnh ln t nht + 3D) i vi mt

lnh lm cho mt ny ch nhn gn m nhn xa khng r.

Gia pht ton b: tra Atropin hng ngy v thng chnh knh mt lnh,

mt nhc th chnh knh bnh thng.

trnh nhc th o ngc cn theo di st bnh nhn theo nguyn tc 1

tun cho 1 nm tui, dng gia pht nu thy gim th lc mt lnh.

Kch thch s dng mt nhc th

+ iu chnh tt khc x: i vi tr em cn nh thuc lit iu tit o

khc x. Cp knh s vi mt b nhc th, eo knh thng xuyn.

+ Kch thch mt nhc th

Xu ht cm

Tp hnh

Tp trn my Synoptophone

5. TIN TRIN V BIN CHNG:

Ph thuc vo cc yu t sau

Tui bt u iu tr: iu tr cng sm kt qu cng cao.

Nguyn nhn: nhc th do tt khc x t khi b nng v thng c

pht hin v chnh knh sm. Nhc th do lch khc x tin lng tt hn nhc

th do lc, nu nhc th do nhiu nguyn nhn phi hp tin lng rt km.

Mc nhc th: Nhc th nh tin lng tt hn nhc th nng.

Kiu nh th: nh th trung tm tin lng tt hn nh th ngoi tm.

Th gic hai mt: C th gic hai mt tin lng tt hn.

13

S tun th phng php iu tr ca gia nh v bnh nhn.

Bin chng: vi tr nh cn theo di st khi dng phng php bt mt

trnh nhc th o ngc.

6. PHNG BNH

Pht hin v iu tr sm cc nguyn nhn c th gy nhc th. iu tr cng

sm th kh nng phc hi ca mt nhc th cng tt. Nhiu nghin cu cho thy

nhc th do lc c th hi phc nu iu tr trc 9 tui, trong khi thi im ny

vi nhc th do lch khc x l 12 tui. Do vi tr b nhc th di 12 tui

th vic iu tr l bt buc v c kh nng hi phc. Cc trng hp do tt khc x

cn phi c chnh knh ti u.

TI LIU THAM KHO

1. Edward M. Wilson (2008), Pediatric Ophthalmology, pp 33-46.

2. Graham E. Quinn, Roy W.Beck, (2004), Recent advances in the treatment of

amblyopia, Pediatrics vol 113 No.6 pp 1800-1802.

3. Kenneth W. Wright (2007), Amblyopia treatment, Color atlas of strabismus

surgery, pp.3-7.

4. Leonard B. Nelson, Scott E. Olitsky (2005), Amblyopia, Harley pediatric

ophthalmology, pp 123-136.

5. Michael Clarke (2006), Modern treatment of amblyopia, Pediatric

Ophthalmology, Neuro-Ophthalmology, Genetics, pp.37-48.

14

LI MT

1. NH NGHA

Li mt l tnh trng nhn cu bnh thng b y ra trc do tng th tch

t chc trong hc mt.

2. NGUYN NHN

C ba nhm nguyn nhn gy li mt:

Li mt do cng nng tuyn gip trng (bnh Basedow).

Li mt do vim.

Li mt do khi u.

3. CHN ON

a. Lm sng

Triu chng c nng

Khai thc bnh s l phn quan trng gi cho chn on nguyn nhn,

bao gm nhng ni dung chnh sau y:

Li mt mi c hay c t lu? (Li mt c t lu thng l li mt

gi do cn th nng hay hc mt nh).

Li mt tin trin nhanh hay chm? (Li mt cp tnh thng gp do

vim t chc hc mt hay khi u c tnh).

Li mt c xut hin sau chn thng khng? (Li mt sau chn thng

thng do thng ng mch cnh xoang hang hay t mu hc mt).

Li mt c tng thm khi thay i t th nh ci u, nn th v rn?

(Li mt khi gng sc thng do bi gin mch trong hc mt.)

Li mt c km theo m mt hay song th? (Li mt do khi u th thn

kinh thng i km gim th lc. Li mt do u mch hc mt c th i km song

th. Thng ng mch cnh xoang hang gy lit dy VI v c song th).

Li mt c km theo cc du hiu khc nh tai, au u v c ting

trong u? (y l nhng triu chng gp trong thng ng mch cnh xoang

hang. Tng p lc ni s nng v lu ngy cng c th gy li mt nh).

Triu chng thc th

Xc nh c li mt tht hay khng bng cch quan st t trn trn

xung, so snh m khe mi, nhn nghing so snh nh gic mc vi cung lng

15

my v o li bng thc Hertel. Li mt mt hay hai bn? (Li mt hai bn

thng do nguyn nhn tuyn gip trng hay bnh mu c tnh tr nh).

nh gi thm mt s du hin i km li mt nh ri lon vn ng mi

mt v nhn cu (thng gp trong bnh Basedow). Lit dy thn kinh vn nhn

c th xy ra trong tn thng xoang hang hay thng ng mch cnh xoang hang.

nh gi tnh trng mi mt v l b (ung th biu m y mi mt c th

xm ln hc mt. U hc t c tnh mi v kt mc c th xm ln hc mt gy li

mt. U ti l gy chy nc mt. U tuyn l chnh gy sng n gc trn ngoi mt.

Ung th biu m tuyn b hay tuyn sn mi xm ln hc mt c tn thng mi v

kt mc c th).

nh gi tnh trng nhn cu (kt mc cng t, ph n trong bnh vim

t chc hc mt, gin mch kt mc trong thng ng mch cnh xoang hang, u

limpho kt mc c mu hng. Khm mng mt thy u mng mt hay nt Lisch

mu nu en trong bnh u x thn kinh. Khm k nhn cu c th thy ung th

vng mc xut ngoi hay u hc t hc mc c tnh xut ngoi hay np gp vng

mc do c khi u ngoi nhn cu gy chn p. U th thn kinh hay u mng no

thng i km ph n gai th).

nh gi hng nhn cu b y li (thng hay lch trc) xc nh v

tr u hc mt. U tuyn l chnh gy li mt lch trc. U th thn kinh gy li mt

thng trc.

nh gi ng t (du hiu tn thng ng ng t hng tm dng

tnh chng t c tn thng th thn kinh)

S nn xc nh v tr khi u, mt u gi chn on (nhn, cng,

di ng chng t c th nang hc mt. U c tnh thng g gh, rn chc, dnh, t

di ng. U xng th cng nh xng v thng gc trong mt).

Cn ch c th lc, nhn p. U th thn kinh thng gy mt th lc.

Bnh li mt do cng nng gip trng v thng ng mch cnh xoang hang

thng km theo tng nhn p.

Triu chng ton thn

Tin s cc bnh ton thn nh lao, vim nhim, bnh mu, u c tnh

(tin lit tuyn, phi hay v), bnh xoang mn tnh rt quan trng. Li mt c th

do u di cn hc mt hay do vim t chc hc mt sau vim xoang sng. Bnh nhn

HIV (+) c th li mt do vim t chc hc mt do nm.

Ngoi ra cn phi c bit ch n la tui ca bnh nhn (u mch

dng hang thng xut hin tui trung nin. U c vn c tnh hay xut hin

tui nh. Phnh mch hay bi gin mch thng xut hin la tui thanh nin).

16

b. Cn lm sng

Chn on hnh nh

Siu m c tc dng phn bit u c, nang hc mt, gi li hc mt, siu

m doppler nh gi tnh trng mch mu trong hc mt

Chp CT xem xng v cc cu trc ln cn hc mt.

Chp cng hng t xem cc cu trc mm quanh nhn cu.

Sinh thit hc mt

Xc nh chnh xc bn cht ca khi u v ra hng iu tr nh u

lympho cn iu tr ho cht, u vim iu tr chng vim, u mng no ch nh tia x.

c. Chn on xc nh

o li: xc nh c li mt tht hay khng bng cch quan st t trn

trn xung, so snh m khe mi, nhn nghing so snh nh gic mc vi cung

lng my v o li bng thc Hertel. li > 10 mm c coi l bt thng.

Cn lm sng: chp CT Scan, cng hng t, siu m.

Khm chuyn khoa: Li mt c khi l biu hin ca mt bnh l ton

thn nn rt cn kin ca cc chuyn gia nh huyt hc, ni tit, u bu, tai mi

hng v thn kinh.

d. Chn on phn bit vi gi li mt

Li mt gi c th xut hin trong nhng trng hp sau:

Lm mt bn kia: li mt bn lnh khng qu 10 mm

Co rt mi trn hay mi di: V tr b mi nm trn ra trn ca gic mc.

Sp mi mt bn: V tr mi mt bn lnh bnh thng.

Nhn cu mt bn to (cn th, glcm bm sinh): ng knh gic mc

ln. Siu m o chiu di trc nhn cu hay o khc x mt.

Nhn cu mt bn nh (vin th, teo nhn cu): Da vo siu m o

chiu di trc nhn cu.

4. IU TR

a. Nguyn tc chung

iu tr theo nguyn nhn.

Phng v iu tr bin chng.

Ty theo bn cht ca khi u m c ch nh iu tr ni khoa, ngoi

khoa hay tia x.

17

b. iu tr c th

K hoch iu tr thay i ty theo bn cht ca li mt. iu tr ni khoa:

p dng vi tn thng do vim nhim, u lympho, sarcoid, thoi ho

dng tinh bt. Mt s loi u c tnh cn phi hp vi iu tr ngoi khoa.

Corticoid c dng n c hay phi hp ho cht.

Ho tr liu p dng vi u c vn c tnh hay ung th vng mc xut

ngoi


Tin trin: Ty theo nguyn nhn gy li mt. Tt nu li mt do vim

hay do bnh Basedow. Xu nu li mt do khi u c tnh.

Bin chng: Lot gic mc, chn p th thn kinh, tng nhn p, hn ch

vn nhn, lc, song th.

6. PHNG BNH

iu tr bnh vim nhim xoang ln cn phng bin chng vim t

chc hc mt.

Khm v iu tr bnh Basedow

TI LIU THAM KHO

1. Sipos JA, Kahaly GJ. Imaging of thyrotoxicosis. Am J Med. 2012

Sep;125(9):S1-2. doi: 10.1016/j.amjmed.2012.05.012. Review.

2. Maheshwari R, Weis E. Thyroid associated orbitopathy. Indian J Ophthalmol.

2012 Mar-Apr;60(2):87-93.

3. Snchez-Orgaz M, Grabowska A, Royo-Oreja A, Asencio-Durn M, Romero-

Martn R, Arbizu-Duralde A. Optic neuropathy following orbital irradiation for

Graves' ophthalmopathy: a case report and literature review.

4. Robinson D, Wilcsek G, Sacks R. Orbit and orbital apex. Orbit. 2012

Feb;31(1):30-3.

5. Poloschek CM, Lagrze WA, Ridder GJ, Hader C. Clinical and

neuroradiological diagnostics of orbital tumors. Ophthalmologe. 2011

Jun;108(6):510-8. Review.

http://www.ncbi.nlm.nih.gov/pubmed/22938934http://www.ncbi.nlm.nih.gov/pubmed/22446901http://www.ncbi.nlm.nih.gov/pubmed/22029640http://www.ncbi.nlm.nih.gov/pubmed/22029640http://www.ncbi.nlm.nih.gov/pubmed/21695605http://www.ncbi.nlm.nih.gov/pubmed/21695605

18

VIM T CHC HC MT

1. I CNG

Vim t chc hc mt l vim ca phn m mm trong hc mt. Vim t

chc hc mt gp c tr em v ngi ln. tr em di 5 tui th hay phi hp

vi vim ng h hp trn. tr em trn 5 tui hay phi hp vi vim xoang.

ngi ln hay gp nhng ngi i tho ng, suy gim min dch hay do d

vt nm trong hc mt.

2. NGUYN NHN

Do vi khun, nm, virus v k sinh trng.

Cc yu t thun li nh :

tr em hay gp do vim ng h hp trn, vim xoang.

ngi ln hay gp nhng ngi i tho ng, suy gim min

dch.

C th gp do nhng nguyn nhn lan truyn trc tip t nhng cu trc

nh nhn cu, mi v phn ph cn ca nhn cu cng nh cc xoang ln cn.

Do chn thng xuyn lm tn thng vch hc mt, c bit nhng

chn thng c d vt hc mt.

Nhng phu thut nh phu thut gim p hc mt, phu thut mi, phu

thut lc, ni nhn vim t chc hc mt cng c th gp sau vim ni nhn sau

phu thut.

3. CHN ON

a. Lm sng

C nng

Xut hin au t ngt, au vng hc mt

au khi vn ng nhn cu, lic mt

au u

Thc th

Mi ph

Xung huyt kt mc

Ph kt mc

Li mt: li mt c th li thng trc hoc khng thng trc

19

Song th

Sp mi

Hn ch vn nhn hoc lit vn nhn

Gim th lc nhiu mc khc nhau

Nu vim gn nh hc mt c th c gim th lc trm trng

C th c vim hc mc hoc vim th thn kinh

C th tng nhn p do chn p

Triu chng ton thn

Mt mi, st

Nhng triu chng h hp hay xoang

b. Cn lm sng

Chp XQ hoc chp CT: hnh nh vim t chc hc mt, hnh nh vim

xoang.

+ C th thy hnh nh vim xoang vi nhng xng v mng xng y

v pha hc mt.

+ Hnh nh p-xe cnh mng xng: in hnh trn CT l hnh nh tn

thng cnh xoang m, c b xung quanh mm mi v c th c kh bn trong.

+ Trong trng hp chn thng c th xc nh c d vt hc mt.

Siu m: c gi tr trong mt s trng hp chn on xc nh v chn

on phn bit nh c vin dch quanh nhn cu.

Cng thc mu: bch cu a nhn trung tnh tng cao, CRP tng trong

nhim khun.

Ly bnh phm hc mt hoc m p-xe lm xt nghim soi ti,

soi trc tip, nui cy vi khun chn on nguyn nhn v iu tr.

Ly bnh phm xoang hay vng mi hng.

Cy mu nu nghi ng hoc c nhim trng huyt

c. Chn on xc nh

Da vo triu chng lm sng

au u, au quanh mt, au khi lic mt

Li mt

Ph mi v kt mc

20

Hn ch vn nhn

Vim hc mc hoc vim th thn kinh, ph gai

Tng nhn p do chn p

Da vo triu chng cn lm sng

CT thy hnh nh vim xoang, hnh nh p xe hay d vt

Siu m c hnh nh vin dch quanh nhn cu

Cng thc mu: bch cu a nhn trung tnh cao.

d. Chn on phn bit

Nhng trng hp li mt khc nh li mt do bnh Basedow, li mt

vim gi u, vim tuyn l: li mt nhng khng au khi vn nhn. Chp CT c th

gip chn on phn bit.

Do khi u hc mt, ung th nguyn bo vng mc xut ngoi, ung th

c vn. Chp CT thy hnh nh khi u hc mt.

Siu m c th thy hnh nh khi u ni nhn c canxi

Bnh sarcoidose: bnh ton thn c biu hin hc mt. Chp XQ phi

v xt nghim min dch gip chn on phn bit.

B cn trng t: ch nh hng n t chc trc vch hc mt.

4. IU TR

a. Nguyn tc chung:

Phi iu tr cp cu vim t chc hc mt cp tnh phng bin

chng vim mng no, tc xoang hang v nhim khun huyt.

Ngi bnh phi c iu tr ni tr.

iu tr theo khng sinh .

Tm cc vim phi hp nh vim xoang, vim ng h hp trn

iu tr.

iu tr ngoi khoa khi cn thit.

b. iu tr c th

Khng sinh ng tnh mch liu cao, ph rng trong giai on sm v

khng sinh c hiu sau khi nui cy phn lp c vi khun.

Trong thi gian ch i nui cy vi khun c th dng khng sinh nhm

Cephalosporin th h 3: 15mg/kg cn nng ung hoc truyn tnh mch.

21

Chng vim: Steroid ng ung v ng tnh mch (Methyl

prednisolon 1mg/kg cn nng).

Nng cao th trng: vitamin nhm B, C.

iu tr phi hp nhng trng hp vim xoang, vim ng h hp,

i tho ng.


Vim t chc hc mt l bnh nng, din bin phc tp v c th gy

bin chng nng. Tuy nhin nu iu tr tt bnh cng c th khi khng li di

chng g.

Nhng bin chng c th xy ra l:

Nhim trng huyt c th gy t vong hoc tc xoang hang.

p xe hc mt.

Vim mng no.

Vim th thn kinh gim th lc.

6. PHNG BNH

iu tr nhng vim nhim ca mi, vim phn trc vch phng lan vo

t chc hc mt.

Phng nhng bnh nh h hp, vim xoang tr em. Khi tr mc bnh

cn c iu tr v theo di cn thn nhng bin chng khng xy ra.

Theo di v iu tr tt nhng ngi c bnh mn tnh nh i tho

ng, vim xoang, vim rng

Khi c vim t chc hc mt phng cc bin chng xy ra

TI LIU THAM KHO

1. Brook I (2009) Microbiology and antimicrobial treatment of orbital and

intracranial complications of sinusitis in children and their management. Int J

Pediatr Otorhinolaryngol.;73(9):1183-6

2. Greenberg MF, Pollard ZF (1998) Medical treatment of pediatric

subperiosteal orbital abscess secondary to sinusitis. J AAPOS. 2(6):351-5.

3. McKinley SH, Yen MT, Miller AM, Yen KG (2007) Microbiology of

pediatric orbital cellulitis. Am J Ophthalmol. 2007 Oct;144(4):497-501

4. Nageswaran S, Woods CR, Benjamin DK Jr, Givner LB, Shetty AK (2006)

Orbital cellulitis in children. Pediatr Infect Dis J.;25(8):695-9.

http://www.ncbi.nlm.nih.gov/pubmed/10532723http://www.ncbi.nlm.nih.gov/pubmed/10532723http://www.ncbi.nlm.nih.gov/pubmed/17698020http://www.ncbi.nlm.nih.gov/pubmed/16874168

22

5. Yen MT, Yen KG. (2006) Effect of corticosteroids in the acute management

of pediatric orbital cellulitis with subperiosteal abscess. Ophthal Plast Reconstr

Surg. 2005 Sep;21(5):363-6

http://www.ncbi.nlm.nih.gov/pubmed/16234700http://www.ncbi.nlm.nih.gov/pubmed/16234700

23

VIM TI L

1. NH NGHA

Vim ti l l mt bnh l thng gp trong nhn khoa, l tnh trng vim

mn tnh hoc cp tnh ti ti l. Bnh thng xy ra th pht sau tc ng l mi

bm sinh hoc mc phi.

2. NGUYN NHN

L hu qu ca tc ng l mi bm sinh hoc tc ng l mi mc phi.

Tc nhn vi sinh vt thng gp gy vim ti l kh a dng. Cc vi

sinh vt c th gy vim ti l bao gm vi khun Gram dng nh Staphylococus

epidermidis, Staphylococus Aureus, Streptococus pneumoniae; vi khun gram m

nh : Pseudomonas aeruginosa, Hemophilus influenza, Proteus, k c vi khun k

kh nh Propionibacterium acnes.

3. CHN ON

a. Lm sng:

Vim ti l biu hin hnh thi mn tnh hoc c nhng t vim cp tnh.

Vim ti l mn tnh

Chy nc mt thng xuyn, c th km chy m nhy.

Dnh mi mt do cc cht tit nhy.

Vng ti l c khi n, cng, n vo c m nhy tro ra gc trong mt.

Vim kt mc gc trong.

Bm l o: nc tro qua l l i din c nhy m km theo.

Vim ti l cp tnh

C tin s chy nc mt, hoc chy nc mt km nhy m.

au nhc vng ti l, c th au tng ln khi lic mt v phn ng vim

c th tc ng n c cho di. au c th lan ra na u cng bn, au tai hoc

au rng.

Vng ti l sng, nng, .

Ti l gin rng, lan ra pha di ngoi hoc mt phn pha trn.

Nu qu trnh nhim trng nng hn, gy p xe ti l.

Giai on mun hn, c th gy d m ra ngoi da. M nhy thot t ti

l ra ngoi qua l d ny.

24

Ton thn: mt mi, st, c bit cc triu chng ton thn th hin r

hn ngi gi. C th c hch trc tai.

b. Cn lm sng

Vim ti l c th c chn on d dng da vo cc triu chng lm

sng m khng cn n cc xt nghim chn on khc. Tuy nhin trong mt s

trng hp, chp phim ct lp vng ti l v hc mt s cho thy r hnh nh ti l

b vim hay u ti l.

Xt nghim vi sinh vt: xc nh loi vi sinh vt gy vim ti l bng xt

nghim nhum soi, nui cy m nhy t ti l.

c. Chn on xc nh

Chn on xc nh cn c vo cc triu chng lm sng:

Vim ti l mn: chy nc mt t nhin lin tc, bm l qun c nhy

m tro ra im l i din.

Vim ti l cp: trc thng xuyn chy nc mt. Vng ti l sng

nng , au nhc, c th c d m ti l.

d. Chn on phn bit:

Vim kt mc mn tnh: mt , kt mc cng t nh. Bnh nhn c

th chy nc mt. Bm l o nc thot tt xung ming.

U ti l: bnh nhn c khi u vng gc trong mt, c th gy chy nc

mt nu u chon ch nhiu, gy tc l o. U c mt chc, n vi khi u khng

thay i v khng c m nhy tro ra l l. Khi bm l o nc thot tt hoc

nc tro ngc v khng c nhy m. Chp ct lp s phn bit c r u v

vim ti l.

U vng ti l: u vng ti l c th gy chn p vo ti l, gy chy

nc mt. U c mt chc, n vo khi u khng thay i v kch thc. Bm l

o nc thot xung ming hoc tro ngc nhng khng c nhy m.

p xe vng ti l: bnh nhn khng c tin s chy nc mt. Bm l

o nc c th thot xung ming, khng c tc l o. Tuy nhin rt kh phn

bit gia vim ti l cp v p xe vng ti l giai on vim cp tnh. Chn phn

bit da vo bm l o sau khi qua giai on vim cp. Sau khi iu tr bng

khng sinh, ht vim cp, bm l o nc thot, khng c tc l o v vim ti

l mn tnh.

4. IU TR

a. Nguyn tc chung

25

iu tr ni khoa c p dng cho cc trng hp vim ti l cp

gii quyt tnh trng nhim trng cp tnh. Sau khi ht vim cp tnh, bnh nhn

cn c iu tr phu thut loi tr vim mn tnh ti ti l.

Vim ti l cn c iu tr bng phu thut ni thng ti l mi

gii phng tnh trng tc nghn v vim mn tnh ti ti l. Nu khng m ni

thng ti l mi c, bnh nhn cn c iu tr bng phu thut ct ti l.

b. iu tr c th

Vim ti l mn tnh

Thng l o: c ch nh cho cc trng hp vim ti l do tc l o

bm sinh. Thng l o lm gii phng ch tc ng l mi, phc hi lu thng

nc mt. Nh vy, khng cn ng dch vim trong lng ti l, ht vim ti l.

Phu thut ni thng ti l mi: phu thut nhm to ra mt ng

thng mi t ti l sang ngch mi gia. C th to ng thng ny bng phu

thut qua ng rch da hoc qua ng mi, kt hp vi t ng silicon qua l

qun xung mi.

Nu khng phu thut ni thng ti l-mi c, hoc m ni thng ti

l mi tht bi, cn m ct b ti l loi tr vim v trnh cc bin chng nh

vim ti l cp hoc nhim trng ti b mt nhn cu.

Vim ti l cp tnh

iu tr vim ti l cp c chia lm 2 giai on: iu tr vim cp tnh v

iu tr d phng ti pht, bao gm c vic iu tr nguyn nhn.

iu tr vim ti l cp tnh:

Dng khng sinh chng nhim trng: dng khng sinh ton thn ng

tim hoc ung ty theo mc nng nh ca vim ti l. Nn dng cc khng

sinh c ph rng. C th phi hp khng sinh. Sau khi tm c tc nhn gy

bnh, nn dng khng sinh theo kt qu kt qu khng sinh .

Khng sinh ton thn: c th dng cc khng sinh ph rng theo ng

ung hoc tim tnh mch ty theo mc vim cp.

o Cefuroxime: liu 250 500mg/ngy x 2 ln/ngy x 5 7 ngy.

Vi tr em c th dng liu 10mg/kg x 2 ln/ngy x 5 7 ngy.

o Khng sinh nhm quinolon: Ciprofloxacin: liu 250 500mg/ngy x 2

ln/ngy x 5 7 ngy. Khng dng thuc nhm ny cho tr em di 12 tui.

Khng sinh nh mt: c th dng

o Levofloxacin: nh mt 4 6 ln/ngy x 1 -2 tun.

26

o Moxifloxacin: nh mt 4 6 ln/ngy x 1 2 tun.

Gim ph n: dng cc thuc gim ph n

Alphachymotrypsin: ung 4 8mg/ngy x 1 2 ln/ngy x 5 7 ngy.

Gim au: dng thuc gim au nu c au nhc nhiu.

Paracetamol: ung 10mg/kg x 2 3 ln/ngy.

Chch rch p xe : tho bt m p xe gip cho bnh nhn au v

ly bnh phm nui cy tm tc nhn gy bnh v lm khng sinh . C th ht

m qua ng l qun hoc rch trc tip vo ti l qua ng rch da.

iu tr d phng ti pht: iu tr ni khoa s lm vim ti l cp n nh

ri chuyn sang giai on vim ti l mn tnh trong vng 1 -2 tun. trnh vim

ti l cp ti pht, bnh nhn cn c tip tc iu tr bng phu thut ni thng

ti l mi hoc ct b ti l.


Nu khng c iu tr, vim ti l mn gy vim kt mc, vim gic mc.

Vim ti l mn c cc t vim cp, gy p xe ti l thm ch gy vim t chc

hc mt. Vim ti l cp c th gy d m ra ngoi da, vim mi, hc mt.

Nhn chung cc trng hp vim ti l mn u c th iu tr khi bng

phu thut ni thng ti l mi. T l khi bnh sau phu thut t 85% - 95% ty

theo tng nghin cu. Cc trng hp iu tr bng phu thut ni thng ti l mi

tht bi, c th iu tr khi hon ton bng phu thut ct ti l. Tuy nhin, sau

ct ti l, bnh nhn ht vim ti l nhng vn b chy nc mt v khng phc hi

c chc nng l o.

6. PHNG BNH

iu tr sm cc trng hp tc ng l mi l bin php c hiu qu

phng vim ti l mn. Cc trng hp vim ti l mn c iu tr sm th s

trnh c bin chng vim ti l cp.

TI LIU THAM KHO

1. Alain Ducasse, J.-P.Adenis, B.Fayet, J.-L.George, J.-M. Ruban (2006) Les

voies lacrymales', Masson.

2. Jeffrey Jay Hurwitz (1996); The Lacrimal System. Lippincott-Raven Publisher.

3. Jack J. Kanski, Clinical Ophthalmology (2008), Third edition.

4. J. Royer, J.P. Adenis, (1982), Lappareil lacrymal, Masson.

5. Jane Olver (2002) : Colour Atlas of Lacrimal Surgery. Elsevier

27

KH MT DO THIU VITAMIN A

1. I CNG

Bnh kh mt do thiu vitamin A l biu hin sm v c hiu mt ca

mt bnh ton thn do thiu Vitamin A gy ra bao gm nhng tn thng trn kt

mc, gic mc v vng mc.

Nhng bin i mt do thiu vitamin A, bao gm nhiu mc : kh kt

mc biu hin tnh trng thiu vitamin A nh, kh gic mc thng ch thiu

vitamin A mc nng hn. Kh nhuyn gic mc l hnh thi trm trng nht

mt, lm tiu gic mc v thng dn n m lo vnh vin. Nhng tr em b kh

mt cn c nhng bnh ton thn km theo nh a chy, cc bnh ng h hp

(vim phi), v bnh si.

2. NGUYN NHN

Do thiu vitamin A, l loi vitamin cn thit cho s pht trin, sc kho, v

chc nng bnh thng ca cc m b mt, nh biu m ca da v nim mc, v

cc m ca mt, c bit l kt mc, gic mc v vng mc.

Nhng i tng c nguy c cao ca thiu vitamin A:

Nhng tr em khng c nui bng sa m hoc cai sa sm, con ca

nhng b m thiu vitamin A d tr trong thi k mang thai hoc nhng a tr c

cn nng sau sinh thp.

Nhng tr < 5 tui b suy dinh dng c bit l suy dinh dng nng.

Nhng tr b mc bnh nhim trng nh si, a chy, nht l tr b a chy ko di

trn 14 ngy. Nhng tr c ch n ngho vitamin A v caroten, tr khng c

n du m...

3. CHN ON

a. Lm sng

Nhng biu hin sm v c hiu ca bnh kh mt gn nh theo mt

trnh t:

+ Qung g (XN): a tr nhn km vo lc c nh sng yu (chp ti).

y l du hiu quan trng cn c pht hin sm, tr s tr li bnh thng khi

dng vitamin A liu iu tr trong 1 - 2 ngy.

+ Kh kt mc (X1A): kt mc bnh thng sng, trng bng, lun c

ph mt lp rt mng nc mt. Khi kt mc kh, c nhng mng mt bng, s s,

khng c nc mt. Cng c trng hp kt mc kh to thnh nhng np nhn.

28

Du hiu kh kt mc l du hiu kh pht hin. Nu pht hin c iu tr bng

vitamin A liu cao sau 2 tun s ht.

+ Vt Bitot (X1B): l m t bo biu m tng sng ho ca kt mc to

thnh mng ni ln thng c mu trng sng hoc vng nht. Vt Bitot thng c

hnh ovan hoc hnh tam gic, v tr kt mc gc mi hoc thi dng v y

bm theo ra gic mc, nh quay v pha mi hoc thi dng. Vt Bitot i khi

khng mt i sau iu tr bng vitamin A liu cao nhng n khng nh hng ti

th lc.

+ Kh gic mc (X2): b mt ca gic mc c nhng chm m c hoc

chm trng. Khi c du hiu ny gic mc thng km theo nhng phn ng chi

s nh sng. Kh mt tin trin nhanh tuy nhin c th iu tr khi hon ton

bng vitamin A liu cao trong 1 - 2 tun.

+ Lot nhuyn gic mc (X3A, X3B): khi kh gic mc khng c iu

tr sm v y s tin trin dn n tn thng biu m gic mc, to ln nhng

lot. Lc ny a tr rt chi, s nh sng, mt lun nhm nghin. Triu chng

ny c th iu tr khi bng vitamin A liu cao nhng thng li so gic mc.

Nhuyn gic mc l giai on nng tip theo ca kh gic mc hoc

lot gic mc khng c iu tr kp thi. Gic mc b ph mt lp trng c,

ton b gic mc b mm nhn, hoi t dn n thng v phi mng mt..

+ So gic mc (XS): so gic mc c mu trng c. C th dnh mng

mt hoc gin li, gy tng bin dng gic mc v tng nhn p.

+ Tn hi vng mc do kh mt.

b. Cn lm sng

nh lng Vitamin A trong huyt thanh

T bo hc: p kt mc tm t bo hnh i

o ngng thch nghi sng ti

in vng mc gim st

c. Chn on xc nh

Da vo cc triu chng lm sng nh qung g, kh kt mc, vt Bitot,

kh gic mc, nhuyn gic mc tr suy dinh dng vi cc bnh ton thn km

theo nh tiu chy, vim phi, si. Cc du hiu cn lm sng nh gim lng

vitamin A trong huyt thanh...

d. Chn on phn bit

Cc vim kt gic mc do cc nguyn nhn khc

29

Cc hi chng kh mt khc : hi chng Stevens- Johnson, Sojgren

Cc bnh l y mt khc gy qung g

4. IU TR

a. Nguyn tc chung

B xung vitamin A

iu tr bnh ton thn km theo: tiu chy, si, vim ng h hp.

Chng nhim trng

iu tr tn thng ti mt nh lot chng dnh

iu tr cc di chng ti mt nh so gic mc

iu tr ngoi khoa khi cn thit

b. iu tr c th

Vitamin A :

+ Ngay sau khi chn on: ung vitamin A 200.000 v x 1 vin (s dng

1/2 liu vi tr di 1 tui).

+ Ngy hm sau: 200.000 v vitamin A ung.

+ Hai tun sau: 200.000 v vitamin A ung.

+ Nu nn ko di hoc a chy nhiu, c th thay th liu u tin bng

tim bp 100.000 v vitamin A tan trong nc.

Chng dnh: Tra Atropin 0,5% 2 ln/ngy

Tng cng dinh dng ti ch v ton thn

Tra nc mt nhn to 1 gi 1 ln.

Nu c nhim trng ti mt iu tr c hiu chng cc tc nhn vi

khun hoc vi rt.

Kt hp vi chuyn khoa nhi iu tr cc bnh ton thn v tng

cng dinh dng cho tr.


a. Tin trin

Bnh c th khi nu c iu tr kp thi giai on XN n X2

Bnh tin trin tun t theo giai on nhng c mt s trng hp tin

trin rt nhanh nh trn bnh nhn b si

b. Bin chng

30

So gic mc

Thng gic mc

Vim m ni nhn

Teo nhn cu

6. PHNG BNH

Ch n y cho tr (b m, vitamin A, protein)

B xung vitamin A nh k theo la tui

Tim chng m rng

iu tr sm v tch cc cc bnh tan thn

Phng chng suy dinh dng.

TI LIU THAM KHO

1. Fawzi W.W., Herrera. W.C., 1993: Vitamin A supplementation and dietary in

relation to the risk of xerophthalmia. The American Journal of clinical Nutrition.

2. Lee WB, Hamilton SM, Harris JP, et al. 2005: Ocular complications of

hypovitaminosis after bariatric surgery. Ophthalmology;112:10314.

3. Peter R Lainson, Christopher J.Rapuano: Diseases of the cornea. Harley,s

Pediatric Ophthalmology 4 th. Editions, Chapter 10 215- 257.

4. Sommer A. 1990: Xerophthalmia, keratomalacia and nutritional blindness. Int

Ophthalmol;14:1959.

31

BNG MT DO HA CHT

1. I CNG

Bng mt do ho cht l mt cp cu c bit trong nhn khoa, bng c th

b mt mt hoc b c hai mt v c th bng rt nng. Tn thng c mi cng

nh kt gic mc v t chc ni nhn, iu tr gp nhiu kh khn. Tin lng d

dt c th gy m khng hi phc.

Thi x tr ban u gip nhiu n tin lng ca bnh.

2. NGUYN NHN

Bng do axt gm cc loi nh axit v c (axit sunfuric, axit Clohydric)

hay axit hu c.

Bng do baz nh bng vi, bng kim.

3. CHN ON

a. Lm sng

C nng

au rt mt, kch thch d di, kh m mt, chy nc mt dn da.

Nhn m hoc khng nhn thy g.

Thc th

Mi mt bng cc mc , c bit b mi, c th im l cng b tn thng.

Kt mc c th gp: cng t, ph kt mc, chm xut huyt xung

quanh ra, xut huyt di kt mc, thiu mu kt mc test Amler (+).

Gic mc c th m c nh, c th xc biu m gic mc hay nng

hn l gic mc m c thm ch c trng s, nn khng thy mng mc, th

thu tinh.

C phn ng vi mng b o: Tyndal (+), dnh mng mt, c th tng

nhn p.

o Ph xc nh tnh cht bng l axt hay bng kim.

Triu chng ton thn

Mt mi, lo lng, hong ht

Nu bng nng, c din tch bng rng c th gy sc.

b. Cn lm sng

Siu m: xc nh cc tn thng phi hp.

32

XQ: xc nh nhng tn thng phi hp nh d vt ni nhn trong n

(V d nh n bnh c-quy).

o pH

c. Phn loi bng:

Theo phn loi ca Poliak (1957): Bng c chia lm 4

d. Chn on xc nh

Da vo hi bnh

Da vo cc triu chng lm sng nh au nhc, nhn m, bng mi,

bng kt mc cc mc , bng gic mc cc mc .

o pH

Cn lm sng nh siu m v X quang tm cc tn thng phi hp.

e. Chn on phn bit

Phn bit gia bng axit hay bng baz.

4. IU TR

a. Nguyn tc chung:

Loi tr cht gy bng.

Chng au.

Chng nhim khun.

Chng dnh.

Tng cng dinh dng gic mc.

iu tr bin chng, di chng.


Biu hin mi Biu hin kt mc v

cng mc

Biu hin gic mc

I Cng t da Cng t kt mc Cht biu m nng

II Bng nc Mng gi (thiu mu kt

mc)

c nng, vn thy r hnh

nh mng mt

III Hoi t da Hoi t kt mc mt phn c su khng hon ton

(nh knh m)

IV Hoi t di da

v sn

Hoi t kt mc v cng

mc

c su hon ton (mu trng

s)

33

b. iu tr c th

Ra mt, ra nhiu nc, nhiu ln, mi ln ra t nht 15 - 30. Dung

dch ra mt l nc mui sinh l, dung dch Ringer hoc nc sch sn c ti

ni xy ra tai nn. Tt nht l truyn nh git lin tc Ringer. Mc ch ra mt

lm long cht gy bng v gim c t cht gy bng.

Ly ht d vt nu c, kim tra k cc ti cng, c bit vi bng vi

phi ly ht vi. V vy phi bc l cng rng bng hai vnh mi, ly d vt bng panh.

Ch : trng hp bng vi sng, trc khi ra phi ly ht vi bm kt

mc sau ra mt.

Chng au bng cc thuc an thn, gim au ti ch v ton thn. Ch

khi s dng cc thuc gim au ti ch nh Dicain nh mt nhiu c th gy c

cho biu m. Thuc gim au ton thn nh Paracetamol (Efferangan).

Chng nhim khun, chng vim

iu tr ch yu lp biu m gic mc ti to trnh lot, thng gic

mc. Sau bng trn nn lot gic mc c th gp nhim trng th pht.

Khng sinh tra v ung kt hp: khng sinh ph rng nh Quinolol th

h 4; m Tetracyclin. ng ung s dng nhm Cephalosporin th h 3: 15mg/kg

cn nng ung hoc truyn tnh mch.

Corticosteroid ti ch v ton thn: tc dng chng vim mng b o,

dng qu trnh pht trin tn mch vo gic mc trong 2-3 tun u sau bng.

Atropin 1%: tc dng chng vim chng dnh. Nu tng nhn p ung

Acetazolamide.

Chng dnh: ra mt lau sch tit t hng ngy, tch dnh cng v

hng dn bnh nhn tp vn ng nhn cu, khng c bng mt.

Cc thuc tng cng dinh dng: CB2, nc mt nhn to, cc thuc

tng cng dinh dng ton thn.

Knh tip xc: c th dng sau vi tun bo v lp biu m v m

nhc, gip lp biu m ti to nhanh.

iu tr bin chng: iu tr cc bin chng nh vim mng b o, tng

nhn p bng cc thuc khng sinh, chng vim v h nhn p ti ch v ton thn.


c im ca ho cht l qu trnh tin trin nng c bit bng kim

thng tin lng kh khn hn, ph thuc vo nhng yu t sau:

+ Mc thiu mu kt mc

34

+ Tnh trng h mi

+ Tnh trng gic mc: gic mc khng c lp biu m che ph s pht

trin mng mu t kt mc vo gic mc. Lot gic mc mn tnh, mch mu xm

nhp vo lp nhu m lm cho gic mc m c v th lc gim.

Nhng tn thng nhn cu kt hp:

Kh mt do tc ng bi tit nc mt.

Tng nhn p do tn thng gc.

c th thu tinh th pht vi nghn ng t.

6. PHNG BNH

Gio dc thc phng chng tai nn bng mt cho tt c mi ngi.

i vi nhng ngi lm ngh c nguy c bng cao phi c trang b

dng bo h lao ng v chp hnh tt cc ni qui quy nh v an ton lao ng.

Ci thin iu kin lm vic: ni lm vic phi thong kh, nh sng,

rng, khng qu cht chi.

T chc tuyn s cu, cp cu v x tr tt t c s ln n tuyn trn.

Cn phi chn on, x tr kp thi trong giai on cp cu.

TI LIU THAM KHO

1. Basu S, Ali H, Sangwan VS. (2012) Clinical outcomes of repeat autologous

cultivated limbal epithelial transplantation for ocular surface burns. Am J

Ophthalmol. 2012 Apr;153(4):643-50,

2. Blackburn J, Levitan EB, MacLennan PA, Owsley C, McGwin G Jr. (2012)

The epidemiology of chemical eye injuries. Curr Eye Res. 37(9):787-93

3. Clare G, Suleman H, Bunce C, Dua H. (2012) Amniotic membrane

transplantation for acute ocular burns. Cochrane Database Syst Rev. Sep 12;9

4. Crawford AZ, McGhee CN. (2012) Management of limbal stem cell

deficiency in severe ocular chemical burns. Clin Experiment

Ophthalmol.;40(3):227-9

5. Dua HS, Miri A, Faraj LA, Said DG.(2012) Free autologous conjunctival

grafts. Ophthalmology. Oct;119(10):2189-2189

6. Thanikachalam S, Kaliaperumal S, Srinivasan R, Sahu PK. (2011) Amniotic

membrane transplantation for acute ocular chemical burns in a child. J Indian

Med Assoc. 2011 Aug;109(8):586-7.

35

VIM KT MC CP

1. I CNG

Vim kt mc cp l tnh trng vim cp tnh ca kt mc, thng do nhim

trng (do virus, vi khun) hoc d ng.

Vim kt mc cp c nhiu hnh thi:

Vim kt mc cp tit t m do vi khun: y l hnh thi vim kt mc

dng nh ti cp.

Vim kt mc cp tit t mng do vi khun: l loi vim kt mc cp tit

t c mng ph trn din kt mc, c mu trng xm hoc trng ng.

Vim kt mc do virus: L vim kt mc c km nh, nhiu tit t v

hoc c gi mc, bnh thng km st nh v cc biu hin cm cm, c hch

trc tai, thng pht trin thnh dch.

2. NGUYN NHN

Vim kt mc cp tit t m do vi khun: thng gp do lu cu

(Neisseria Gonorrhoeae), him gp do no cu (Neisseria Menigitidis).

Vim kt mc cp tit t mng do vi khun: : thng gp do vi khun

bch hu (C. Dipptheria) v lin cu ( Streptococcus Pyogene), ph cu,...

Vim kt mc do vi rus: do virus Adeno virus, Entero virus ...

3. CHN ON

a. Lm sng

Ti mt:

Bnh xut hin lc u mt mt, sau lan sang hai mt. Thi gian

bnh t vi gi n vi ngy, thng m nhiu nht vo ngy th 5. Bnh din

bin rt nhanh:

+ Mi ph n

+ Kt mc cng t, ph n mnh. C nhiu tit t m bn, hnh thnh rt

nhanh sau khi lau sch.

+ C th c xut tit hoc mng gi.

+ Nu khng iu tr kp thi gic mc b thm nhim rng, tin trin

thnh p xe gic mc v c th hoi t thng gic mc.

Ton thn:

C th c hch trc tai, st nh.

36

b. Cn lm sng

Nhum soi: Nhum gram.

Nui cy trn mi trng thch mu: phn lp vi khun.

c. Chn on xc nh

Ti mt

Mi ph n.

Kt mc cng t, ph n mnh, c nhiu tit t bn.

Ton thn

C th c st.

C hch trc tai.

d. Hnh thi

Vim kt mc cp tit t c m.

Thi gian bnh t vi gi n vi ngy, thng m nhiu nht vo

ngy th 5. Bnh din bin rt nhanh.

Bnh xut hin mt mt, sau lan sang hai mt.

C nhiu tit t m bn, hnh thnh rt nhanh sau khi lau sch.

Xt nghim: Nhum soi (tit t m kt mc): c song cu khun Gram (-)

hnh ht c ph.

Vim kt mc cp tit t mng do vi khun.

Ti mt:

Mi ph n, cng cng kh m. Sau 1-3 ngy mi mm dn.

Kt mc cng t, ph n. Sau 1-3 ngy xut hin mng tht hoc mng

gi trn b mt kt mc. Mng thng bn, mu xm. Mng tht khi bc s l lp

t chc lin kt pha di v chy mu nhiu. Mng gi bc d dng v t chy

mu.

Nu khng iu tr kp thi c th b vim lot gic mc, vim ni nhn.

Ton thn: C th c st, kh th.

Cn lm sng:

Nhum soi: Vi khun Gram (+)

Nui cy: phn lp vi khun.

37

Vim kt mc do virus

Ti mt:

Cm gic xn cm nh c bi trong mt.

Mi ph n.

Kt mc cng t, ph n, ra nhiu tit t trng hoc dch hng.

Sau 3-5 ngy c th thy c gi mc mu trng kt mc sn mi dy

mng ty tng trng hp.

Gic mc c th vim chm biu m.

Ton thn:

Triu chng cm cm: nhc u nh, au mi ngi st nh

Hch trc tai.

4. IU TR

a. Nguyn tc iu tr

iu tr tch cc v khn trng

iu tr ti ch v ton thn

iu tr theo nguyn nhn

Pht hin ngun ly iu tr v phng ly lan

b. Phc iu tr

Ti mt:

+ Bc mng hng ngy

Ra mt lin tc bng nc mui sinh l 0,9 % loi tr m v tit t

Trong nhng ngy u bnh din bin nhanh, tra nhiu ln thuc di

dng dung dch (15-30 pht/ln) mt trong cc nhm sau:

Aminoglycosid: tobramycin...

Fluoroquinolon: ofloxacin, ciprofloxacin, levofloxacin, moxifloxacin,

gatifloxacin...

Thn trng khi dng Corticoid: Prednisolon acetat, Fluorometholon.

Khi bnh thuyn gim c th gim s ln tra mt.

Phi hp tra thuc m mt trong cc nhm trn tra v ti.

Dinh dng gic mc v nc mt nhn to.

38

Ton thn: Ch dng trong vim kt mc do lu cu, bch hu. C th

dng mt trong cc loi khng sinh sau khi bnh tin trin nng, km theo triu

chng ton thn.

Cephalosprin th h 3:

Ngi ln:

Nu gic mc cha lot: Liu duy nht 1 gram tim bp

Nu gic mc b lot: 1 gram x 3 ln / ngy tim tnh mch

Tr em: Liu duy nht 125mg tim bp hoc 25mg/kg cn nng 2-3

ln/ngy x 7ngy tim bp.

Fluoroquinolon: chng ch nh dng cho tr em di 16 tui.

Thuc nng cao th trng.


i vi hnh thi vim kt mc do lu cu: Tt nu iu tr sm v tch

cc, c th thng hoi t gic mc nu iu tr mun v khng tch cc.

i vi hnh thi vim kt mc do bch hu thng khng tt nu khng

iu tr ton thn kp thi v ng.

i vi hnh thi vim kt mc do vi rus: iu tr tch cc, ng phc

bnh s khi sau 5-10 ngy, bnh c th ko di gy vim gic mc biu m.

6. PHNG BNH

iu tr bnh lu ng sinh dc (nu c).

V sinh v tra thuc st khun /khng sinh cho tr s sinh ngay khi ra.

Tim phng y cc bnh theo ng qui nh ca tr.

Lun nng cao th trng.

Nu b bnh cn iu tr tch cc trnh ly lan thnh dch.

TI LIU THAM KHO

1. Messmer EM. (2012): Bacterial conjunctivitis-diagnosis and theragyupdate.

Klin Monbl Augenheikd. May;229(5):529-33.doi:10.1055/s-0031-1299523. Epub

2012 May 16. Review. German.

2. Hong Minh Chu, Phm Ngc ng (2011): Bnh hc kt mc. Chng 1:

Kt mc Gic mc Cng mc. Nhn khoa tp 2, Nh xut bn y hc, trang 12

14.

39

3. Hong Minh Chu (2004): Vim kt mc do vi khun. Chng 5: Kt mc.

Nhn khoa gin yu tp 1. Nh xut bn y hc, trang 114 - 116.

4. Hong Minh Chu (2004): Vim kt mc do vi virus. Chng 5: Kt mc. Nhn

khoa gin yu tp 1. Nh xut bn y hc, trang 117 - 118.

5. Hong Minh Chu (2004): Vim kt mc do chlamydia. Chng 5: Kt mc.

Nhn khoa gin yu tp 1. Nh xut bn y hc, trang 119 - 122.

40

VIM KT MC D NG CP TNH

1. I CNG

Vim kt mc d ng cp tnh l hnh thi d ng nhanh ca vim kt mc d

ng khi bnh nhn tip xc vi d nguyn.

2. NGUYN NHN

D nguyn thng l cc m phm l, thuc tra mt, ha cht, bi, phn

hoa,.

3. CHN ON

a. Lm sng

Triu chng xy ra rt cp tnh.

Triu chng c nng: bnh nhn c cm gic bng rt trong mt, nga

mt, au, s nh sng, chy nc mt, nhiu khi khng m c mt.

Du hiu thc th: mi sng n, mng , kt mc cng t, ph n

mng nc, chy nhiu dch, tit t nhy, pht trin nh to trn kt mc sn mi,

i khi xut hin vim gic mc chm.

b. Cn lm sng

Xt nghim tm d nguyn khi c iu kin.

c. Chn on xc nh

Lm sng:

Nga mt, au, bng rt, s nh sng, chy nc mt

Mi kt mc ph n, tit t nhy, nh vim trn kt mc sn mi.

d. Chn on phn bit

Vim kt mc cp: khng c tin s tip xc d nguyn, kt mc cng t

nhng khng ph n nhiu nh d ng, nhiu tit t nhy

4. IU TR

a. Nguyn tc iu tr

Ngng tip xc vi d nguyn gy d ng (nu xc nh c)

Chng d ng ti ch v ton thn.

Tra ti ch: chng vim, chng d ng

Ton thn: chng d ng

chng ph (nu cn)

41

b. iu tr c th

Vic u tin l phi loi tr tc nhn gy d ng bng ra mt bng

dung dch nh nc mui sinh l.

Dng thuc:

Thuc tra:

Corticosteroid: prednisolon acetate 1%, fluorometholone 0,1% 6-8

ln/ngy, trong vi ngy u, sau bnh gim c th tra rt xung 3-4

ln/ngy v dng khi cc triu chng khi hn.

Nu da mi ph, nga: bi da mi m c corticoid: m hydrocortison

1%.bi da mi 3 ln/ ngy

Thuc ung:

Thuc khng histamin: c th dng 1 trong cc loi thuc chng d ng

nh: loratadine, fexofenadine hydrochloride.

Loratadine 10mg: Ngi ln, tr em 12 tui: 1 vin/ngy

Tr em 6-12 tui 30kg: 1 vin/ngy

Tr em 6-12 tui 30kg: 1/2 vin/ngy

Fexofenadine hydrochloride: ngi ln, tr em 12 tui: 60mg/vin x 2

ln/ngy hoc 120mg-180mg/ 1 ln/ngy.

Trong nhng trng hp c km theo triu chng ton thn nng cn

phi hp hoc chuyn bnh nhn n chuyn khoa d ng.


Bnh thng khi sau vi ngy.

Bnh c th ti pht khi bnh nhn li tip xc vi d nguyn gy d ng.

6. PHNG BNH

Trnh tip xc vi d nguyn nu xc nh c tc nhn gy d ng.

TI LIU THAM KHO

1. Andrea Leonardi (2010): Allergic disease of Conjunctiva and Cornea, Cornea

and external eye disease, chapter 8, pp97-116.

2. Etsuko Takamura, Eiichi Uchio, Nobuyuki Ebihara et al. Japanese Guideline

for Allergic Conjunctival Disease, Allergology International, vol 60, N2, pp191-202.

3. Hong Minh Chu," Vim kt mc d ng do tip xc", Nhn khoa gin yu tp

1. Nh xut bn y hc, trang 127.

42

4. Hong Minh Chu, Phm Ngc ng," Vim kt mc d ng do tip xc",

Nhn khoa (tp 2). Nh xut bn y hc, trang 21.

5. Tn Kim Thanh, Hong Minh Chu, Phm Khnh Vn, Hong Th Phc,"

Vim kt mc d ng", Bi ging nhn khoa bn phn trc nhn cu. Nh xut bn

y hc, trang 73-82.

43

VIM KT GIC MC MA XUN

1. I CNG

Vim kt gic mc ma xun l mt hnh thi lm sng ca vim kt mc d

ng, gp ch yu nam gii, tui thanh thiu nin. Bnh thng khi pht tr

em vo khong 4-5 tui, bnh tin trin mn tnh, thng theo ma v hay c

nhng t kch pht.

2. NGUYN NHN

Bnh c c ch d ng r rng, tuy nhin vic xc nh d nguyn l g

cn gp nhiu kh khn.

D nguyn thng gp: phn hoa, bi nh.. .

Bnh c lin quan mt thit vi s thay i thi tit lc giao ma (nht

l xun h), nh nng, thay i ni tit v yu t di truyn.

3. CHN ON

a. Lm sng

Triu chng c nng

Nga l du hiu in hnh ca vim ma xun, thng xut hin thnh

tng cn vo nhng gi nht nh (c th vo bui sng khi mi ng dy lc tip

xc vi nh nng hoc bui chiu ti).

Bnh nhn c cm gic nh c d vt trong mt, cm, s nh sng, chy

nc mt, gim th lc. D mt nhiu, c c im dnh, dai v c th ko thnh si.

Du hiu thc th

Tn thng c hiu trong vim ma xun:

Nh vim hnh a gic: trn din kt mc sn (ch yu mi trn, i khi

cng thy c vi nh to trn kt mc sn mi di) c nhng nh a gic, mt

phng xp st nhau vi cc rnh ngn cch su, mch mu an thnh li trong

lng nh. Trng hp tin trin nng, cc nh ph i khng l vi tit t nhy m

lp y cc khe gia cc nh.

Vim gic mc chm nng: l tn thng thng gp trong nhng t

bnh tin trin cp. Cc chm bt mu fluorescein dy c v ng u trn khp

din gic mc, gy kch thch chi sng v co qup mi. Triu chng ny s ht i

khi t vim cp c iu tr n nh.

Mng mu gic mc: c hnh thi ging li lim mu xm, b sc nt,

cc mch mu i song song hng tm, khng ni thnh quai nh mch mu mt ht.

44

Lot gic mc: lot c mu trng xm, y phng, sch, b gn, c

bit t gy kch thch, nu khng c bi nhim km theo, do vy nn c gi l

lot tr.

Cc hnh thi lm sng

C 3 th lm sng ty v tr tn thng c hiu: kt mc sn mi, ra v hn hp.

Hnh thi sn mi: cng t kt mc km theo nh tng sn ch yu trn

kt mc sn mi trn, hnh thi nh khc nhau ty theo giai on pht trin ca bnh.

Hnh thi nhn cu: c trng bi cng t vng ra gic mc, kt mc

vng ra dy ln, mu hng xm hay vng xm. Trong nhng trng hp bnh

nng trn nn kt mc vng ra dy xut hin nhng chm trng (ht Trantas).

Hnh thi hn hp: gm tn thng in hnh phi hp c vng ra v

trn kt mc sn mi.

b. Cn lm sng

Xt nghim t bo hc: cht no kt mc sn mi trn: c bch cu i toan.

Xt nghim tm d nguyn.

c. Chn on xc nh:

Lm sng:

Nga mt, cm mt, chy nc mt, d mt dai dnh.

Nh vim hnh a gic trn kt mc sn mi trn, vim kt mc vng ra.

Cn lm sng:

T bo hc: c bch cu i toan.

d. Chn on phn bit:

Mt ht:

Tn thng c hiu: ht trn kt mc sn mi, ht c th tt c cc la tui.

Mng mu trn gic mc: cc mch mu ni vi nhau thnh quai mch.

Vim kt mc ht

Vim kt mc ht c tn thng c hiu l: ht trn kt mc sn mi

di thng cng la tui, v ht khi iu tr vim kt mc n nh.

Vim kt mc ma xun tn thng c hiu l: nh vim kt mc sn

mi trn v nh cn tn ti trong thi gian di d iu tr chng vim tch cc.

Vim kt mc nh gai khng l

45

Thng tm thy nguyn nhn: knh tip xc ( b c 2 mt), mi ch khu

trn b mt nhn cu ( thng ch 1 mt). ( Vim kt mc ma xun khng thy

nguyn nhn trn mt)

Vim kt mc d ng do c a

Tn thng c hiu: khng c nh vim trn kt mc sn mi.

Thng km tn thng trn da.

Vim kt mc d ng theo ma

Tn thng c hiu khng c nh vim trn kt mc sn mi trn.

Tnh cht theo ma r.

4. IU TR

a. Nguyn tc iu tr

Ti mt iu tr triu chng l ch yu

Chng d ng: khng Histamin, n nh dng bo...

Chng vim: corticoid.

Tng cng dinh dng cho biu m kt gic mc, iu tr kh mt phi hp.


Ton thn:

iu tr gii mn cm nu tm c d nguyn.

Nu ngoi biu hin mt bnh nhn cn c cc biu hin d ng cc

c quan khc: vim mi d ng, hen ph qun, vim da d ng.cn dng thuc

chng d ng ton thn (ung hoc tim), cn thit phi phi hp iu tr vi

chuyn khoa d ng.

b. iu tr c th:

Ngoi cn kch pht

Tra ti ch

+ Cc thuc khng histamin v n nh dng bo nh: Pemirolast K

0,1% tra mt 3 ln/ngy, Olopatadine hydrochlotide 0,2% tra mt 1 ln/ngy,

Ketotifen 0,025% tra mt 2 ln/ngy, Epinastine HCL 0,05% tra mt 2

ln/ngycho n khi ht triu chng. C th dng li khi xut hin bnh.

+ Nc mt nhn to nh: Cacboxymethyl cellulose sodium, Polyethylene

glycol 0,4% v Propylen glycol 0,3%, acid Hyaluronic tra mt 4 ln/ngy.

Trong cn kch pht

46

Tra theo phc nh ngoi cn kch pht.

+ Phi hp vi thuc tra c corticosteroid : Prednisolon acetate 1% hoc

Fluorometholon 0,1%: 4-6ln/ngy, tra mt t 7-10 ngy.(khi dng corticosteroid

iu tr cn kch pht phi lu nhng tc dng ph ca corticoid, c bit l

bin chng tng nhn p: phi theo di nhn p nh k)

+ Thuc khng sinh nh mt: phng nhim trng, c th dng 1trong cc

loi ch c khng sinh n c hoc thuc phi hp c khng sinh v

corticosteroid: 3-4 ln/ngy.

+ Thuc co mch: Naphazoline HCL hoc Naphazolin Nitrat n thun 3

4 ln/ngy hoc thuc nh mt phi hp c thuc co mch v khng histamin:

Naphazoline HCL v Pheniramin maleat tra mt 3-4 ln/ngy.dng trong thi

gian ngn 3-5 ngy gip lm gim nhanh triu chng mt v nga mt.

5. TIN TRIN V BIN CHNG.

Tin trin.

+ Bnh hay c nhng t kch pht d c iu tr lin tc.

+ Mt s trng hp bnh c th thuyn gim khi bnh nhn n tui dy th.

Bin chng.

+ Tn thng gic mc: vim gic mc, lot gic mc, lot thng gic

mc, so gic mc.

+ Bin chng do dng thuc c Corticoid: tng nhn p, c thy tinh th.

6. PHNG BNH

Hn ch tip xc vi nng, gi.

Trong t kch pht phi n khm v iu tr tch cc.

Ngoi t kch pht vn nn khm nh k.

TI LIU THAM KHO

1. Andrea Leonardi (2010): Allergic disease of Conjunctiva and Cornea, Cornea

and external eye disease, chapter 8, pp97-116

2. Hong Minh Chu, Vim kt gic mc ma xun, Nhn khoa gin yu (Tp

1), Nh xut bn y hc, trang 123-127.

3. Hong Minh Chu, Phm Ngc ng, Vim kt gic mc ma xun, Nhn

khoa (Tp 2), Nh xut bn y hc, trang 18-21.

4. Sunil Kumar, Vernal keratoconjunctivitis: a major review, Acta

Ophthalmol 2009:87:pp133-147.

47

5. Tn Kim Thanh, Hong Minh Chu, Phm Khnh Vn, Hong Th Phc,

Vim kt mc d ng, Bi ging nhn khoa bn phn trc nhn cu, Nh xut

bn y hc, trang 73-82.

48

VIM LOT GIC MC DO VI KHUN

1. NH NGHA

Vim lot gic mc do vi khun (bacterial keratitis) l hin tng mt t

chc gic mc do hoi t gy ra bi mt qu trnh vim trn gic mc do vi khun,

l mt nguyn nhn thng gp gy m lo.

2. NGUYN NHN

Cc loi vi khun thng gp gy vim lot gic mc

1. Vi khun Gr(+): Staphylococcus aureus, Steptococcus pneumonia,

Staphylococcus epidermidis, Mycobacterium, Nocardia

2. Vi khun Gr(-): Pseudomonas aeruginosa, Moraxella, Hemophilus

influenza,

3. CHN ON

a. Lm sng

Triu chng c nng

+ au nhc mt, cm chi, s nh sng, chy nc mt.

+ Nhn m hn, c th ch cm nhn c nh sng.

Triu chng thc th

+ Kt mc cng t ra.

+ Trn gic mc c mt lot ranh gii khng r, y lot thng ph

mt lp hoi t bn. Khi nhum gic mc bng fluorescein 2% lot s bt mu

xanh, nu lot hoi t nhiu s c mu vng xanh.

+ Gic mc xung quanh lot b thm lu.

+ Mng mt cng c th b ph n, mt sc bng. ng t thng co nh,

c th dnh vo mt trc th thu tinh, tuy nhin kh quan st.

b. Cn lm sng

Bnh phm: l cht no lot.

Soi ti: thy c vi khun.

Soi trc tip: xc nh vi khun gram (+) hay gram (-).

Nui cy vi khun: xc nh c cc loi vi khun gy bnh: t cu,

lin cu, trc khun m xanh,...Nu c iu kin c th kt hp lm khng sinh

xc nh khng sinh iu tr ph hp.

49

d. Chn on xc nh

lot gic mc c c im: b nham nh, ranh gii khng r, y

thng ph lp hoi t bn, gic mc xung quanh thm lu nhiu.

Xt nghim vi sinh cht no lot s tm thy vi khun.

e. Chn on phn bit

Lot gic mc do nm: mt lot ranh gii r, b gn, y lot

thng ph mt lp hoi t dy, ng thnh vy g cao, b mt vy kh rp v

kh bc. Xt nghim vi sinh cht no lot s tm thy nm.

Lot gic mc do virus herpes: lot c hnh cnh cy hoc a , nhu

m xung quanh thm lu t. Xt nghim t bo hc cht no b lot s thy mt

trong cc hnh nh: t bo nhiu nhn, hin tng ng c nhim sc cht quanh

ra nhn, t bo thoi ha nhn trng hoc tm thy tiu th Lipschutz. Xt

nghim PCR cht no b lot hoc thy dch s tm c gen ca virus herpes.

Lot gic mc do amip (acanthamoeba): gic mc c lot trn hoc

bu dc, xung quanh c vng thm lu c (p xe vng). Xt nghim vi sinh cht

no lot s tm thy acanthamoeba.

4. IU TR

a. Nguyn tc iu tr

Cn phi tm c vi khun gy bnh v iu tr bng khng sinh nhy

cm vi loi vi khun (da vo khng sinh ), nu khng xc nh c loi vi

khun gy bnh cn phi dng khng sinh ph rng.

iu tr bng thuc tra mt l chnh, c th kt hp vi dng ng ton thn.

Phi hp iu tr triu chng v bin chng.


b. iu tr c th

Khng sinh chng vi khun (theo khng sinh ). Nu khng c kt qu

khng sinh th iu tr nh sau:

Thuc tra mt:

+ Nu do vi khun gram (-): tobramycin 0,3% hoc levofloxacin 0,5%

+ Nu do vi khun gram (+): ofloxacin 0,3% hoc moxifloxacin 0,5%

hoc gatifloxacin 0,5%. Hai thuc sau c ph khng khun rng nn c th dng

iu tr c vi khun gram (-). Cch dng: Ngy u c th tra mt lin tc cch

nhau 30 pht, nhng ngy sau tra mt 10 ln/ ngy.

50

Thuc ung: c th dng mt trong cc loi khng sinh sau

+ Cefuroxime axetil 250 mg ngy ung 2-3 vin chia 2 ln, trong 5-7 ngy.

+ Ofloxacin 0,2 g ngy ung 2 vin chia 2 ln, trong 5-7 ngy

+ Truyn ra mt lin tc trong nhng trng hp nng bng khng sinh

(gentamycin 4mg x2 ng) v nc nui sinh l (nacl 0,9%) x 200 ml.

iu tr phi hp

+ Chng vim non- steroid: Tra mt: dung dch indomethacine 0,1% tra

mt 4 ln/ngy.

+ Gin ng t, lit c mi: Dng atropin 1- 4 % tra mt 2 ln mi ngy.

Nu ng t khng gin phi tim tch dnh mng mt (tim di kt mc bn

im cnh ra) hn hp: atropin 1% v adrenalin 0,1%.

Tng cng dinh dng ti ch v ton thn.

H nhn p: khi lot gic mc gy tng nhn p, lot da thng hoc

thng. Ung acetazolamide 250 mg 2 vin mi ngy chia 2 ln. Cn phi hp vi

ung kali chloride 0,6 g ung 2 vin mi ngy chia 2 ln trnh mt kali.

Tim huyt thanh t thn di kt mc: c tc dng tng cng dinh

dng cho gic mc v hn ch hoi t gic mc. Dng trong nhng trng hp

lot hoi t nhiu (c bit do trc khun m xanh).

Chng ch nh tuyt i dng corticoid trong giai on lot ang tin trin.


a. Tin trin

Lot gic mc do vi khun l mt bnh nng, nht l nhng bnh nhn

c iu tr mun v dng corticoid trc . Khi bnh khi s li so trn

gic, nh hng n th lc ca ngi bnh.

b. Bin chng

Lot gic mc do thng (phng mng Descemet).

Tng nhn p.

Trng hp nng c th gy lot thng gic mc, vim m ni nhn.

6. PHNG BNH

Lun gi gn mt sch s, trnh nhng sang chn vo mt.

Khi b chn thng trn gic mc cn phi pht hin v iu tr kp thi

bng cc khng sinh tra mt phng bin chng vim lot gic mc do vi khun.

51

Cn phi iu tr cc bnh mt l yu t thun li gy vim lot gic

mc: lng qum, lng xiu, h mi,

TI LIU THAM KHO

1. Bourcier T, Thomas F, Borderie V, et all (2003): Bacterial keratitis:

predisposing factors, clinical and microbiological review of 300 cases. Br J

Ophthalmol. Jul;87(7):834-8.

2. Dahlgren MA, Lingappan A, Wilhelmus KR. (2007) The clinical diagnosis of

microbial keratitis. Am J Ophthalmol. Jun;143(6):940-944. Epub Apr 3.

3. Gicquel JJ, Bejjani RA, Ellies P, et all (2007): Amniotic membrane

transplantation in severe bacterial keratitis. Cornea. Jan;26(1):27-33.

4. Mary E Marquart, Emma BH Hume, Xiadong Zheng, et all (2002): Bacterial

Keratitis. Texbook of ophthalmology, vol 2: 991-1009. Japee Brothers Medical

Publishers, New Delhi.

5. Raymond L.M. Wong, R.A. Gangwani, Lester W.H. Yu, et all (2012): New

Treatment for Bacterial Keratitis. J Ophthalmol. Sep, 28 (5): 125-130.

http://www.ncbi.nlm.nih.gov/pubmed/12812878http://www.ncbi.nlm.nih.gov/pubmed/12812878http://www.ncbi.nlm.nih.gov/pubmed/17408586http://www.ncbi.nlm.nih.gov/pubmed/17408586http://www.ncbi.nlm.nih.gov/pubmed/17198010http://www.ncbi.nlm.nih.gov/pubmed/17198010

52

VIM LOT GIC MC DO NM

1. NH NGHA

Lot gic mc do nm l hin tng mt t chc gic mc do hoi t, gy ra

bi mt qu trnh vim trn gic mc do nm, l mt nguyn nhn gy m lo.

2. NGUYN NHN

C nhiu loi nm c th gy vim lot gic mc: Aspergillus Fumigatus,

Fusarium Solant, Candida Albicans, Histoblasma, Cephalosporum,

3. CHN ON

a. Lm sng

Triu chng c nng

au nhc mt, cm chi, s nh sng, chy nc mt.

Nhn m hn, c th ch cm nhn c nh sng.

Triu chng thc th

Kt mc cng t ra.

Trn gic mc c mt lot ranh gii r, b gn thng c hnh trn

hoc hnh bu dc. y lot thng ph mt lp hoi t dy, ng thnh vy g

cao, b mt vy kh rp v kh bc.

Xung quanh lot c thm lu, mt sau gic mc v tr lot c th c

mng xut tit bm.

Tin phng c th c ngn m. M thng xut hin ri mt i, xut

hin nhiu ln nh vy.

Mng mt cng c th ph n, mt sc bng. ng t thng co nh, c

th dnh vo mt trc th thu tinh, tuy nhin kh quan st.

Cn lm sng


Soi ti, soi trc tip: thy c nm.

Nui cy trn trng Sabouraud c ng: xc nh c loi nm gy bnh.

b. Chn on phn bit

Lot gic mc do vi khun: lot ranh gii khng r, y lot thng

ph mt lp hoi t bn. Lm xt nghim vi sinh cht no lot s tm thy vi

khun.

53

Lot gic mc do virus Herpes: lot c hnh cnh cy hoc a , nhu

m xung quanh thm lu t. Xt nghim t bo hc cht no b lot s thy mt

trong cc hnh nh: T bo nhiu nhn hin tng ng c nhim sc cht quanh

ra nhn, t bo thoi ha nhn trng hoc tm thy tiu th Lipschutz. Xt

nghim PCR cht no b lot hoc thy dch s tm c gen ca virus Herpes.

Lot gic mc do Amip (Acanthamoeba): gic mc c lot trn hoc

bu dc, xung quanh c vng thm lu c (p xe vng). Xt nghim vi sinh cht

no lot s tm thy Acanthamoeba.

4. IU TR

a. Nguyn tc chung

iu tr bng phi hp cc loi thuc khng nm c hiu, phi hp vi

thuc khng sinh tra ti mt phng bi nhim.

Thuc chng vim non-steroid tra ti mt, ung.

Dinh dng: Tng cng hn gn tn thng: Tra ti mt, ung.

Phi hp iu tr triu chng v bin chng.

Phi hp iu tr ngoi khoa khi cn thit.

b. iu Tr c th

Ti mt:

Natamycin: tra mt 10 15 ln mi ngy tu mc nng ca bnh.

Ketoconazole: tra mt 10 - 15 ln mi ngy.

Ngoi ra c th phi hp dng amphotericin B pha vi glucose 5%

nh mt vi nng 0,15% hoc truyn ra mt lin tc vi nng 0,02%.

Nu lot nng km theo m tin phng c th tim tin phng

amphotericin B (mi ln tim 5g/0,1 ml), c th tim 2 hoc 3 ln cch nhau 1

tun. Nu thm lu c c th tim nhu m gic mc (vi liu lng nh tim

tin phng).

Chm lugol 5% vo lot hng ngy.

in di IK 2% hng ngy.

Chng vim non steroid: tra mt indomethacin.

Gin ng t, lit c th mi: Atropin 1 4% tra mt 4 ln mi ngy.

Nu ng t khng gin phi tim tch dnh mng mt (tim di kt mc bn

im cnh ra) hn hp: Atropin 1% v Adrenalin 0,1%.

Tng cng dinh dng.

54

Ton thn: Intraconazole 0,1g ngy ung 2 vin ung mt ln sau n

trong 20 n 30 ngy.

Lu : cc thuc ung chng nm chng ch nh dng cho ph n c thai

v cho con b. C th dng thuc ko di tu theo tin trin ca bnh nhng phi

kim tra chc nng gan nh k cho bnh nhn.

Ung : cc vitamin.

H nhn p: khi lot gic mc gy tng nhn p. Ung acetazolamide

250 mg ngy 2 vin chia 2 ln. Cn phi hp vi ung Kaldium 0,6 g, 2 vin mi

ngy chia 2 ln trnh mt kali.

Chng ch nh tuyt i dng corticoid.


a. Tin trin

Lot gic mc do nm l mt bnh nng, iu tr kh khn. Bnh thng

tin trin nng nhng bnh nhn c iu tr mun v dng corticoid trc

. Khi bnh khi s li so trn gic, nh hng n th lc ca ngi bnh.

b. Bin chng v iu tr

Lot gic mc do thng hoc thng

Tng nhn p dng thuc khng c th phi m l d.

Trng hp lot gic mc nng c th bin chng sang vim ni nhn.

6. PHNG BNH

Lun gi gn mt sch s v trnh cc sang chn.

Khi b chn thng mt (c bit l chn thng trn gic mc) cn phi

n ngay cc c s y t ra mt v tra mt bng thuc st khun (Betadin 5%).

Cn theo di cht ch tn thng trn gic mc.

TI LIU THAM KHO

1. Chen HC, Tan HY, Hsiao CH, Huang SC, el al (2006): Amniotic membrane

transplantation for persistent corneal ulcers and perforation in acute fungal

keratitis. Cornea, Jun;25(5):564-72.

2. Namrata Sharma, Rasuk B Vajpayee, Vishal Gupta, Tanuj Dada (2002):

Fungal Keratitis. Texbook of ophthalmology, vol 2: 1032-1037. Japee Brothers

Medical publishers, New Delhi.

3. Thomas PA. (2003): Fungal infection of the cornea. Eye (Lond).

Nov;17(8):852-62. Review.

55

4. Xie L, Zhai H, Shi W. (2007): Penetrating keratoplasty for corneal perforation

in fungal keratitis. Cornea, Feb;26(2):158-62

5. Yildiz EH, Abdalla YF, Elsahn AF, et al(2010): Update on fungal keratitis

from 1999 to 2008. Cornea. 2010 Dec;29(12):1406-11

56

VIM GIC MC DO HERPES

1. NH NGHA

Vim gic mc do herpes l hin tng thm nhim t bo vim v hoi t

gy tn thng mt t chc gic mc do herpes.

2. NGUYN NHN

Do virus herpes c tn khoa hc l herpes simplex virus (HSV) thuc h

herpes viridae. Herpes c 2 type: type 1 (HSV-1) gy bnh na trn c th t

tht lng tr ln (gy vim lot gic mc), type 2 (HSV-2) gy bnh na di c

th t tht lng tr xung. Tuy nhin, c trng hp HSV-2 gy bnh mt do

mt b nhim dch tit ng sinh dc (c bit tr s sinh) nhng rt him gp.

3. CHN ON

a. Lm sng

Triu chng c nng

au nhc mt.

Kch thch: cm chi, chy nc mt, s nh sng.

Th lc: gim nhiu hay t ty mc tn thng.

Triu chng thc th

Tn thng ca gic mc do herpes c c im: a dng, hay ti pht, gy

gim hoc mt cm gic gic mc.

Lot gic mc hnh cnh cy: l triu chng c trng v in hnh.

Lot gic mc hnh a .

Vim gic mc hnh a: nhu m gic mc trung tm thm lu lm cho

gic mc ph dy ln v pha ni m, c th c np gp mng Descemet, ta sau

gic mc.

Vim nhu m k: l hnh thi nng ngay t u. Trong nhu m c nhng

m thm lu mu trng vng, ranh gii khng r (hnh phomt). C th c vnh

phn ng min dch cnh tn thng.

Vim mng b o: tn thng gic mc do herpes c th km theo

vim mng b o hoc vim bn phn trc. Khm lm sng s thy: c ta mt

sau gic mc, t bo vim trong thy dch (Tyndall tin phng), ng t co nh, c

th dnh vo mt trc th thy tinh. y l hnh thi nng, kh iu tr.

Cm gic gic mc: b gim hoc mt.

57

Ngoi ra bnh nhn c th b st, ni hch trc tai. Xut hin mn nc

mp, mt,

b. Cn lm sng

Xt nghim t bo hc: bnh phm l cht no b lot, s thy cc tn

thng:

T bo biu m nhiu nhn.

Hin tng ng c nhim sc cht quanh ra nhn (nhim sc cht p

ven): l du hiu in hnh.

C tiu th Lipschutz: l du hiu c hiu.

T bo biu m thoi ha trng.

Xt nghim PCR: tm gen ca virus herpes, bnh phm l cht no b

lot hoc thy dch. Xt nghim c tnh c hiu cao.

c. Chn on xc nh

Lot gic mc hnh cnh cy, hnh a hoc vim gic mc hnh a.

Cm gic gic mc gim.

Xt nghim t bo hc cht no b lot thy mt hay nhiu du hiu:

t bo nhiu nhn, hin tng ng c nhim sc cht quanh ra nhn, t bo biu

m thoi ha nhn trng, hoc tm thy tiu th Lipschutz.

Xt nghim PCR: tm c gen ca virus herpes.

d. Chn on phn bit

Lot gic mc do vi khun: lot b khng r, thng nham nh, thm

lu hoc hoi t nhiu. Xt nghim vi sinh cht no lot s tm thy vi khun.

Lot gic mc do nm: lot thng c hnh trn hoc bu dc, y ph

bi lp hoi t dy, g cao, nhu m xung quanh lot c thm lu v tinh. Xt

nghim vi sinh cht no lot s tm thy nm.

Lot gic mc do acanthamoeba: lot gic mc thng km theo p xe

vng. Xt nghim vi sinh s tm thy acanthamoeba.

4. IU TR

a. Nguyn tc chung

Dng thuc c ch tng hp axit nhn (AND) ca virus ng tra v ung.

Phi hp iu tr thuc chng vim, tng cng dinh dng v khng

sinh chng bi nhim khi cn thit.

58

iu tr bin chng

b. iu tr c th

iu tr c hiu

Thuc tra mt: dng mt trong cc loi thuc sau

Acyclovir 3%: tra mt 5 ln mi ngy.

IDU (5 Iodo 2 Dezoxyuridin): thuc c dng nc hoc m. Thuc

khng ngm su vo gic mc c nn dng trong trng hp c tn thng

nng. Tra thuc 5 ln/ngy (khng nn dng qu 15 ngy do c th gy c biu

m gic mc).

TFT (Trifluoro Thymidin): dng nc hoc m. Thuc c th ngm su,

nhanh vo gic mc. Tra mt 5 ln mi ngy.

Thuc ung: Acyclovir vin 200 mg, 800mg. Thng dng vin

Acyclovir 200mg, ung ngy 5 vin chia 5 ln trong 7-10 ngy. Tr em di 2 tui

liu dng bng na liu ca ngi ln, tr em trn 2 tui dng bng liu ngi ln.

iu tr b sung

Chng bi nhim vi khun: dng khng sinh ph rng tra mt, mt trong

cc loi sau: tobramycin, ofloxacin: tra mt 5 ln mi ngy.

Thuc gin ng t, lit c th mi: tra atropin 1-4% khi c phn ng

mng b o.

Thuc chng vim steroid: dng trong cc trng hp sau

Vim gic mc hnh a.

Vim nhu m k khi c phn ng mng b o.

Dng corticoid dng tra mt. Tuy nhin, cn ht sc thn trng v bao gi

cng phi dng km vi thuc chng virus. Khi bnh thoi trin phi dng liu

gim dn.

in di dionin: gip lm gim thm lu v hn ch hnh thnh so gic mc.

Tng cng dinh dng ti ch v ton thn.

Ghp mng i: vi nhng trng hp bnh ko di, lot kh hn gn,

c th phu thut gt gic mc ghp mng i s cho kt qu tt.

iu tr chng ti pht

C th dng liu acyclovir 200 mg ngy ung 4 vin chia 2 ln trong 1 n

2 nm phng ti pht. Ngoi ra bnh nhn cn c cuc sng lnh mnh tng

cng sc khng.

59


Nu khng c pht hin sm v iu tr kp thi bnh c th gy ra mt

s bin chng

Lot gic mc do thng (phng mng Descemet) hoc thng.

Tng nhn p do phn ng mng b o.

Trng hp nng c th bin chng vim m ni nhn.

6. PHNG BNH

Trnh b s nhim herpes (HSV v varicella zoster): bng cch trnh xa

cc ngun ly l dch tit t nhng tn thng ca ngi bnh b herpes. Nu

ngi m mang thai b herpes ng sinh dc th phi iu tr khi trc khi sinh

hoc phi m trnh ly nhim cho con.

Khi b nhim herpes: phi nng cao th trng bng vic tp luyn, c

ch lm vic, sinh hot lnh mnh trnh herpes ti pht.

TI LIU THAM KHO

1. Gupta N, Sachdev R, Sinha R, Titiyal JS, Tandon R.(2011) Herpes zoster

ophthalmicus: disease spectrum in young adults. Middle East Afr J Ophthalmol.

Apr;18(2):178-82.

2. Kaufman HE. (2011) Adenovirus advances: new diagnostic and therapeutic

options. Curr Opin Ophthalmol. Jul;22(4):290-3. Review.

3. Kennedy DP, Clement C, Arceneaux RL, Bhattacharjee PS, Huq TS, Hill JM.

(2011) Ocular herpes simplex virus type 1: is the cornea a reservoir for viral

latency or a fast pit stop?. Cornea. Mar;30(3):251-9.

4. Kolb AW, Schmidt TR, Dyer DW, Brandt CR. (2011) Sequence variation in

the herpes simplex virus U(S)1 ocular virulence determinant. Invest Ophthalmol

Vis Sci. Jun 28;52(7):4630-8.

5. Seitz B, Heiligenhaus A. (2011) Herpetic keratitis: Various expressions

require different therapeutic approaches. Ophthalmologe. Apr;108(4):385-95.

http://www.ncbi.nlm.nih.gov/pubmed/21731332http://www.ncbi.nlm.nih.gov/pubmed/21731332http://www.ncbi.nlm.nih.gov/pubmed/21537185http://www.ncbi.nlm.nih.gov/pubmed/21537185http://www.ncbi.nlm.nih.gov/pubmed/21304287http://www.ncbi.nlm.nih.gov/pubmed/21304287http://www.ncbi.nlm.nih.gov/pubmed/21519032http://www.ncbi.nlm.nih.gov/pubmed/21519032http://www.ncbi.nlm.nih.gov/pubmed/21448683http://www.ncbi.nlm.nih.gov/pubmed/21448683

60

VIM LOT GIC MC DO AMIP (ACANTHAMOEBA)

1. NH NGHA

Lot gic mc do acanthamoeba l hin tng mt t chc gic mc do hoi

t gy ra bi mt qu trnh vim trn gic mc do acanthamoeba.

2. NGUYN NHN

Acanthamoeba l sinh vt n bo (amoeba) c nhiu trong khng kh, t,

nc ngun t nhin, tn ti 2 dng: dng hot ng (gy vim lot gic mc) v

dng nang (dng ny rt bn vng vi mi tc ng ha, l do tn ti rt lu

trong mi trng). Bnh thng gp nhng ngi eo knh tip xc khng ng

cch, sau sang chn mt (bi, que chc, t ct bn vo mt).

3. CHN ON

a. Lm sng

Triu chng c nng

Nhn m, chi, chy nc mt.

au nhc rt nhiu (i khi khng tng xng vi tn thng trn gic mc).

Triu chng thc th

Giai on sm (1-4 tun u): tn thng khng in hnh vi nhng

vim quanh ra. i khi c vim gic mc chm nng hoc lot gic mc hnh

cnh cy (ging vim lot gic mc do herpes).

Giai on mun: gic mc c lot trn hoc hnh bu dc, xung quanh

c vng thm lu c (p xe vng). C th c m tin phng.

Khi bnh tin trin, p xe lan vo cc lp su ca gic mc v ra cng

mc. c th lan vo ni nhn.

b. Cn lm sng

Soi ti


Phng php nhum: Giemsa hoc Gram.

Thy hnh nh nang ca acanthamoeba hnh sao hoc a din vi 2 lp

v, din tch gn bng t bo biu m, bt mu tm.

Nui cy: trn mi trng thch ngho c th quan st c th hot

ng ca acanthamoeba.

61

c. Chn on xc nh

Bnh nhn au nhc nhiu (triu chng au i khi khng tng xng

vi tn thng trn gic mc).

lot gic mc hnh trn hoc bu dc, xung quanh c th c p xe vng.

Xt nghim vi sinh cht no lot pht hin thy acanthamoeba.

d. Chn on phn bit

Lot gic mc do vi khun: lot gic mc ranh gii khng r, y

thng ph mt lp hoi t bn. Xt nghim vi sinh cht no lot s tm thy vi

khun.

Lot gic mc do nm: lot ranh gii r, b gn thng c hnh trn

hoc hnh bu dc. y lot thng ph mt lp hoi t dy, ng thnh vy g

cao, b mt vy kh rp v kh bc. T lot c th c nhng nhnh thm lu

chy vo nhu m (thm lu hnh lng v), c th c nhng p xe nh xung quanh

lot ( p xe v tinh). Xt nghim vi sinh cht no lot s tm thy nm.

Lot gic mc do herpes: lot gic mc in hnh c hnh cnh cy

hoc a , xung quanh thm lu t, cm gic gic mc gim. Xt nghim t bo

hc cht no b lot s thy mt trong cc hnh nh: t bo nhiu nhn, hin

tng ng c nhim sc cht quanh ra nhn, t bo thoi ha nhn trng hoc

tm thy tiu th Lipschutz. Xt nghim PCR cht no b lot hoc thy dch s

tm c gen ca virus herpes.

4. IU TR

a. Nguyn tc chung

iu tr nguyn nhn: bng thuc c hiu.

Thuc chng vim (khng dng corticosteroid) tra ti mt v ng ung.

Thuc gin ng t, lit c th mi tra ti mt.

Thuc dinh dng: tra ti mt v ung.

iu tr ngoi khoa: gt gic mc, ghp gic mc.

b. iu tr c th

iu tr nguyn nhn: thng dng phi hp cc loi thuc

Thuc c hiu: propamidin isethionat 0,1% tra 2 gi/ln.

Phi hp 3 khng sinh tra mt: neomyxin, polymyxin B v gramicidin

tra 8-10 ln/ngy.

62

Khng sinh chng nm nhm imidazol: tra ti mt hoc ung

ketoconazol 200mg x 2 vin/ngy hoc itraconazol 100 mg x 2 vin/ ngy (thng

ung 1 ln sau n).

Chm lugol 5%: trong trng hp lot rng, nng.

+ Thuc chng vim non-steroid: tra mt indomethacin.

+ Ung thuc chng vim gim ph n.

+ Tra mt Atropin 1%, 2%.

+ Tng cng dinh dng ti ch v ton thn.


a. Tin trin

Lot gic mc do acanthamoeba thng tin trin chm, nu c pht hin

sm v iu tr kp thi bnh c th khi. Tuy nhin, bnh thng li so trn

gic mc gy gim th lc.

b. Bin chng

Lot gic mc da thng (phng mng Descemet).

Tng nhn p.

Trng hp nng c th gy thng gic mc, vim m ni nhn.

6. PHNG BNH

Lun gi gn mt sch s, i ng bi hoc lao ng phi eo knh bo

v mt.

Khi b chn thng mt, c bit l cc chn thng vo gic mc, cn

phi n khm v iu tr ti cc c s nhn khoa. Khng c t mua thuc v

iu tr.

Khi eo knh tip xc cn phi tun th nghim ngt cc nguyn tc eo

cng nh v sinh knh hng ngy.

TI LIU THAM KHO

1. Chew HF, Yildiz EH, Hammersmith KM et al (2011). Clinical outcomes and

prognostic factors associated with acanthamoeba keratitis. Cornea.

Apr;30(4):435-41.

2. Meltendorf C, Duncker G. (2011) Acanthamoeba keratitis. Klin Monbl

Augenheilkd. Mar;228(3): 29-43.

3. Nielsen E, Hjortdal J. (2011) Early stage of Acanthamoeba keratitis. Ugeskr

Laeger. Nov 14;173(46):2959-60.

63

4. Nielsen E, Heegaard S, Hjortdal J. (2011) New diagnostic update in

Acanthamoeba keratitis. Ugeskr Laeger. May 30;173(22):1567-70.

5. Oldenburg CE, Acharya NR, Tu EY et al. (2011) Practice patterns and

opinions in the treatment of acanthamoeba keratitis. Cornea. 2011

Dec;30(12):1363-8.

64

VIM MNG B O CP TNH TR EM

1. I CNG

L tnh trng vim cp ca mng b o (MB), c th xy ra MB

trc, MB trung gian, MB sau hoc ton b MB.

Vim MB cp tnh tr em c th kt hp vi vim nhim ton thn nh

vim khp t pht tr em hoc bnh sarcoidosis tr em.

Vim MB tr em thng tin lng xu hn ngi ln do vic pht

hin, iu tr mun v hay ti pht.

2. NGUYN NHN

Tc nhn gy vim MB c th l nhim trng (vi khun, vi rt, nm, k

sinh trng), nhim c hoc min dch (do cht nhn th thy tinh).

3. CHN ON

a. Lm sng

Triu chng c nng

mt

au nhc mt

Nhn m, i khi c hin tng rui bay

Triu chng thc th

Cng t kt mc, cng t ra

Ta mt sau gic mc, c th ph gic mc

Phn ng tin phng (Tyndal thy dch hoc m tin phng)

Phn x ng t chm (giai on sm); mun hn c xut tit din

ng t, dnh b ng t .

c dch knh

Soi y mt c th thy xut tit trn vng mc, ph gai th vng mc.

Triu chng ton thn

St, au khp

C cc vim nhim ton thn khc

b. Cn lm sng

65

Chc ht dch tin phng ( soi ti, soi trc tip v nui cy vi khun)

gip chn on chnh xc tc nhn gy vim MB t la chn khng sinh thch

hp iu tr.

Phn tch mu, phn ng Mantoux

Xt nghim nc tiu,

Khm ton thn, Tai-Mi-Hng, Rng- Hm- Mt pht hin cc

vim nhim c th l nguyn nhn dn n vim MB.

c. Chn on xc nh

Da vo cc du hi

hƯỚng dẪn chẨn ĐoÁn vÀ ĐiỀu trỊ cÁc bỆnh vỀ mẮt

Health & Medicine