A TS. NGUYEN HUfU QUOC NGUYEN GS. TS. TON THI KIM THANH

Phau thuot#

Phoconhop mon

TS. NGUYiN HQU QUOC NGUYEN

GS. TS. TON THj KIM THANH

PHAU THUAT PHACO NHAP MON■ ■

NHA XUAT BAN Y HOC

HA NOI - 2004

LOI NOI OAU

Hien nay, ky thuat phaco da trd thanh pho bien trong phau thuat lay thuy tinh the due dat thuy tinh the nhan tao trong long bao. Tii cac bac si nhan khoa cho den ngiidi dan deu hieu dUdc tmh liu viet cua ky thuat phaco qua cac phiidng tien thong tin nhu td rdi, sach bao, va ttf van cua cac bac si nhan khoa cung nhii truyen mieng tvf ngifdi nay sang ngtfdi khac.

V6i ky thuat difdng rach nho tvt 2,5 - 3 mm, khong can khau, it chay mau, thi lUc hoi phuc nhanh, thdi gian liiu lai benh vien ngan tvf 6 tieng den 12 tieng dong ho, ky thuat phaco da noi len dUdc sil vtfdt troi so v6i cac ky thuat khac trvfdc day.

Toi viet cuon sach nay chi vdi muc dich la muon cung cap mot so" khai niem va kien thCfc cd ban cua phudng phap phaco den cac bac si nhan khoa m6i vao nghe de lam tU lieu tham khao sd dang ve cac tinh nang ly hoc, cac ky thuat mo, cac thao tac mo, cac cach s i dung thuoc, chat nhay va cac van de lien quan...Chac chan ban doc se Wdng ttfdng ra nhieu dieu m6i la hdn.

Co nhufng cum tCf Anh ngii chi cac dung cu mo, ky thuat mo, cac chat heu,... se dufdc toi giut nguyen van tieng Anh (vi co dich cung khong het y dufdc tham chi' con lam toi nghia cau van tieng Viet).

Chac chan quyen sach se khong tranh khoi nhiing sai sot. Toi xin chan thanh cam dn va don nhan tat ca nhufng ldi gop y cua ban doc.

Moi chi tiet xin gxli ve theo dia chi: TS.Nguyln Hflu Quoc Nguyen - 60 TrUng Nuf VUdng Da Nang

TAC GIA

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nhutng tl/ t ie n g a n h oi/dc sCr d u n g■ ■Ng u y e n v a n

Phaco: Chu! viet tac cua Phacoemulsification: Su tan nhuyen thuy tinh the (TTT)

Phacotip: dau tip phaco dung de dao ranh va tan nhan Handpiece tip: Tay cam dung de gan dau phacotip I/A tip: Dau rUa hutCortex: L6p vo TTT ( hay goi la chat nhan)Vac (Vaccum): Luc hut ap luc amU/S tip: Dau tan nhan b&ng nang liidng sieu am (tUdng tU

dau phacotip)U/S handpiece: Tay cam tan nhuyen b^ng sieu am (tUdng

tU dau handpiecetip)Aspiration orifice: Lo mieng hut cua dau phacotip hoac dau

I/A tipPhacoemulsifier: Bo phan tan nhuyen tan nhuyin TTTHandle: Dung cu cam tayPedal: Ban dap dieu khi; n bang chanSleeve: Boc nhUa dau phacotipOrifice: Lo hut dau tip.Hydroclavage: Tach nhan bang nU6cHydrodissection: Thuy tach hay tach nhan b&ng nUdc.

Tach phan thUdng nhan v6i 16p vo thuy tinh theHydrodelineation: Tach giuta 16p nhan trong Ooi cting)

vdi 16p nhan ngoai(16p thUdng nhan)Hydrodelamination: Tach 16p thUdng nhan vdi 16p nhan trong Hydrofracture: Tach phan nhan trong v6i nhan ngoai

bang dau Hydrosonic: ket hdp bdm dich.

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CCC: Continuous curvature capsulorhexis -Xe bao hinh tron lien tuc

Rhexis: Lo xe baoSideport: DUdng md tien phong ben phia 9 gid de dUa

spatule hoac chopper vao tien phong.Spatule: dung cu mo co be mat trdn lang, bang phang Forceps: Kep dung de mo, xe bao...Asp (Aspiration): Hut Ampl (Amplitude): Bien do Thresh: NgUdngBurst: Pha nhan bang xung sieu am nganChopper: Dung cu che nhan TTTCataract: Thuy tinh the - TTTIOL: Thuy tinh the nhan tao - TTTNTOptic: phan quang hoc cua TTTNTPhaco chop: Ky thuat che nhan TTTChop and flip: Ky thuat che va bay nhan TTTStop and chop: Ky thuat diing va che nhan TTTCrack and flip: Ky thuat be va bay nhan TTTStop, chop, chop and stuff: Ky thuat dufng, che, che va

an nhan TTTStep-by-step chop in situ: Ky thuat che nhan TTT tai

cho theo tufng bu6c mot.Vaccum seal: Hut chat bang chan khong. Ky thuat dung

dau phacotip vui chat trong manh nhan de co"dinh manh nhan Contact: num dieu khienFocus: Dieu'chmh tieu cU kinh hien vi phlu thuat.Zoom: Phong to, thu nho phlu trUdng kinh hien vi phiu thuat Sculpting: Dao ranhRemoval: Hut nhan va chat nhan ra khoi mat.

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LjCH Sir PHACO

1. Ba thap ky phat trien

Thang 04 nam 1997 la ll ky niem lan th i 30 ngay “Phaco” ra ddi, phUdng phap phaco dUdc BS. Kelman mo ta dau tien tren Thdi bao Nhan khoa Hoa Ky so thang 4 nam 1967. Trong suot thdi gian do, phUdng phap phaco da co nhufng thay doi dang ke.

Lich s i phat trien cua phUdng phap nay dUdc chia thanh 3 thap ky ro ret.

1.1 Thap ky thur nhat: (1967 - 1977) goi IA the he ‘Phaco tien phong”

Dau tien, BS. Kelman mo ta ky thuat dUa nhan TTT len tien phong va dao ranh, tan nhan thuy tinh the (TTT) thanh tin g manh nho. The he phaco dau tien dUa tren nang lifdng la chinh. Hut cac manh nhan ra ddn gian vdi do sau tien phong on dinh. Dieu nay se dUdc nh^c d phan cd che bdm hut hoac cai dat che do hut. Bdi vi “cong viec cua phaco” la tan nhuyen nhan TTT nguyen khoi bang cach s i dung nang lu<?ng phaco tang dan.

1.2. Thap ky thur hai (1977 - 1987) goi la the he ‘Phaco hau phong”

Bat dau c ia thap ky phaco th i 2 la BS. Kratz da chuyen phaco vao hau phong de bao ve noi mo giac mac tot hdn trong ky nguyen c ia dich nhay. Day cung la ky thuat dUa vao nang

O _ 9 , ^

lUdng sieu am de tan nhuyen. O thap ky nay, sU hut cung chi la vai tro phu trong qua trinh phaco.

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1.3. Thap ky thtrba (1987 - 1997) goi la the he ‘Phaco trong long bao TTT”

Nam 1987 da chinh thtic danh dau budc khdi dau cua thap ky phaco thti 3. Su ra ddi cua mot giai doan ky thuat phaco dien ra hoan toan trong long bao TTT. Tai sao phaco chuyen vao trong long bao TTT hdn la d nhiing khoang khong gian khac? Do la nhd sU cai tien cua xe bao hinh tron lien tuc, da dUdc mo ta lan dau tien nam 1987. Viec thuc hien phaco trong long bao TTT lien quan den 2 cai tien quan trong nhat do la pha nhan (be hoac che) va lUu thong dich hut. Su chuyen tiep tif the he 2 sang the he 3 cho thay nhiing phat hien m6i ve phaco v&n con tiep tuc.

Ve ban chat, phaco trong long bao TTT da lam thay doi moi dieu ve phaco. “Cong viec cua phaco trong long bao” la dong dich hut dUdc van hanh du de hut di nhflng manh nhan bi tan nho. Luc nay sU tan nhuyen trd thanh mot phUdng tien chi de lam thay doi dan kich thu6c va hinh dang cua nhiing manh nhan bi pha ra de hut di. Thay doi cd ban d day la phaco chu yeu dUa tren lUc hut va luon co mot tac dong sau skc giiia ky thuat mo vdi ky thuat van hanh may. Ky nghe phaco dUa tren lUc hut nay gom: dau tip sieu nho nen se khong bi do dich va bdm hut se co siic hut manh hdn vi nhiing may phaco hien dai se lap trinh dUdc day du vdi nhiing thiet ke cai tien de lam tang kha nang dong dich hut.

1.4. Thap ky thir 4 (1997 - 2007) goi la the he ‘Phaco trong tuctng la i”

Nhiing cai tien ky thuat may dUa tren lUc hut nhu mo ta d tren da lam cho ky thuat mo co sU thay doi mot lan niia do co sU lap trinh tren may. Ngoai nhiing thanh tUu dac biet, the he tiep theo cua ky thuat phaco co le se la cai tien dung cu, dong dich chay dUdc sii dyng vdi dung ludng manh hdn. Dieu nav dan den su phat trien gan day nhat ve phau thuat phaco la

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phaco tren bao, cach nay duy tri ldi diem cua xe bao hinh tron lien tuc de loai trijf sU co keo trong bao va miic do hut se nhanh hdn va hieu qua hdn. Khi phaco dUdc thUc hien d phia xa trong long bao, thi se khong an toan khi dung lUc hut cao vi de gay rach bao. Phaco tren bao se khong gidi han qua trinh phaco trong long bao TTT nen khong gay co keo bao va lUc hut co hieu qua cao hdn.

Tom lai, tien trinh phaco hom nay khac hoan toan vdi cach day 10 - 20 nam. Cuoc cach mang ky thuat nay van con tiep tuc, phaco la phUdng phap phau thuat lay TTT due cua tUdng lai.

2. Cuoc cach mang ve khuc xa, con dudng dan den phau thuat khuc xa thuy tinh the

Phau thuat lay TTT co tam quan trong dang ke, phaco (va khai niem dUdng mo nho) da co tac dong manh me nhu la chat xuc tac de nang cao tam voc cua phau thuat due TTT tijf mot qua trinh chi la lay nhan ddn thuan den nhiing thuan ldi ve mat khuc xa rat co gia tri. Khi BS. Kelman gidi thieu phau thuat phaco vao nam 1967, Ong ta da dUa chung ta vao mot con dudng mdi vdi hudng di mdi. Canh cong cua con dudng la phaco va dudng mo nho. Hudng di cua con dudng la theo hudng phau thuat due TTT de dat dUdc nhiing hieu qua hoan hao nhat. Nen nhd rSng day la phUdng phap phSu thuat lay TTT co kha nang dat dUdc hieu qua khuc xa hoan hao. Phaco that sU phat trien cham va chi dong vai tro phu trong gan 20 nam. Hay lang nghe cac chuyen gia trUdc day noi “khong ai nghi ngd r&ng phaco la phUdng phap lay nhan toi Uu” , nhung hau het chuyen gia cho rang chi mot dieu nay ma thoi thi khong chiing minh dUdc budc phat trien cua phaco. Chi sau khi co nhiing thay doi dinh hudng ve mat khuc xa trong phau thuat TTT chang han nhu thuy tinh the nhan tao (TTTNT) mem thi phaco la phUdng phap mo ngoai bao rat hoan hao. Ngoai ra phaco con dUa ra vien canh dudng mo nhd do do lam tang nhiing ldi diem ve khuc xa.

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2.1. Phau thuat thuy tinh the

Nham de khai quat hoa dieu cd ban nay va cac khai niem ve ph&u thuat TTT, chung ta can tom liidc cac phau thuat trtfcic day Bdi vi stf tien hoa nay da that sii tien biidc nen chung ta lui lai khong chi 30 nam qua ma la 30 the ky. Tii s\J nghien ctiu bao quat nay, se co nhufng hieu biet sau sac de dat nen tang vuing chac nhat cho phau thuat TTT phat trien.

2.2. Ba muoi the ky cua phau thuat thuy tinh the

2.2.1. Tl/ nam 1000 tri/dc Cong nguyen den nam 1750: la 2800 nam... ph§u thuat cataract bang cach danh rdi nhan TTT vao buong dich kinh.

Gan nhii la 28 the ky cua lich s i 30 the ky, phau thuat TTT da difdc thilc hien bang cach danh rdi TTT vao buong dich kinh, mot ky thuat dufdc thiet ke de “day qua mot ben” biic mang che d phia triidc TTT (dtfdc nghi la nhif vay), vi TTT dUdc xem la cd quan thi giac nguyen phat rdi d dau do trong buong dich kinh.

2.2.2. TCf nam 1750 - 1967 la 200 nam phau thuat lay TTT due ra khoi m it

Jacque Daviel, phlu thuat vien ngiidi Phap, trong khi thvta hien phau thuat trong thdi gian dau, da hieu thau dao khai niem nham lln ve viec danh rdi TTT vao buong dich kinh va nam 1752 da thvfc hien lay TTT.

200 nam gan day phlu thuat TTT da trai qua nhieu phat trien va nhufng ky thuat dude trau chuot de ap dung tot hdn cac khai niem m6i ve lay TTT due. Tien trinh 200 nam do da len den tot dinh cua ph^u thuat lay TTT due do la tan nhuvln TTT(Phacoemulsification).

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2.2.3. TCf 1967 - 1997 la 30 nam cua phau thuat khuc xa TTT

Nam 1967, ky nguyen lay TTT 200 nam qua da cham dtit, phaco tiep tuc phat trien nhif chung ta da thay. Day la thdi diem phat trien cua phau thuat TTT vdi 3 thap ky phat trien cua phaco.

TCf nghien ciiu nay, vai tro cua phaco that sii quan trong. Do la mot cuoc cach mang that sii. Phaco bat dau cuoc cach mang triet de nhat “No lam thay doi suy nghi cua chung ta” . Bang cach md rong khai niem ve muc dich cua viec lay TTT due, phaco da nang len den cac gidi han ma chung ta co the ao ufdc difdc tij£ phiidng phap nay. Phaco khong chi la tien bo cua TTTNT mem va nhiing cai tien khac ma bao gom ca phau thuat khuc xa the thuy tinh ngay nay. Phaco lam cho phau thuat khuc xa TTT them hieu qua. Charlie Kelman la ngifdi dau tien nhan thay sau sac nhiing ldi diem khuc xa that sii cd y nghia cua phau thuat TTT. Hieu qua sau rong cua phaco nhif la mot silc manh difa chung ta den vdi nhiing khai niem mdi ve phlu thuat TTT theo hifdng khuc xa.

Nhin lai, hau nhif moi mot cai tien k§ tii 1967 deu la cd y thiic - triic tiep hiidng den sii cai thien nhiing ket qua khuc xa cua phau thuat TTT. Tii biidc doi mdi nay den budc doi mdi khac cho den nay, sau 30 nam, tien trinh phat trien dan dan, chac chan da d£n chung ta den mot phiidng phap dat den nhiing ket qua ngoai silc tiicing tiidng trong mot vai nam qua. Trong khi do ky nguyen cua phau thuat lay TTT trai qua hdn 300 nam de dat difdc ky thuat phaco. Ky nguyen phau thuat khuc xa the thuy tinh da dat den ciic diem chi trong 30 nam. Ro rang la qua 30 nam ke tii khi Charlie Kelman gidi thieu phaco lan dau tien, stf tien trien dat difdc trong mot “thdi gian vang” cua phau thuat TTT da difa chung ta den thdi ky nhd te, phaco tren giac mac va TTTNT mem.

Nhieu ngifdi cam nhan rang do ban chat cong nghe mdi cua phlu thuat TTT, “thdi gian vang” nay dang cha'm diit. Vao

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