Đánh giá tổn thương hắc võng mạc vùng hoàng điểm qua chụp mạch với xanh indocyanin

1 B GIO DC V O TO B Y T TRNG I HC Y H NI Lấ H ĐáNH GIá TổN THƯƠNG HắC VõNG MạC VùNG HOàNG ĐIểM QUA CHụP MạCH VớI XANH INDOCYANIN Chuyờn ngnh: Nhón khoa Mó s: 60720157 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS CUNG HNG SN H NI - 2014 LI CM N Trong quỏ trỡnh hc tp, lm lun ti Trng i hc Y H ni, Bnh vin Mt Trung ng tụi ó c s dy d giỳp , to mi iu kin ca Nh trng, Bnh vin, ca cỏc thy cụ, cỏc khoa phũng Trc ht tụi xin c by t s bit n sõu sc i vi Ban Giỏm Hiu, Khoa Sau i hc, B mụn Nhón khoa, cỏc phũng ban ca Trng i hc Y H ni Xin Cm n Ban Giỏm c, Khoa ỏy Mt Mngb o, khoa Chn oỏn Hỡnh nh, cỏc khoa phũng ó ging dy, ch bo v to mi iu kin thun li cho tụi hc nghiờn cu cng nh hon thnh ti ny Xin chõn thnh cm n s giỳp ca PGS TS Cung Hng Sn Phú Giỏm c Bnh vin Mt Trung ng Xin chõn thnh cm n TS nguyn Th Nht Chõu, Trng khoa, ThS ng trn t, Phú khoa ỏy mt Mng B o, ThS Nguyn Th Ngc Hiờn, Cỏc bỏc s, iu dng, K thut viờn khoa ỏy mt Mng B o ó dy d, ch bo , to iu kin cho tụi quỏ trỡnh hc nghiờn cu cng nh hon thnh ti ny Xin chõn thnh cm n Bỏc s Nguyn c Doanh, cỏc bỏc s, iu dng, k thut viờn khoa Chn oỏn hỡnh nh Bnh vin Mt Trung ng ó giỳp to mi iu kin thun l cho tụi quỏ trỡnh hoc cng nh hon thnh ny. ti Xin chõn cm n bn bố ng nghip, b m cỏc ngi thõn ca tụi ó chia s thụng tin, to iu kin thun li cho vic hc v hon thnh ti ny H Ni, thỏng 10 nm 2014 Hc viờn Lờ H LI CAM OAN Tụi xin cam oan õy l cụng trỡnh nghiờn cu ca riờng tụi, ó c cỏc thy cụ hng dn khoa hc nghiờm tỳc v tn tỡnh Cỏc kt qu v s liu vit bn lun ny l trung thc v cha tng c cụng b bt k cụng trỡnh no khỏc H Ni, thỏng 10 nm 2014 Hc viờn Lờ H DANH MC CH VIT TT AMD Bnh thoỏi húa hong im tui gi (Age-related Macular Degeneration) ICG Indocyanin Green (cht mu xanh Indocyanin) ICGA Mch ký hunh quang vi xanh Indocyanin (Indocyanine Green Angiography) OCT Chp ct lp vừng mc (Optical Coherence Tomography) MC LC T VN Chng 1: TNG QUAN 12 1.1 C IM GII PHU SINH Lí CA VNG HONG IM 12 1.2 MT S BNH Lí HONG IM 14 1.2.1 Thoỏi húa hong im tui gi 14 1.2.2 Bnh mch mỏu hc mc dng polyp 17 1.3 MCH Kí HUNH QUANG VI INDOCYANIN (ICGA) 18 1.3.1 Lch s i 18 1.3.2 Nguyờn lý 19 1.3.3 Ch nh chp mch hunh quang vi ICG 19 1.3.4 K thut chp 20 1.3.5 c tớnh ca ICG 20 1.3.6 c phim chp mch hunh quang vi ICG 21 1.4 MT S TN THNG VNG HONG IM KHI CHP ICGA 25 1.4.1 Tn thng hay gp thoỏi húa hong im tui gi th t.25 1.4.2 Bong biu mụ sc t 33 1.4.3 Bnh mch mỏu hc mc dng polyp 34 1.5 LIấN QUAN GIA TN MCH HC MC V CC YU T 36 1.5.1 Liờn quan gia thi gian xut hin bnh v tn thng trờn ICGA 36 1.5.2 Liờn quan gia du hiu lõm sng v tn thng trờn ICGA 36 1.5.3 Liờn quan gia ICGA v OCT v mch ký hunh quang vi fluorescein 37 Chng 2: I TNG V PHNG PHP NGHIấN CU 40 2.1 I TNG NGHIấN CU 40 2.1.1 Tiờu chun la chn 40 2.1.2 Tiờu chun loi tr 40 2.2 PHNG PHP NGHIấN CU 40 2.2.1 Thit k nghiờn cu 40 2.2.2 C mu nghiờn cu 40 2.2.3 Chn mu 41 2.2.4 Phng tin nghiờn cu 41 2.2.5 Quy trỡnh nghiờn cu 41 2.3 CC TIấU CH NH GI V CCH NH GI 45 2.3.1 ỏnh giỏ tn thng hong im qua chp ICGA: 45 2.3.2 ỏnh giỏ liờn quan 46 2.4 X Lí S LIU 46 2.5 O C NGHIấN CU 46 Chng 3: KT QU NGHIấN CU 48 3.1 C IM CA NHểM NGHIấN CU 48 3.1.1 c im bnh nhõn theo tui v gii 48 3.1.2 c im bnh nhõn theo ngh nghip 48 3.1.3 c im bnh nhõn theo thi gian n vin 49 3.1.4 c im bnh nhõn theo triu chng a bnh nhõn n vin 49 3.1.5 Th lc 50 3.1.6 c im bnh nhõn theo dy hong im trờn OCT 50 3.2 TN THNG HONG IM QUA ICGA 51 3.2.1 Loi tn thng 51 3.2.2 V trớ tn thng 52 3.2.3 Kớch thc tõn mch 52 3.2.4 Loi tõn mch 53 3.2.5 c im ca bnh mch mỏu nhc mc dng polyp 53 3.2.6 c im ca cỏc tn thng phi hp 54 3.2.7 c im ca cỏc tn thng xut huyt 54 3.3 LIấN QUAN GIA LM SNG V ICGA TRONG CHN ON TN THNG VNG HONG IM 55 3.3.1 Liờn quan vi thi gian n vin 55 3.3.2 Liờn quan gia chn oỏn lõm sng v ICGA 56 3.3.3 Liờn quan gia tn thng v chn oỏn mch ký hunh quang, OCT, ICGA 58 Chng 4: BN LUN 60 4.1 C IM CA NHểM NGHIấN CU 60 4.2 C IM TN THNG HONG IM TRấN ICGA 63 4.2.1 Tõn mch hc mc 63 4.2.2 Bnh mch mỏu hc mc dng polyp 66 4.2.3 Cỏc tn thng khỏc 69 4.3 MT S YU T LIấN QUAN GIA TN THNG TN MCH HC MC LM SNG V MCH Kí HUNH QUANG, OCT, ICGA 75 KT LUN 80 TI LIU THAM KHO PH LC DANH MC BNG Bng 3.1 Phõn phi bnh nhõn theo tui v gii 48 Bng 3.2 Phõn phi bnh nhõn theo ngh nghip 48 Bng 3.3 Phõn phi bnh nhõn theo thi gian n vin 49 Bng 3.4 Phõn phi bnh nhõn theo triu chng a bnh nhõn n khỏm 49 Bng 3.5 Th lc bnh nhõn n khỏm 50 Bng 3.6 Phõn phi bnh nhõn theo chiu dy ca vừng mc trờn OCT 50 Bng 3.7 Phõn phi bnh nhõn theo loi tn thng 51 Bng 3.8 Phõn phi bnh nhõn theo v trớ tõn mch n so vi hong im 52 Bng 3.9 Kớch thc tõn mch hc mc 52 Bng 3.10 Phõn phi bnh nhõn theo loi tõn mch 53 Bng 3.11 Phõn phi bnh nhõn theo c im ca bnh mch mỏu hc mc dng polyp 53 Bng 3.12 Cỏc tn thng kốm theo ca hong im 54 Bng 3.13 c im ca tn thng xut huyt vừng mc 54 Bng 3.14 Liờn quan gia thi gian n vin v tn thng 55 Bng 3.15 Liờn quan gia chn oỏn lõm sng v chn oỏn ICGA 56 Bng 3.16 Liờn quan gia tn thng v kt qu chn oỏn trờn 58 Bng 4.1 c trng c bn khỏc bit gia hai loi tn thng hong im 69 Bng 4.2 Kt qu bng gia mch ký hunh quang v ICGA 78 DANH MC HèNH NH Hỡnh 1.1 Thoỏi húa hong im tui gi giai on sm 15 Hỡnh 1.2 Thoỏi húa hong im tui gi 16 Hỡnh 1.3 Bnh mch mỏu hc mc dng polyp gõy nờn dũ dch, bong dch vừng mc 18 Hỡnh 1.4 Hin tng t hunh quang v che lp bi cht noón hong 22 Hỡnh 1.5 Hin tng khụng truyn tc mch 22 Hỡnh 1.6 T hunh quang 23 Hỡnh 1.7 Hiu ng ca s 24 Hỡnh 1.8 Xut huyt hong im chp mch ký hunh quang thụng thng 24 Hỡnh 1.9 Xut huyt hong im, tõn mch n xut hin chp ICGA 24 Hỡnh 1.10 Tõn mch n trờn ICGA v OCT 28 Hỡnh 1.11 Tõn mch n dng Spots 30 Hỡnh 1.12 Tõn mch n dng plaques 30 Hỡnh 1.13 Tõn mch n dng Spots trờn ICGA v OCT 30 Hỡnh 1.14 Mng tõn mch xut hin thỡ trung gian ca ICGA 31 Hỡnh 1.15 Rỏch biu mụ sc t 32 Hỡnh 1.16 Drusen hong im AMD 33 Hỡnh 1.17 Tn thng bnh mch mỏu hc mc dng Polyp mch hc mc 35 Hỡnh 1.18 Bnh mch mỏu hc mc dng polyp 35 Hỡnh 1.19 Bnh mch mỏu hc mc dng polyp 35 Hỡnh 1.20 Tõn mch ó phỏ hy mng Bruch nhiờn cha cú biu hin lõm sng 36 Hỡnh 1.21 Tõn mch n 37 Hỡnh 1.22 Chp mch hunh quang khụng thy tõn mch hc mc, chp ICGA thy tõn mch n xut hin 39 10 T VN Hong im l vựng cú cu trỳc gii phu c bit, chc nng quan trng ca mt, õy l vựng cú nhiu bnh lý nng v cú nguy c gõy mự lũa cao [1] Cỏc tn thng hc vừng mc vựng hong im thng hay gp trờn nhng bnh nhõn cú mt s bnh lý nh: viờm biu mụ sc t vừng mc, viờm hc mc hong im, viờm mao mch hc mc, bnh lý thoỏi húa ca vựng hong im nh: thoỏi húa hong im tui gi, bnh lý ca mch mỏu hc mc, bnh lý mch hc mc dng polyp Nhng triu chng chung c trng cú tn thng hong im l hi chng hong im (nhỡn m, ỏm im trung tõm, nhỡn mộo hỡnh, i mu) vi cỏc mc khỏc nhau[3] Trờn th gii, cỏc bnh cnh gõy mự liờn quan n nhng bnh lý v ỏy mt nh cỏc bnh v thoỏi húa hong im tui gi chim t l trờn 30% ngi t 80 tui tr lờn b bnh, ngi ta thy cú nhng im chung nh: tn thng hong im mun phi hp nhiu tỏc nhõn, xut hin trờn c a di truyn, biu hin lõm sng ph thuc vo nhiu yu t khỏc nhiờn cũn ph thuc nhiu vo iu kin mụi trng, kt hp nhng biu hin bt thng khỏc ca biu mụ sc t, biu mụ thn kinh hay nhng drusen v tõn mch di vừng mc[2][4][5][6] Gn õy cựng vi s tin b ca cỏc phng tin chn oỏn hỡnh nh, c bit l chp ct lp vừng mc (OCT), chp mch ký hunh quang vi fluorescein v chp mch hunh quang vi xanh indocyanin (indocyanine green angiography) (ICGA), nhng bnh lý liờn quan n tn thng ca hc mc c chn oỏn cỏch d dng v chớnh xỏc hn c bit chp mch vi indocyanin cho phộp xỏc nh cỏch chn lc hn nhng ri lon nhng tn thng thng b che khut bi lp biu mụ sc t vừng mc v cỏc thoỏi húa cng nh xut huyt, bao gm nhng trng hp cú tõn mch 78 Bng 4.2 Kt qu bng gia mch ký hunh quang v ICGA Mch ký hunh quang thụng thng Tõn mch loi c in trờn mch ký hunh quang ICGA Gim mch ký hunh quang trờn ICGA Mc hunh quang khụng cú gỡ c bit Bong biu mụ Dũ chm khụng Bongbiu mụ sc sc t x húa xỏc nh rừ t trm trng x phỏt hin bi gianh gii bi húa cú tõn mch mch ký hunh mch ký hunh trờn hay b quang quang tn thng 0 27 (84%) (13%) (7%) (50%) (16%) (17%) 12 (17%) (30%) 16 (70%) 54 (76%) (20%) Tng hunh quang nh vi gii hn khụng rừ Tng hunh quang mnh vi gii hn rừ Cỏc nghiờn cu ch vai trũ ca ICGA chn oỏn tõn mch n, bong dch biu mụ sc t kốm tõn mch, hay kốm theo mỏu di vừng mc Guyer v CS [TDT6] thy rng trờn 413 mt cú tõn mch n trờn mch ký hunh quang tt c u cú tng hunh quang, v kớch thc cú 89 mt cú ng kớnh nh hn ng kớnh gai th, s cũn li 324 mt ng kớnh tõn mch ln hn ng kớnh gai th Cng nhúm ú cú thờm 14% s mt cú bong dch ca biu mụ sc trờn mch ký hunh quang nhng ch trờn ICGA mi phỏt hin tõn mch n Nghiờn cu khỏc tỏc gi thy ch cú 1% s 1000 mt vi tõn mch n ch phỏt hin c mch ký hunh quang Yuzawa v cs bỏo cỏo ch cú 4/18 bong dch biu mụ sc t co tõn mch c phỏt hin bi mch ký hunh quang v 17 ca phỏt hin c tõn mch nh ICGA Baumal v cs [TDT44] bỏo cỏo s 23 mt ch cú mt cú bong biu mụ sc t phỏt hin c bng mch ký hunh quang 19 mt cú tõn mach phỏt hin c bng ICGA Avvad v cs [TDT 6] nghiờn 79 cu 23 bnh nhõn cú tõn mch cú gii hn rừ tt c cú tng hunh quang vi cỏc mc khỏc Lim v cs [TDT6] nghiờn cu 77 bnh nhõn c chp c mch ký hunh quang v ICGA thy rng bong biu mụ sc t v tõn mch n l tn thng AMD, tỏc gi thy rng ICGA cú tng hunh quang 50% tõn mch n v 82% vi mt cú bong biu mụ sc t Nghiờn cu ca Gisele Soubran 2007 [6] so sỏnh gia mch ký hunh quang v ICGA thy rng 87% s mt cú tõn mch dng c in (20/23) v 93% s mt cú bong biu mụ sc t cú tõn mch x húa (66/71) cú s tng hunh quang cỏc nc vựng tn thng Cú 50% s mt cú s tng hunh quang cú im dũ khụng xỏc nh c ngun gc nh vy cú s phự hp tt gia mch ký hunh quang vi ICGA ch rng ch cú tõn mch mi gõy dũ hunh quang, ngc li ch cú t l rt thp (4/104) cú s tng hunh quang trờn ICGA m khụng cú tõn mch trờn mch ký hunh quang Khi cú xut huyt nu cú tng hunh quang b gi ý 97% trng hp bong biu mụ sc t l cú tõn mch v cỏc tỏc gi cng ch rng cú khong 83-96% nhng trng hp ny l cú tõn mch n Vi mỏu ch cú 48% mch ký hunh quang gi ý cú tõn mch cũn trờn ICGA cú ti 23/25 (92%) ch cú tõn mch Tỏc gi Florian Sulzbacher v CS 2011 [54] nghiờn cu tõn mch vi ba k thut chp (OCT, ICGA v mch ký hunh quang) tỏc gi thy rng lm ICGA kớch thc tõn mch l 1382 654 àm, kớch thc theo OCT ln hn ỏng k 1962 1192 àm (vi p = 0,017) Nh vy t OCT sang ICGA t l chờnh kớch thc tõn mch l 0,73 0,27 Cng nh vy lm mch ký hunh quang kớch thc trung bỡnh ca tõn mch hn hp l 1629 888 àm cũn vi OCT kớch thc l 1961 975 àm (P=0,029) v nh vy gia mch ký hunh quang v OCT cú s khỏc bit l 0,88 0,37 iu ny cú ngha l ỏnh giỏ kớch thc tõn mch tt nht phi qua OCT Vic s dng ba phng tin : mch ký hunh quang, ICGA, OCT ỏnh giỏ tõn mch hc mc l cn thit v b xung cho nhiờn kớch thc tõn mch c ỏnh giỏ l chớnh xỏc nht dựng OCT 80 KT LUN Nghiờn cu mt s tn thng vựng hong im trờn nhúm 32 bnh nhõn 32 mt Qua chp mch hunh quang vi ICG chỳng tụi rỳt kt lun sau: Cỏc tn thng phỏt hin c trờn chp ICGA: - Tõn mch hc mc: Tõn mch hc mc loi l 3,12%, tõn mch n 46,87% Tn thng nm sỏt hong im chim 60%, nm sau hong im 6,67%, bao quang hong im 33,33%, nm ngoi hong im gp 4/15 mt cú tõn mch n v 19 ln cú tõn mch (26,67%) Kớch thc tõn mch ng kớnh gai th 52,63%, ln hn ng kớnh ớa th gp 47,36% Tõn mch dng mng 57,89%, loi hn hp gp 36,84% Nh vy gp dng mng 18/19 trng hp 94,73% , tõn mch dng im 42,1% - Bnh mch mỏu hc mc dng polyp: Trong 40,62% bnh mch mỏu hc mc dng Polyp cú (69,23%) nm gn gai th, 23,07% nm gn hong im hn, nm gia hong im v gai th a s kớch thc t di ng kớnh gai (61,53%) ,cú 38,46% cú kớch thc ln hn ng kớnh gai th - Cỏc tn thng khỏc bao gm: thng gp nht l xut huyt hong im v cnh hong im 93,75% Bong biu mụ sc t v bin i biu mụ sc t, xut tit v phự hong im Xut huyt hong im hn hp nhiu loi 63,33%, xõm ln h trung tõm 70% cú 30% cha xõm ln h trung tõm Liờn quan gia tn thng tõn mch v mt s yu t: - Liờn quan gia triu chng v thi gian n khỏm: Trong thỏng u tt c cỏc bnh nhõn u cú tn thng bong biu mụ sc t, bong dch vừng mc v xut huyt vừng mc Thi gian 1-3 thỏng cú th thy tt c cỏc loi tn thng tõn mch hc mc 31,25%, bnh mch mỏu hc mc dng polyp 81 23,07%, bong biu mụ sc t ln 31,25%, bong dch vừng mc 50% v xut huyt hong im vừng mc 53,33% Sau thỏng: tõn mch 68,75%, bnh mch mỏu hc mc dng polyp 76,92%, bong biu mụ sc t 20% bong dch vừng mc 25% v xut huyt hong im vừng mc 23,33% - Liờn quan gia chn oỏn lõm sng v v chn oỏn tn thng qua ICGA: Trờn lõm sng chn oỏn l xut huyt hong im (10 ln), vi ICGA cú 8/10 cú bong dch vừng mc, 100% cú xut huyt v bin i biu mụ sc t, bong biu mụ sc t 5/10 Vi trng hp chn oỏn thoỏi húa hong im tui gi cú tõn mch nhúm 2, cú tõn mch n, 7/8 bnh mch mỏu hc mc dng polyp cỏc tn thng xut huyt v bin i biu mụ sc t u cú th phỏt hin c chp ICGA - Phi hp ICGA, OCT, mch ký hunh quang: vi tõn mch n lm mch ký hunh quang ch cú th nghi ng cú tõn mch 13,33% vi OCT nghi ng cú tõn mch n rt cao (73,75%) lm ICGA vi cỏc thỡ khỏc ngi ta cú th xỏc nh c tõn mch n tt c cỏc trng hp TI LIU THAM KHO nh Hn (2013) chuyờn dch kớnh vừng mc, NXB Y hc H ni Nh Hn v CS (2013) Nhón khoa 1,3 NXB Y hc H ni Anita Agarwal (2012) Grass Atlas of Macular diseases, fifth edition Elsevier , Gabriel Coscas, Florence Coscas, Alain Zourdani (2005), Atlas of indocyanine green angiography (fluorescein 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diagnostic evaluation of type (Classic) choroidal neovascularization: optical coherence tomography, indocyanine green angiography, and fluorescein angiography, Am J Ophthalmol 2011, 152,799-806 BNH N NGHIấN CU I HNH CHNH H v tờn bnh nhõn: Tui: Gii: Ngh nghip: a ch liờn lc: 4.Ngy khỏm : Lý n khỏm: II TIN S Hỳt thuc lỏ Tng huyt ỏp Ri lon m mỏu ỏi thỏo ng Cú b m, anh, ch, em rut cng mc bnh ny Khụng cú TS gỡ c bit III KHM BNH 1.Ton thõn: Khỏm mt: 2.1.Triu chng c nng: - Th lc (mt bnh): MP: Th lc khụng kớnh : MT: Th lc khụng kớnh: Th lc sau chnh kớnh : Th lc sau chnh kớnh : - Triu chng : Nhỡn m ỏm im Nhỡn vt nh i ( vin th tng) Khỏc Mộo hỡnh Ri lon mu 2.2.Triu chng thc th: Drusen cng Drusen mm Bong BMST Bong TDVMTT Tõn mch 10 Xut tit Phự H 11.Khỏc Bin i BMST Xut huyt So x vừng mc - Hỡnh thỏi xut huyt Di VM Trong VM Hn hp - V trớ XH Xõm ln h trung tõm Cha xõm ln h trung tõm - Kớch thc XH: ng kớnh gai th - Kớch thc tn thng: ng kớnh gai th - Tỡnh trng th thy tinh t IOL/ ó m ly TTT Cũn TTT - Du hiờu tn thng trờn ICG - V trớ tõn mch trờn ICG Ngoi H Quanh H Sỏt H Sau H - Hỡnh thỏi tõn mch n trờn ICG: Hot-spot Mng Loi hn hp - Du hiu trờn OCT: Bong BMST Bong TDVM Drusen Xut huyt Tõn mch n Tõn mch nhỡn thy Tn thng phi hp - Kớch thc hong im trờn OCT Chiu dy TT H : Chiu dy trung bỡnh H : - Du hiu chp mch hunh quang: Xut huyt Tõn mch nhỡn thy Nghi ng cú tõn mch Nghi ng cú polyp ... hong im tui gi (Age-related Macular Degeneration) ICG Indocyanin Green (cht mu xanh Indocyanin) ICGA Mch ký hunh quang vi xanh Indocyanin (Indocyanine Green Angiography) OCT Chp ct lp vừng mc... mc vựng hong im qua chp mch vi xanh indocyanin vi hai mc tiờu: Mụ t mt s hỡnh nh tn thng hc vừng mc vựng hong im trờn chp mch hunh quang vi xanh indocyanin Tỡm hiu mt s yu t liờn quan gia tõn mch... ct lp vừng mc (OCT), chp mch ký hunh quang vi fluorescein v chp mch hunh quang vi xanh indocyanin (indocyanine green angiography) (ICGA), nhng bnh lý liờn quan n tn thng ca hc mc c chn oỏn cỏch