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NHUNG TON THI/ONG PHAN SAU NHAN CAU BONG VONG MAC Bong v5ng mac co bieu hien dac trufng tren sieu am ve vi tri cung nhiZ mute bong, kem theo co hoac khong co xuat huyet dich kmh, mang tang sinh Bong vong mac di/dc phat hien ro tren sieu am B Bong thap, det hoac bong cao va rong toan the ti/ dia gai thi cho den tan vung ora serrata Tren sieu am bong hac mac co the phan biet di/dc vdi bong vong mac dUa tren hinh dang mat cau cua no va h&c mac co the bong qua ca vung ora serrata den tan the mi Tren sieu am A bong vong mac co the phat hien di/dc mot hoac hai xung co bien cao cua be mat vong mac va ke la mot khoang am bieu hien dich dv/di vong mac 127 Hinh minh hoa cac tinh trang vong mac (Day hinh ben trai) Cac bieu sieu am B I6p hcic vong mac bj dciy len di/oc hien thj v6i nhan cam he thong toi da (A) va nhay cam he thong di/pc tem giam (B); Bong vong mac toan the dang pheu (C) va Bong vong mac 128 xep nep ngoai bien (D) ( Day hinh ben phai) Cac bieu sieu am A ldp hac vong mac bj day len (E) va hac mac bj day len (F); Bong vong mac chu bien va rieng le (G) va bong vong mac toan the hinh phlu (H) ( R: Vong mac; C: Hac mac; S: Cung mac) Do day cua ldp hac vong mac ma co the diidc xac dinh ro tren bieu sieu am B, diidc dat mot cach chinh xac tren sieu am A lam giam nhay he thong Vdi sieu am A chuan hoa, be mat cua vong mac co the dtfdc phan biet vdi be day cua hac mac Bong vong mac dtfdc bieu hien tren ca sieu am A va sieu am B Bong vong mac dang pheu toan bo va nhiing bong vong mac co keo rat nho deu diidc phat hien ro tren sieu am B Tuy nhien, nhieu triidng hdp chi vdi sieu am B thi kho phan biet diidc bong vong mac vdi mang dich kmh sau dam dac ma co sii lan rong, hinh dang va co keo rat giong vdi bong vong mac Trong nhiing triidng hdp nay, bieu sieu am A co thiidc diidc yeu cau de do phan chieu cua nhiing cau true mang mat dtfa tren phan chieu cung mac lam chuan Bong vong mac thiidng tao nhiing tin hieu manh dac hieu Vdi bieu sieu am chuan hoa, bong vong mac co the phan biet diidc vdi mang dich kmh dam dac vdi chinh xac tren 98% (bong vong mac khong ro nguyen nhan) hoac 96% (bong vong mac phiic tap chang han bong vong mac cac triidng hdp cat dich kinh) Khoang diidi vong mac co the danh gia diidc 129 mot cach dang tin cay bang sieu am A ma co the phan biet diidc dich, mau tiidi, can lin g, tinh the cholesterol va nhiing to chiic ciing Bong vong mac co va van due dich kinh Bong vong mac diidc phau thuat cat dich kinh that dai va bctm silicone theo thiet theo true triidc sau va sd khao sat dien gidi Dai silicone bao boc toan the ciic sau The tich nhan cau tang len va bi bien dang Manh an don thay ro tren bieu sieu am 131 Bong silicone ap sat toan ctfc sau nhan cau.an sat vao ph&n trtfdc nhan cau Hinh anh “mang” nam doc tren bieu sieu am la mat sau cua bong an don tai vi tri that dai cung mac Bong vong mac phia dtfdi ngoai tren cac thiet a gid b Dien dtfdi c gid d Dien mui e 12 gid f Dien tren g- gid h Dien thai dtfdng 132 133 Hinh anh sieu am B cho thay bong vong mac toan bo cho den vung ora serrata va dTa thi Mang djch kinh dam dcic giong nhi/ vong mac Trong sieu am dinh khu thi bong den day cua mong m it la dSc trimg cho bong dich kinh 134 Bone vdne mac dai diCdne Thiet thing ddng chinh giu'a va thiet khao sat phan tren Co nhiing mane triidc vong mac, ciing, keo va khong di dong a Thiet khao sat kinh tuyen di qua hoang diem va khao sat kinh tuyen thang goc vdi kinh tuyen tren thiet b Co cac mang djch kinh, hut am manh, khong di dong d cue sau 135 M a n g vong m ac thiidng gap d mdt can thi nang (phan biet vdi bong vong mac) Thiet ngang Thiet doc BONG HAC MAC Cac dau hieu am hoc cua bong hie mac la vi tri, hinh dang va day cua chung Ca cac hien thi tren sieu am A va sieu am B deu cho thay vi tri cua chung, bieu hien dang vom, sii co keo tang giam tren day mat la dfl kien tot nhat tren sieu am B Khong co sii co keo d dia thi ca bong h ie mac nhieu Do day gia tang cua chung (diidc so sanh vdi bong v5ng mac) va di dong sau cd dong nhan cau cua chung diidc bieu hien ro tren sieu am A 136 md rong, cac ky thuat vien vdi kien thiic va ky nang dtfdc nang cao da trd nen doi hoi trtfc tiep kham cho benh nhan Vai tro cua bac si dtfdc gidi han lai viec htfdng dan ky thuat vien cac trUdng hdp co phiic tap va kho khan cung nhtf kiem tra chan doan cuoi cung Sii thay doi vai tro gitia bac si va ky thuat vien co hai ly chinh: (1) cac dich vu sieu am cang ban ron, bac si khong du thdi gian de thifc hien kham dac biet doi hoi sieu am chuan hoa c ln than va hoan toan ky lifSng, va (2) sii chuan hoa cua thiet bi va ky thuat cho phep ky thuat vien thiic hien cac chan doan sieu am ca kien thiic cua ho ve nhan khoa han che Trtfdc tien, ky thuat vien hoc cach dac chieu dai true nhan cau Thu thap dti lieu anh cua cac bieu sieu am chuan hoa cho phep bac si xem xet lai cuoc kham cua ky thuat vien de dam bao rin g ky thuat thich hdp da diidc ap dung va cac ket luan la c h ic chan Stf xem xet lai chi can vai phut Ke den, ky thuat vien hoc cach thtic hien cuoc kham cd ban de phat hien ton thtfdng Day la phtfdng phap doi hoi stf quan sat can than ve stf thay doi cua cac hien thi tren man hinh Thong thtfdng sU chan doan phai dtfdc thtfc hien kham, chi mot phan nho thong tin dtfdc sti dung de phat hien, hoac loai trtf ton thtfdng dtfa tren hinh anh va can thiet de cho bac si xem lai Vi vay, ky thuat vien co nhiem vu thtfc hien kham cd ban Sau ket, b ln g cach hoc de dinh ltfdng am doi, de hieu diidc hien ttfdng dong va de cau true mot btic tranh khong gian ba chieu ttfdng tiidng cua ton thiidng dtfa tren chiing cii hoa, cac ky thuat vien co the giup dac, khu tru ton thtfdng va ca phan biet to chiic bang thtfdc chia hoan chinh pham vi hoat dong cua ky thuat vien Vi vay, cac ky thuat vien co the thiic hanh kham sieu am chuan hoa mot cach hoan hao d mot so trung tam 278 De dat dtfdc nhtfng ket qua chac chan, ky thuat vien sieu am phai thtfc hien kham ti mi va kien nhan Ky thuat vien cung phai that chu tam de nhan biet cac tinh trang ma cac dau hieu sieu am bi nghi van va can phai hoi chan vdi bac si Bac si phai htfdng dan can than ttfng ky thuat vien mot de danh gia kha nang chan doan dung cua ho Dao tao mot ky thuat vien la mot no ltfc lau dai nhtfng no la bo ich bdi vi no ltfc phoi hdp giiia bac si va ky thuat vien mang lai mot dich vu sieu am tot hdn, hieu qua hdn va kinh te hdn Ky thuat vien dtfdc huan luyen chu dao se tap trung hoan toan vao viec chan doan sieu am nen co the quet nhan cau va hoc mat mot cach ti mi de tim ton thtfdng va co the theo duoi cac phtfdng phap sieu am dac biet ma bac si nhan khoa khong co nhieu thdi gian de thtfc hien Cac ky thuat vien co mot thuan ldi ntfa so vdi bac si nhan khoa la ho khong bi anh htfdng bdi an ttfdng lam sang va vi vay it cd dinh kien trtfdc kham sieu am Stf chuan hoa cua cac ky thuat kham va thiet lap nhtfng tieu chuan am hoc dtfdc xac dinh tot nhat cho phep ky thuat vien ghi lai cac ton thtfdng va di den chan doan cuoi cung ma khong bi anh htfdng bdi cac dau hieu lam sang ma doi lam han che hdn la thuc day bac si nhan khoa dtfa chan doan dung Ngtfdc lai, bac si nhan khoa stf dung kien thtfc chuyen nganh va kinh nghiem lam sang de kiem tra lai cac dtf lieu sieu am va ky thuat vien va de hdp nhat cac dau hieu sieu am vdi cac dau chiing lam sang tren mot benh nhan Chi cd bac si nhan khoa co the thao luan ve nhtfng tinh huong chan doan mdi ma se luon doi chat vdi ngtfdi lam sieu am, ca sau nhieu nam thtfc hien sieu am 279 TAI LIEU THAM KHAO Clinical Ophthalmology (1986) publisher - Philadenphia USA Harper & Row Myron Yanoff (1999) Ophthalmology - first edition copyright Mosby International Ltd Olivier Berges et Marc Torrent (1986) Echographie de loeilet de orbit K .Ossoining - Sandra Byrne (1979) Ophthalmic Ultrasonography - Boston ltd Nguyen Dtic Thuan va Cong sii (2003) Cd sd ky thuat sieu am - Nha xuat ban khoa hoc va ky thuat Ha Noi Nguyen Thi Thu Lien (1998) Hiiclng dan thiic hanh sieu bung tong quat - Benh vien Chd Ray liiu hanh noi bo Barry B GoldBerg (1993) Textbook of Abdominal Ultrasound-William & Wilkins, USD P.E.S Palmer (1995) Manual of Diagnostic Ultragnostic Ultrasound - World Health Organization, Geneve 1995 Nguyen Phiicic Bao Quan (2002) Sieu am bung tong quat - Nha xuat ban y hoc, 2002 10 Dictionarry of ultrasound (1996) Edited by the publisher Lexicographical Department - Blackwell science 11 280 Roger C Sandors (1984) Clinical Sonography - Little and Brown company MUC LUC Ldi noi dau Ljch sur sieu am mat Sieu dm chuan hod Cac ting dung lam sang va ket qua 10 Gidi thieu ve may sieu am 18 Cau tao may sieu dm 18 1 19 Dau 1.1.1 Hinh dang 20 1.1.2 Tan so 21 1.1.3 Do ly giai va xuyen thau 21 1.2 Than may 22 1.2.1 22 2 Gain Cac bien phap xxi ly anh 23 1.2.3 Cac bo phan nhap dii lieu 24 1.2.4 Cac chiic nang tinh toan 24 1.2.5 Cac yeu to'xvf ly anh khac 24 1.2.7 Thang xam Phan hu ng dan dinh vi di vat nhan cau 26 26 1.3 Thiet bi xuat 26 Mot so van de lien quan 26 281 The 2 nao la may sieu am chuan cho kham mat? Van de dinh hiidng tren hinh sieu am 26 26 2.3.Cac sai lam thtfdng gap stf dung may sieu am 27 2.4.Cac dieu can biet bao quan may 27 Nhac lai cd sd vat ly, tao hinh sieu am 28 Phan loai song dm 28 1 28 Theo phtfdng dao dong 1.2 Theo tan so" 29 1.3 Do sinh hoc nhan cau 31 Stf phan hoi vd stf khuc xa dm 34 Stf tan xa 36 3.1 Stf khuech dai - gain 36 3.2 Khuech dai bu trii theo sau 37 Ky thuat cua phtfdng phap tao hinh bang sieu dm 37 282 4.1 Nguyen ly tao hinh 37 4.2 Chan doan sieu am nhan khoa 38 4.2.1 Sieu am theo phtfdng thtfc A 39 4.2.2.Sieu am theo phtfdng thiic B 40 4.2.3 Sieu am dong theo phtfdng thiic M 40 4.4 Cac hinh thiic the hien 41 Sieu dm Doppler 42 5.1 Ky thuat sieu am Doppler 42 5.1.1 Hieu iing Doppler 42 5.1.2 Cong thiic Doppler 43 5.1.3 Am Doppler 44 5.1.4 Ky thuat Doppler - mau 44 5.1.5 Ky thuat Power Doppler 45 Hinh anh tinh vd hinh anh dong 46 Hinh Anh gia 47 6.2 Hien tiidng nhieu 47 6.3 Hien tiidng “bong liing” va hien tiidng tang ciidng am 47 6.4 Hien tiidng doi lai 48 Mot so nhat cat cd ban nhan khoa 48 7.1 Qui lidc chieu hiidng tren man hinh 48 7.1.1 Tii the dau vdi “dau chi” hiidng ve phia mi tren 49 7.1.2 Tii the dau vdi “dau chi” hiidng ve phia thai diidng 49 7.1.3 Tii the dau vdi “dau chi” hiidng ve phia mi tren 49 7.1.4 Tii the dau vdi “dau chi” hiidng ve phia th in g len tran nha 49 Sieu am chuan hoa 51 Su chuan hod sieu am A 51 Su chuan hod sieu dm B 53 Sieu dm A so vdi sieu dm B 57 283 3.1 Sieu am A va sieu am B dtfa thong tin khac 58 3.2 Sieu am A va sieu am B doi hoi nhtfng thiet bi cau tao khac 59 3.3 Sieu am A cho nhieu thong tin hdn sieu am B 61 3.4 Cac bieu sieu am co the so sanh vdi tranh hoat hinh 62 3.4.1 Sieu am B co the dtfdc goi la nhtfng btfc tranh va sieu am A la nhtfng ldi van 62 3.4.2 Cac ket qua chan doan toi tfu dtfdc ghi nhan bdi stf ket hdp sieu am B va sieu am A chuan hoa 3.4.3 Sieu am Doppler 63 65 Ket luan 66 Cac phtfdng thtic kham sieu am dac biet va cd ban 68 Suphat hien cac ton thUdng noi nhan 68 Sieu dm dinh khu 70 Sieu dm dinh lUOng 71 3.1 Sieu am dinh ltfdng loai I 71 3.2 Sieu am dinh ltfdng loai II 73 Sieu dm dong 75 Phat hien cac ton thuang hoc mat 75 Chan doan phan biet cac ton thUOng hoc mdt 78 Sieu am dinh ltfdng 6.2 Sieu am dinh khu 284 78 80 6.3 Sieu am dong 81 N h lc lai giai phau hoc 83 Cung mac 84 Hac mac 87 Hoang diem 87 Thuy tinh the 87 Tien phong 88 Dich kinh 88 Day than kinh thi giac 88 Nhiing mach mau hoc mat 89 Nhiing tuyen le 89 Cach tham kham 90 Thiet true cat theo chuoi 92 thiet cat ngang dich kmh tham mat 93 Thiet c&t ngang qua dich kinh tham mot kinh tuyen 96 Thiet tham hoang diem 98 Thiet tham gai thi va thi than kinh 99 Nhiing thiet canh nhan cau 103 Nhtfng dau hieu sieu am nhan cau binh thi/dng 114 Nhumg ton thtfdng d phan trade nhan cau 116 Ton thiidng giac mac 116 Ton thiidng tien phong 117 285 Ton thiidng thuy tinh the 117 Cac tinh trang dich ki'nh 121 NhCirng ton thi/dng d phan sau nhan cau 127 Bong vong mac 127 Bong hac mac 136 Lom gai thi benh glaucom 141 Nhiing khoi u cua vong mac 142 4.1 U nguyen bao vong mac 142 4.1.1 Ve lam sang 142 4.1.2 Trieu chiing hoc sieu am cua u nguyen bao vong mac 4.1.3 Sii lan tran hac mac 147 4.1.4 Sii lan tran den thi than kinh 147 4.1.5 Sii lan tran hoc mat 148 4.1.6 Chan doan phan biet 151 4.2 Nhiing khoi u than kinh vong mac 154 4.3 Nhiing khoi u mach mau cua vong mac 155 Nhiing khoi u cua hac mac 156 5.1 U cua mong mat va cua the mi 158 5.2 U hac to"lanh tinh 160 5.3 U hac to" ac tinh 161 5.3.1 U hac to ac tmh co kich thiidc nho 5.3.2 U hac to" ac ti'nh co kich thiidc trung binh 286 143 168 169 5.4 Nhiing di can cua hac mac 177 5.5 U mach mau cua hac mac 178 5.6 Nhiing Melanocytome cua gai thi 179 5.7 U xiidng hac mac 179 5.8 Nhiing u hiem 180 Khoi hoc m it 180 Benh hoc cua day than kinh thi giac 183 1.1 Nhiing u than kinh dem cua day than kinh thi giac 186 1.2 Nhiing u mang nao cua bao day than kinh thi giac 188 1.3 Nhiing ton thiidng viem gia u 190 Nhiing khoi mach mau 192 2.1 Triidng tinh mach hoc mat 192 2.2 Do dong tinh mach 193 2.3 Nhiing tat di dang tinh mach 195 2.4 Nhiing u mach hang 197 2.5 U mach mau dang mao mach 204 2.6 U mach mau the phoi hdp dang mao mach va hang 206 2.7 Nhiing u bach mach 206 2.8 Nhiing hinh thai khac cua u mach mau 208 Nhiing khoi u phan triidc nhan cau xam lan vao phan tren hoc mat vung mat 217 287 288 3.1 Nhiing nang dang da 217 3.2 Nhiing khoi u cua vung t u y e n le 219 3.2.1 Nhiing nang cua tuven le 220 3.2.2 Nhiing khoi u hon hdp lanh tinh 220 3.2.3 Nhiing khoi u ac tinh 221 3.2.4 Nhiing gia u va nhiing u limpho 222 3.2.5 Nhiing khoi u cua mi mat 224 Benh hoc cd 224 4.1 Cac roi loan cua cd ngoai nhan 224 4.2 Benh ly mat Grave-Basedow 231 4.3 Viem cd cap tinh 233 4.4 Nhiing u cd van ac tinh 233 Nhiing khoi u ben hay/ vd ngoai hinh chop 234 5.1 Nhiing khoi u ac tinh 234 5.1.1 U xd mo bao 234 5.1.2 U hac to ac tinh nguyen phat cua hoc mat 235 5.2 Nhiing benh mau va nhiing ton thiidng viem gia u 237 5.3 Nhiing khoi u nang hoa 241 5.3.1 Nhiing boc nhay 241 5.3.2 Nhiing nang ddn thuan 241 5.3.3 Nhiing nang ket mac 243 5.3.4 Nhiing nang san 244 5.3.5 Nhiing thoat vi mang nao 244 5.4 Nhiing u Schwann va u vo bao than kinh 245 5.5 Nhiing u xam lan theo kieu “cdi ngiia” 245 Nhiing ton thiidng quanh hoc mat 247 6.1 U nhay hoc mat 250 6.2 Loan san xd b vung quanh hoc mat 250 Di vat nhan cau 250 7.1 Thii nghiem nam cham 255 7.2 Do sinh hoc nhan cau va ti'nh cong suat TTTNT 258 7.2.1 Do sinhhoc 258 7.2.2 Ti'nh cong suat TTTNT 260 Phan ket 262 Y nghia lam sang 262 Phau thuat vong mac dich kinh 262 Nhung cau hoi can phai dUdc trd ldi bang sieu dm cho cac phau thuat vien vong mac dich kinh 263 •Do chieu dai true nhan cau 265 D i vat noi nhan 265 U noi nhan 266 •Nhiing ton thUdng quanh hoc matva nhan cau 267 Chup cat ldp dien toan 267 •Sieu dm chuan hod 268 Ba yeu cau cd ban 271 289 - Stf thao cua ngtfdi kham 271 - Thiet ke dac biet cua dung cu 272 - Stf chu&n hoa cua thiet bi va ky thuat kham 277 Viec thuc hien sieu dm chuan hod cua ky thuat vien211 Tai lieu tham khao 280 Muc luc 281 290 NHA XUAT BAN Y HOC SIEU AM NHAN KHOA C0 BAN C h ju trach nhiem x u a t ban HOANG TRONG QUANG Bien tap: BS TO DINH QUY SCra ban in: BS TO DINH QUY Trinh bay bia: CHU HUNG K tv itin h : LE HA NINH In 1000 cuon, kho 14.5x20.5cm tai Xirong in Nha xuat ban Y hoc Can cCf ke hoach xuat ban so: 121-13/XB-QLXB 10/01/2005 In xong va nop lull chieu quy IV nam 2005 ... vong mac phiic tap chang han bong vong mac cac triidng hdp cat dich kinh) Khoang diidi vong mac co the danh gia diidc 129 mot cach dang tin cay bang sieu am A ma co the phan biet diidc dich, mau... mac phia dtfdi ngoai tren cac thiet a gid b Dien dtfdi c gid d Dien mui e 12 gid f Dien tren g- gid h Dien thai dtfdng 1 32 133 Hinh anh sieu am B cho thay bong vong mac toan bo cho den vung ora... dieu tri hay sau chay tia 4.1 .2 Trieu chung hoc sieu am cua u nguyen bao vong mac Kham nghiem sieu am lam noi bat mot hoac nhieu dam co ki'ch thiidc khac (Hinh 4.1 va 4 .2) , cau true sieu am khong