B Y T

BAN CH O PHNG CHNG M LA QUC GIA

Bnh vin mt Trung ng

HNG DN
CHN ON, IU TR V QUN L
BNH GLCM NGUYN PHT

NH XUT BN Y HC
H NI 20.....

MC LC
LI GII THIU
LI NI U
I CNG
PHN 1: CHN ON GLCM NGUYN PHT
1. Mc ch
2. i tng
2.1. Cc yu t nguy c chung
2.2. Cc yu t nguy c ti mt
3. Chun b cc iu kin
3.1. Nhn lc
3.2. Phng tin, dng c, thuc men
3.3. Kh nng cc tuyn v quan h phi hp
4. Quy trnh khm bnh nhn glcm nguyn pht
4.1. Hi bnh
4.2. Th th lc (khng knh v chnh knh)
4.3. o nhn p
4.4. Khm bng nh sng n (dng n pin, my soi y mt)
4.5. Khm sinh hin vi (SHV)
4.6. Khm y mt
4.7. Khm th trng
4.8. Cc nghim php pht hin glcm
5. Chn on xc nh glcm nguyn pht
6. Chn on mt s hnh thi glcm nguyn pht
6.1. Glcm gc m nguyn pht
6.2. Glcm gc ng nguyn pht
6.2.1. Glcm gc ng cn cp din
6.2.2. Glcm gc ng bn cp
6.2.3. Glcm gc ng mn tnh
6.2.4. Glcm mng mt phng
6.2.5. Glcm c tnh nguyn pht
PHN 2: IU TR BNH GLCM NGUYN PHT
1. Mc ch
2. Chun b cc iu kin
2.1. Nhn lc
2.2. Trang thit b
2.3. a im
3. Phc iu tr
3.1. iu tr glcm gc m nguyn pht
3.1.1. iu tr thuc
3.1.2. iu tr laser
3.1.3. iu tr phu thut
3.2. iu tr glcm gc ng nguyn pht
3.2.1. iu tr thuc
3.2.2. iu tr laser
3.2.3. iu tr phu thut
3.3.4. iu tr mt s hnh thi glcm gc ng

PHN 3: THEO DI, QUN L NGI BNH GLCM

1. Mc ch
2. i tng
3. Chun b cc iu kin
3.1. Nhn lc
3.2. a im
3.3. Dng c, trang thit b
3.4. H s qun l
4. Phng thc lm vic
5. nh gi s tin trin ca bnh glcm
Ti liu tham kho

DANH MC CC CH VIT TT
CA
CAI
CSLO
CSMB
T
HA
HRT
L/
NA
OCT
RAAB
SHV
SLP
TL
TT
TG
UBM

Men carbonic anhydrase

Thuc c ch men carbonic anhydrase
Chp ct lp vng mc bng my qut laser ng tiu (confocal scanning
laser ophthalmoscopy)
Chm sc mt ban u
i tho ng
Huyt p
Heidelberg Retina Tomograph
ng knh lm a th gic / ng knh a th gic
Nhn p
Chp ct lp vng mc kt quang (optical coherence tomography)
Rapid Assessment of Avoidable Blindness:
nh gi nhanh m la c th phng trnh c
Sinh hin vi
o phn cc bng laser qut (scanning laser polarimetry )
Th lc
Th trng
Th gic
My siu m sinh hin vi

LI GII THIU
Trc yu cu y mnh nhng hot ng phng chng m lo Vit Nam
hiu qu hn, cc chuyn gia v Glcm v cng l hi vin Hi Nhn khoa Vit Nam
cng tc ti Khoa Glcm ca Bnh vin Mt trung ng bin son cun Hng
dn chn on, iu tr v qun l bnh glcm nguyn pht. Tn sch nu r mc
tiu c th, r rng nhng vic thc hin li rt phc tp, rt a dng v ph thuc vo
trnh c o to v hun luyn, vo nhn thc y hay khng, vo ngun nhn
lc v kh nng trang thit b, thuc men khng phi a phng no cng ging
nhau. Phm vi bnh tt cng c hn ch trong nhng hnh thi ca Glcm nguyn
pht.
Ch ring chn on v iu tr l nhng lnh vc c quan tm t lu
nhng chng ta cng cha th va v cn nhiu bnh nhn khi c pht hin
giai on tn thng nng n, tuy phng php iu tr ngy cng phong ph, kt qu
ngy cng tt nhng cng cn vn phi suy ngh.Vn qun l ngi bnh
gim st bnh trng mt cch hiu qu (ngn chn bnh tin trin, bo v tt nhng
chc nng th gic c lu di) l mt lnh vc ht sc quan trng m trc y
cha c quan tm y , nay c t ra mt cch nghim tc, i hi mt s hp
tc cht ch gia cc tuyn t c s n cc tuyn cao hn.
thc hin mt mc tiu tt p nh vy, cun sch ny c gi tr nh mt
cm nang ngi c c th tham kho tm chn gii php hp l. Cch vit do
cng phi c tnh cht cng ng, ngha l nn n gin, d hiu, d thc hin cho
ngi cng tc nhng tuyn di, l nhng tuyn tuy thp nht nhng c l li rt
quan trng trong vic chn on sm, iu tr sm v theo di thng xuyn cc ngi
bnh glcm. Cc vn phc tp, cc k thut cao siu khng cn m t chi tit
(khng phi khng quan trng) v c bn c nghin cu, gii quyt ti cc trung tm
l nhng ni c ngun nhn lc chuyn su, c trang thit b hin i, c th vin vi
ngun thng tin phong ph.
Mt yu t ca mi thnh cng cng nh thc hin hiu qu mc tiu ca
cun sch ny l s hp tc gia ngi thy thuc (bc s, y s, iu dng) v ngi
bnh, cng nh gia cc tuyn t thp nht n cao nht theo tinh thn Chung mt
chin ho.
Chc cc tc gi cun sch ny t c mong mun tt p.
H Ni, 06 thng 3 nm 2011
GS.TS. Nguyn Trng Nhn
Ch tch Hi Nhn khoa Vit Nam

LI NI U

Bnh glcm nguyn pht l cn bnh nguy him v thng gp Vit Nam
cng nh trn th gii. Bnh c th xy ra mi la tui, c kh nng gy m la
khng th hi phc v lm nh hng n cht lng sng ca ngi bnh, nhiu khi
l gnh nng ca gia nh v x hi. Tuy nhin glcm l mt tnh trng m lo c th
phng trnh c bng cch pht hin sm, iu tr kp thi, ng cch v theo di
hp l. Mc d c ch bnh c cp n t rt lu nhng k t nhng nm cui
ca th k XX, rt nhiu quan nim v c ch bnh glcm thay i hoc c nhng
cp nht mi ko theo mt lot thay i v iu tr v qun l bnh glcm. Bn cnh
, vic thng tin khoa hc v bnh glcm cn cha ton din v kp thi khin vic
iu tr cng nh phn cp iu tr, qun l bnh glcm cn cha thng nht, hp l
v ng b gia cc a phng.
Chnh v vy, c s ti tr ca B Y t, Bnh vin Mt Trung ng, Hi
Nhn khoa Vit Nam v s gip ca Nh xut bn Y hc cun sch Hng dn
chn on, iu tr v qun l bnh glcm nguyn pht c ra mt nhm gip
cc cc cn b chm sc mt cc tuyn y t c th tham kho, la chn p dng
trong iu kin thc t ca c s mnh cc phng php khm pht hin, x tr v
qun l bnh glcm. Ngoi ra, yu cu v trang thit b, con ngi, trnh chuyn
mn cng c trnh by chi tit theo tng tuyn y t (x, huyn, tnh thnh v trung
ng) nhm gip ngi bnh c th c tip cn iu tr, theo di mt cch ph hp
nht. Thng qua , tnh trng m la do bnh glcm c th bt trm trng v khng
cn l gnh nng ca ngi bnh cng nh ca x hi.
Chng ti xin by t lng bit n su sc n GS.Nguyn Trng Nhn v cm
n cc nh khoa hc, cc anh ch ng nghip trong khoa Glcm Bnh vin Mt
trung ng ng gp nhiu kin qu bu hon thnh cun sch ny.
Ln u bin son nn khng trnh khi nhng thiu st. Rt mong c cc
ng nghip gn xa gp b xung cun sch c hon thin hn. Mi gp xin
c gi v:
Khoa Glcm , Bnh vin Mt trung ng, 85 B Triu, H Ni.
Email: glvnio@yahoo.com
Chng ti xin chn thnh cm n !

TS.BS. O TH LM HNG
Khoa Glcm Bnh vin Mt Trung ng

I CNG
Glcm nguyn pht l mt bnh l ca dy thn kinh th gic, c trng bi
s tn hi ca cc t bo hch vng mc, lp si thn kinh th gic, teo lm a th, tn
thng th trng in hnh v cc chc nng th gic khc (th lc), thng c lin
quan ti nhn p cao. Nhng tn hi chc nng v thc th do glcm gy nn s
khng c kh nng hi phc.
Bnh glcm l mt bnh nguy him, thng gp, mang tnh x hi cao, nh
hng n sc kho cng ng v l mt trong nhng nguyn nhn ch yu gy m
la vnh vin trn th gii cng nh Vit Nam. Glcm ng th hai trong cc
nguyn nhn gy m, thng ch ng sau c th thy tinh. Theo cng b ca T
chc Y t th gii nm 2008 ti Hi ngh Phng chng m la th gii Argentina
nguyn nhn gy m do glcm chim 10%. Kt qu iu tra RAAB (Rapid
Assessment of Avoidable Blindness) nm 2007 cho thy Vit Nam t l m hai mt
do glcm ngi trn 50 tui chim khong 6,5%, ng th hai trong cc nguyn
nhn gy m. Vit Nam hin nay c khong 24.800 ngi m do glcm.
Bnh glcm rt phc tp do c rt nhiu hnh thi vi nhng c ch bnh sinh,
biu hin lm sng a dng, i hi cc phng php iu tr khc nhau.
V nguyn sinh bnh cha hon ton r rng nn khng d phng nga bnh
glcm. Tuy nhin tnh trng m la do glcm c th phng trnh c bng cch
pht hin sm, iu tr thch hp v theo di thng xuyn.

Phn 1
CHN ON GLCM NGUYN PHT
1. MC CH
Pht hin bnh glcm cc giai on, cng sm cng tt kp thi iu tr
nhm ngn chn cc tn thng chc nng v thc th ca mt, bo v c chc
nng th gic cho bnh nhn.
2. I TNG
Ngi dn 35 tui. c bit lu nhng ngi c nguy c cao xut hin
bnh glcm.
2.1. Cc yu t nguy c chung
- Tui 35
- Ngi rut tht ca bnh nhn glcm
- Bnh ton thn: HA cao, tt HA v m, co tht mch trong bnh l mch
vnh, hi chng Raynaud, ri lon tun hon no, au na u Migren, tng m mu,
bnh T, bnh l tuyn gip.
2.2. Cc yu t nguy c ti mt
- Tt khc x: cn th cao (nguy c glcm gc m), vin th cao (nguy c
glcm gc ng). Lo th sm, tng s knh lo nhanh.
- Nhn p trong khong nghi ng (22< NA< 25 mmHg vi NA k Maclakov), km
theo cc cm gic ch quan thng gp ca glcm nh nhc mt lan ln u cng
bn, nhn m, nhn ngun sng thy qung xanh ...
- Tin phng nng < 2,5 mm: nguy c ng gc
- Cc du hiu y mt nghi ng c bnh glcm: L/ > 6/10; chnh lch L/
gia 2 mt > 2/10, xut huyt trn b hoc cnh a TG, chuyn hng mch mu, teo
quanh a TG.
Nhng ngi c cc yu t nguy c cao cn c kim tra mt theo quy trnh
pht hin hoc loi tr bnh glcm.
3. CHUN B CC IU KIN
3.1. Nhn lc
3.1.1. Tuyn y t c s ( Trm y t x): cc cn b chm sc mt ban u
(CSMB) c hc tp v cc triu chng c bn ca glcm, bit cch kim
tra n gin th lc (TL), th trng (TT), bit o nhn p (NA).
3.1.2. C s y t t bnh vin tuyn huyn tr ln c bc s, iu dng
chuyn khoa mt c o to v cc phng php khm pht hin bnh glcm.
Trnh cao theo phn cp.
3.2. Phng tin, dng c, thuc men
3.2.1. Tuyn trm y t x
- Ti thiu cn c:
+ Cc thuc tra mt thng thng nh Cloroxit 0,4% (nc), Betadin 1% (nc).
+ Bng o TL.

+ n pin.
- Nu c iu kin trang b: B o NA Maclakov, qu cn 10g, mc o NA, thuc
gy t tra mt dicain 1% (nc).
3.2.2. C s chuyn khoa mt tuyn huyn
- Ti thiu cn c:
+ Cc thuc tra mt thng thng: Betadin 1% (nc), Cloroxit 0,4% (nc),
dicain1% ( nc), pilocarpin 1% (nc), neosynephrin 10% (nc), thuc nhum
mu fluorescein.
+ Bng o TL, hp th knh.
+ B o NA Maclakov, qu cn 10g, mc o NA.
+ Sinh hin vi khm bnh.
+ My soi y mt trc tip.
- Nu c iu kin trang b: knh Volk, knh soi gc tin phng, dch nhy
Methocel.
3.2.3. C s chuyn khoa mt tuyn tnh, thnh ph
Ti thiu cn c:
- Nh tuyn huyn.
- Knh soi gc tin phng.
- Knh Volk.
- My TT k.
3.2.4. Tuyn cc trung tm
Bnh vin Mt Trung ng v mt s trung tm mt ln mt s tnh, thnh c
khoa Glcm cn c y cc trang thit b tin tin phc v cho khm chn on,
nghin cu chuyn su bnh glcm, c kh nng h tr cc tuyn di v cc c s y
t trong cc vng min khm xc nh chnh xc hnh thi, giai on bnh.
- Phng tin chn on hnh nh: my chp nh y mt, chp ct lp a th
gic, vng mc, gc tin phng, o chiu dy gic mc (UBM, OCT phn trc, phn
sau nhn cu, HRT...).
3.3. Kh nng cc tuyn v quan h phi hp
Hin nay trong chn on bnh glcm khng c mt phng php thm khm
no va n gin, va nhy v c hiu. xc nh v theo di tin trin bnh cn
c s tng hp kt qu ca nhiu khm nghim chc nng, thc th. V vy cn phi
kt hp cht ch, h tr ln nhau gia cc tuyn y t chuyn khoa mt t tuyn c s
n tuyn trung ng trong chn on, iu tr v theo di bnh nhn glcm. Nhng
c s khng c phng tin chn on chc nng cn gi bnh nhn ln tuyn c
iu kin hi chn xc nh bnh v hng theo di, iu tr tip.
3.3.1. Ti trm y t x
Cn b CSMB c th khm pht hin bnh nhn glcm, chuyn ngay bnh nhn
ln tuyn chuyn khoa mt khm v iu tr kp thi.
Cn ngh ngay n bnh glcm gc ng cp, bn cp khi ngi bnh n khm
vi cc du hiu sau:
- Nhc mt, nhc u, nhn m, nhn n qung xanh .
- Khm bng n pin: mt , gic mc ph, mt bng.
- Du hiu cn ch : ng t gin, phn x ng t mt hoc li.
- Khm bng nh sng cho: mng mt vng, tin phng nng.
- o nhn p c lng bng tay thy mt cng cng.
Cn cnh gic vi cc hnh thi glcm gc ng mn tnh, glcm gc m
nhng ngi c yu t nguy c cao n khm vi cc triu chng: nhn m mc

d mt khng hoc t au nhc, thu hp hoc khuyt vng nhn ca mt pha mi,
nhn hnh ng
3.3.2. Ti c s chuyn khoa mt tuyn huyn
Bc s khm pht hin bnh glcm da vo:
- Triu chng ch quan c hiu ca glcm.
- Du hiu lm sng in hnh ca glcm: khm bng sinh hin vi, soi y mt.
- o NA bng NA k Maclakov: NA cao 25 mmHg., lm cc th nghim pht
hin glcm (nu NA mc nghi ng).
Sau cn gi ngi bnh ln tuyn trn lm th trng chn on giai on
bnh, soi gc xc nh hnh thi bnh, hi chn hng theo di v iu tr tip tc.
3.3.3. Ti c s chuyn khoa mt tuyn tnh, thnh ph
- Khm pht hin sm glcm trong s nhng ngi c y t nguy c cao.
- Khm chn on xc nh bnh glcm da vo:
+ Cc khm nghim nh tuyn huyn vi trang thit b y hn.
+ Soi gc tin phng chn on hnh thi glcm.
+ Lm th trng chn on giai on bnh.
- C s c trang thit b: Lm cc xt nghim chn on hnh nh gc tin phng,
y mt, dy gic mc trung tm.
3.3.4. Tuyn chuyn su glcm
- Tt c cc khm nghim vi trang thit b hin i.
- Cc xt nghim chn on hnh nh gc tin phng, y mt, o dy gic
mc bng cc trang thit b k thut cao.
4. QUY TRNH KHM BNH NHN GLCM NGUYN PHT
4.1. Hi bnh
- Khai thc cc triu chng ch quan c hiu ca glcm: nhn m, mt , nhc
mt, au u, nhn n thy qung xanh , thch nghi sng ti km, nhn khuyt gc.
- Khai thc tin s bnh glcm trong gia nh, dng thuc corticoid, chn
thng mt, m mt, cc bnh ton thn.
4.2. Th th lc (khng knh v chnh knh)
Trc khi th th lc cn xc nh s b vng th trng bnh nhn cn nhn
thy, sau mi nh gi kh nng nhn xa, gn ca bnh nhn.
nh gi kt qu: theo bng phn loi ca T chc Y t th gii nm 1975
Ch : i khi th lc trung tm cn tt nhng nu th trng:
- Thu hp di 10 : m mc 3
- Thu hp di 5: m mc 4
4.3. o nhn p
- NA cao ( o bng NA k Maclakov: > 25 mmHg; NA k Goldmann: > 21 mmHg,
NA k Schiotz: > 20 mmHg): cn khm a th gic, th trng xc nh bnh
glcm.
- Trng hp NA nghi ng (23-25 mmHg vi NA k Maclakov, 20-21 mm Hg vi
NA k Schiotz, 21-22 mmHg vi NA k Goldmann) cn ch nh theo di dao ng NA

4 ln 6 ln/ ngy trong 3 ngy hoc lm th nghim. nh gi kt qu nh sau:

+ Kt qu (+) khi chnh lch NA gia cc ln o 5 mmHg: mt c tng NA.
+ Kt qu (-): khi chnh lch NA gia cc ln o < 5 mmHg.
- Mc chnh lch NA gia 2 mt 5 mmHg : mt c NA cao hn b tng NA.
- NA khng cao nhng c cc triu chng lm sng, c lm a th gic rng v tn
thng th trng in hnh ca glcm l nhng du hiu nghi ng ngi bnh c
glcm ngoi cn hoc glcm nhn p khng cao: soi y mt, lm cc xt nghim
chn on hnh nh, lm th trng, kim tra loi tr cc tn thng do bnh l th
thn kinh, thiu mu th thn kinh, tn thng trong h thn kinh trung ng, thiu
nng tun hon no, ri lon gic ng, bnh l tim mch, huyt p, c bit lu cc
bnh mch mu ngoi vi, cc bnh mu. Cc trng hp bnh kh nn gi hi chn
tuyn chuyn su cao hn.
4.4. Khm bng nh sng n (n pin, my soi y mt)
- Kim tra phn x ng t.
- c lng su tin phng v m gc tin phng bng Nghim php nh
sng cho (Nu khng c sinh hin vi khm bnh): s dng nh sng chiu t pha thi
dng i ngang b mt mng mt. nh gi kt qu nh sau:
+ Nu chn mng mt pha n chiu cng vng cao th phn mng mt pha i
din cng b che ti: gc c xu hng b ng.
+ Nu ton b phn mng mt pha bn i din sng u: gc c kh nng m.
4.5. Khm sinh hin vi (SHV)
- Pht hin cc tn thng ti mt do glcm: cng t kt mc, ph gic mc,
thoi ha mng mt, ng t gin mo, gim hoc mt phn x... cc mc khc
nhau ty thuc vo hnh thi v giai on bnh.
- Nghim php c lng gc tin phng Van Herick: t khe sng ca n khe
chch 60 chiu vo st ra v tip tuyn ra gic mc, iu chnh khe sng tht nh v r
nt, so snh khong cch t mt sau ca gic mc n mt trc ca mng mt vi
chiu dy gic mc.
nh gi kt qu theo bng phn loi m gc tin phng (bng 1).
- Soi gc tin phng: quan st hnh nh ca gc tin phng, m ca gc, mc
dnh gc, gia tng sc t ti vng b, du in sc t trn vng b, gip chn on
chnh xc hnh thi glcm v nh hng iu tr.
Bng 1. Phn loi m gc tin phng
Phn
loi

m
gc

Theo
V. Herick

m
gc

M rng

> 1/2 chiu

dy ca GM

45-35

Ton b chi tit gc ti di th mi

Khng

Trung
bnh

1/2 n >1/4
chiu dy ca
GM

35-20

Chi tit gc ti ca CM, khng thy

di th mi

Khng

Hp

= 1/4 chiu
dy ca GM

20-10

Chi tit gc ti di b, khng thy

di th mi v ca CM

C th ng

Rt hp

< 1/4 chiu

dy ca GM

< 10

ng

Cu trc gc nhn c

Vng Schwalbe hoc mt phn di

b
Khng thy cu trc gc

Kh nng
ng gc

Rt c th
ng
ng hon
ton

4.6. Khm y mt
Dng my soi y mt hoc knh Volk khm trn SHV pht hin nhng tn
thng c hiu ca bnh glcm.
- Lm teo a th gic: giai on sm ca bnh lm thng pht trin theo
chiu dc ( hnh oval dc), sau rng dn ng tm.
- Vin thn kinh mng dn hoc to thnh khuyt hnh chm.
- Teo l sng l cc l ca l sng.
- Cc du hiu ca mch mu: mch mu dt pha mi; Mch mu gp khc hnh
li l; Mch mu un ln theo b cong ca lm a th gic pha trn hoc di,
trong lng lm a th gic khng quan st thy ng i lin tc ca mch mu.
- Xut huyt: thng xut hin trn b mt a th gic, hoc cnh a, c hnh
ngn la nm theo cc si trc, hay gp nht pha thi dng di.
- Teo quanh a th gic: hay gp bnh glcm NA khng cao.
- Nu chnh lch t l L/ > 0,2 gia hai mt hoc cc du hiu tn thng in
hnh ca glcm khng r rng cn lm cc khm nghim b xung: theo di NA nhiu
ln trong ngy, lm th nghim pht hin glcm, o chiu dy gic mc hiu chnh
s o NA, khm nghim th trng, chp ct lp vng mc (OCT, HRT), chp nh y
mt theo di mc tin trin ca tn thng.

Hnh 1: Lm teo a th gic glcm

4.7. Khm th trng

4.7.1. Phng php lm sng: n gin, nhanh, cho php xc nh s b gii hn
th trng, bng cch so snh th trng ca ngi bnh v th trng ca thy thuc.
K thut: ngi bnh v thy thuc ngi i din, cch nhau 1m; ngi
bnh m mt cn o th trng (v d mt phi) v bt mt cn li (mt tri); thy
thuc s bt bn mt ngc li vi ngi bnh (mt phi). Thy thuc v ngi bnh
nhn thng vo mt nhau. Thy thuc di chuyn ngn tay ca mnh khong gia hai
ngi theo cc kinh tuyn khc nhau t ngoi vo v hi ngi bnh c nhn thy
ngn tay hay khng, sau so snh th trng ca ngi bnh v thy thuc.

Ch nh:
- nhng ni khng c my th trng k.
- Tre nho.
- Bnh nhn nm lit hoc mt mi, km phi hp khi lm th trng.
- Bnh nhn co thi lc qu km: < NT 0,3m.

Hnh 2. Cc giai on tn thng th trng trong bnh glcm

4.7.2. o th trng bng my

- Th trng k ng (Landolt, Maggiore, Goldmann): gip xc inh ranh gii
ngoi vi cua thi trng. Trong bnh glcm lc u th trng thu hp pha mi, sau
thu hp ng tm, ch cn li mt o nh trung tm (th trng hnh ng) hoc
pha thi dng ri mt hon ton.
- Th trng k tnh (Humphrey, Goldmann): c chnh xc cao, cho php xac
inh b va su cua cc m im, gip xc nh ngng cm th nhiu im khc
nhau trong th trng t v nn bc tranh ton cnh ca th trng.
giai on sm ca bnh glcm th trng c th cha b tn thng.

Tn thng sm ca th trng bao gm cc hnh thi: tn hi ta lan, tn hi

khng ng u, m rng im m, m im n c cnh trung tm, m im hnh
cung Bjerrum, m im Seidel, co hp cc ng ng cm, khuyt pha mi.
4.8. Cc nghim php pht hin glcm
C th thc hin cc c s chuyn khoa mt t tuyn huyn tr ln.
* Tc dng
- Gip chn on xc nh bnh glcm khi nghi ng v nhn p (23 25 mmHg
vi NA k Maclakov qu cn 10g); rt ngn thi gian theo di glcm gc m; c th
ch nh iu tr d phng glcm gc ng.
- Xc nh bnh giai on tin glcm khi ngi bnh nhn c yu t nguy c cao.
- nh gi hiu qu ca cc phng php iu tr:
+ Kt qu iu tr tt nu trc iu tr nghim php dng tnh, sau iu tr
nghim php m tnh.
+ Kt qu iu tr cha t yu cu nu sau iu tr kt qu th nghim dng tnh.
* Nguyn tc ch nh
- Glcm gc ng: cc nghim php u c th p dng nhng ch yu l cc
nghim php lm gin ng t.
- Glcm gc m: nghim php ung nc v nghim php pilocarpin.
* nh gi kt qu
- Nghim php dng tnh khi mc bin i NA 5 mmHg (NA k Maclakov).
- Tuy nhin nghim php m tnh khng cho php loi tr kh nng b bnh glcm.
4.8.1. Cc nghim php lm gin ng t
C ch: ng t gin gy bt gc tin phng.
- Tra thuc gin ng t: homatropin 1% (nc), neosynephrin 10% (nc). Lu
: khng dng atropin v tc dng ko di, nguy him do c th gy cn glcm gc
ng cp sau th nghim.
- Nghim php bung ti
Nghim php (+) trong glcm gc ng vi t l 50%. Vi kt qu (-) cha loi
tr c kh nng s ln cn glcm.
4.8.2. Nghim php ung nc
- T l dng tnh: 30% vi glcm gc m, 40% vi glcm gc ng.
- C ch: lm thay i p lc thm thu gia huyt tng v thy dch, do lm
tr lu tng v cc t bo ni m ca b cng gic mc b ph tm thi.
- Ch nh: glcm gc ng, glcm gc m.
- Chng ch nh: suy gan, thn, bnh nhn b ct d dy, cao huyt p.
4.8.3. Nghim php pilocarpin
Ch nh: glcm gc m. Khi NA trong khong nghi ng ( 22 25 mmHg
vi NA k Maclakov, qu cn 10g).
ngi bnh thng nh pilocarpin khng lm thay i NA nhiu (1-2
mmHg). Trn bnh nhn glcm pilocarpin c tc dng h NA r rt ( > 6 mmHg ).
5. CHN ON XC NH GLCM NGUYN PHT
Bng 2. Phn loi glcm nguyn pht
(Dng trong cc c s y t chuyn khoa mt chung)
Hnh thi

Giai on

Tnh trng

10

Din bin chc

nhn p
1. Glcm gc ng
2. Glcm gc m
3. Glcm th hn hp

1.Tim tng
2. S pht
3. Tin trin
4. Trm trng
5. Gn m v m

Khng cao
Cao
Rt cao

nng th gic
n nh
Khng n nh

Cn glcm gc ng cp
din

Bng 3. Phn loi b sung glcm nguyn pht

(Dng trong cc c s y t chuyn su glcm)
Hnh thi

Glcm gc ng

1.
2.

Nghi ng gc ng nguyn
pht
Gc ng nguyn pht

Cc dng khc nhau

V tr tr lu thy
dch

C nghn ng t:
Glcm gc ng cp tnh
Glcm gc ng bn cp
Glcm gc ng mn tnh
Khng c nghn ng t: glcm
mng mt phng.

Trc b

Glcm gc b

3.

Glcm nguyn pht gc

ng

Glcm gc m

C nghn mn chn th thy tinh th mi - dch knh:

glcm c tnh
1. Glcm nguyn pht gc m c
nhn p cao
2. Glcm nhn p khng cao
3. Nhn p cao n thun

Glcm th hn hp

Vng b
Sau b ( k c xp ng
Shlemm)
Tn thng phi hp

Chn on hnh thi glcm: da vo kt qu soi gc tin phng.

Chn on giai on bnh: da vo tn thng a th gic v th trng.
Giai on tim tng: mt cha c biu hin tn thng c hiu ca bnh, thng
l mt th hai ca ngi bnh c bnh glcm nguyn pht xut hin mt mt.
Giai on s pht: cha c tn thng in hnh a th gic v th trng. C
th bt u xut hin nhng tn hi th trng nh vng cnh trung tm nh
im m di ra, cc ng ng cm trung bnh v trung tm hp li, loi im m
ra ngoi. a TG: lm a hnh oval ng, mt cn xng v rng lm a gia
hai mt.

11

 Giai on tin trin: m rng nhng m im sn c vng cnh trung tm hoc

nhng m im sn c ny lin kt vi nhau thnh mt m im ln. Th trng
chu bin thu hp dn pha mi gc trn hoc gc di hoc c hai gc trn v
di t >100 cho ti ch cn 15 0 k t im nh th. Lm a glcm pht trin
rng ra pha b a th gic .
Giai on trm trng: th trng thu hp hnh ng. Xut hin m im hnh cung
Bjerrum vi khuyt th trng pha mi in hnh. Ranh gii th trng chu bin t
nht mt gc 1/4 ch cn vng <150 k t im nh th. Tn thng m rng ra
thnh hnh vng hoc na vng khu tr 01 o th gic trung tm. giai on
mun th trng trung tm cng b tn thng, ch cn li mt o th trng pha
thi dng. Lm a glcm tin ra gn st b a th gic.
Giai on gn m v m: khng lm c th trng do th lc qu km n mc
khng cn nhn thc c nh sng. Lm teo a th gic hon ton.

6. CHN ON MT S HNH THI GLCM NGUYN PHT

6.1. Glcm gc m nguyn pht
Glcm gc m nguyn pht thng xut hin m thm, khng au nhc mt v
u, tin trin chm, ln lt qua tng giai on. Bnh hay gy tn thng c hai mt
nhng mc tin trin li t khi ng u, thng c mt mt nng hn mt bn kia.
6.1.1. Triu chng c nng
Cc triu chng thng biu hin rt kn o (tr trng hp c tn thng nng
trn th trng). V vy ngi bnh kh pht hin c bnh giai on sm.
- a s ngi bnh ch c cm gic hi cng tc mt hoc nhn m nh thong qua
khi lm vic bng mt nhiu, khi cng thng thn kinh, khi lo lng nhiu.
- C nhng ngi bnh nhn nh c mn sng mng trc mt vo bui sng.
- Mt m dn khin cho ngi bnh khng nhn thy. C khi tnh c pht hin ra
mt b m t lc no khng bit.
6.1.2. Du hiu thc th
- Thng t khi c cng t ra, hoc ch cng t rt nh.
- Gic mc trong.
- Tin phng su, gc tin phng m rng hoc trung bnh c khi NA cao, y l
du hiu quan trng chn on phn bit vi glcm gc ng.
- ng t thng trn u, phn x bnh thng, giai on mun c th gin nh,
mt vin sc t, phn x li hoc mt phn x vi nh sng.
- y mt: mc teo lm a glcm ty theo giai on bnh, thng i km du
hiu mch mu dt pha mi, i khi c xut huyt a th gic hoc cnh a th gic,
vin thn kinh mng dn.
6.1.3. Cc xt nghim chc nng
- Th lc: trong nhiu trng hp th lc trung tm vn cao hoc kh cao trong khi
th trng ch cn hnh ng.
- Th trng: bin i ty theo 5 giai on tin trin ca bnh.
- NA: tng cao. Tuy nhin cn ghi nh c hnh thi glcm NA khng cao.

12

- Cc phng php chn on hnh nh:

+ c s dng cc tuyn chuyn su glcm.
+ Chp nh a th gic, chp ct lp vng mc-a th (OCT, RNFL, HRT),
chp si thn kinh th gic, qut laser ng tiu (CSLO), o phn cc bng laser
qut (SLP)...: cho php o c chnh xc v ghi chp, lu gi cc thng tin v mc
lm a, tn thng vin thn kinh v cc si thn kinh quanh a th gic gip chn
on glcm giai on rt sm v theo di qu trnh tin trin ca bnh.
+ o chiu dy gic mc trung tm nhm hiu chnh gi tr NA thc t ca mt
6.1.4. Chn on phn bit
Glcm gc m NA khng cao cn chn on phn bit vi cc bnh l khc
ca th thn kinh nh vim th thn kinh, tn thng th thn kinh hu nhn cu, tn
thng thn kinh s no, teo a th trn mt c lm a sinh l rng, thiu mu th
thn kinh.
- Hi chn chuyn khoa su.
- Chp cng hng t (MRI), CT-scanner s no, chp Doppler ng mch cnh
trong, ng mch trung tm vng mc gip chn on xc nh bnh.
6.2. Glcm gc ng nguyn pht
6.2.1. Glcm gc ng cn cp din
Bnh khi pht t ngt, c th xy ra sau mt s yu t pht ng nh xc ng
mnh, sau khi dng mt s thuc c tc dng ln h thn kinh thc vt, hoc lu
trong bng ti.
* Triu chng ch quan
- Nhn m nhanh, t ngt, nh qua mn sng m.
- Nhn ngun n thy c qung xanh .
- au nhc mt, au na u cng bn.
- Ton thn: mt mi, bun nn, nn khan hoc nn vt, au bng, chm nhp
tim, v m hi
* Du hiu thc th
- Mi mt ph n do mt kch thch, s nh sng, chy nc mt nhiu.
- Kt mc cng t ra hoc cng t ton b gy du hiu mt .
- Gic mc ph n, mt sc bng, c bng biu m, np gp mng Descemet, ta
sc t mt sau gic mc, mt trc th thy tinh.
- Tin phng nng, nghim php Van Herrick < b dy gic mc hoc p st
mt sau gic mc.
- ng t gin na vi hoc gin ti a, c th mo, bin dng, mt phn x nh
sng, c th mt vin sc t b ng t, dnh b ng t vi mt trc th thu tinh.
- Th thu tinh ph c, c th c rn bao trc to thnh m c nh di bao
trc th thu tinh.
- Dch knh c th ph n lm kh soi y mt r rng.
- y mt: a th gic ph, xut huyt nh cnh a th, c th thy ng mch
trung tm vng mc p, teo lm a cc mc , mch mu dt pha mi. Trong nhiu
trng hp khng soi r y mt do cc mi trng trong sut b ph n nhiu.
- Nhn p tng rt cao.
- Soi gc tin phng: gc tin phng ng kn, cn lm nghim php Forbes vi
knh Zeiss hoc soi ng vi knh Goldmann nhm phn bit ng gc c nng hay
dnh gc thc th quyt nh phng php iu tr. Tuy nhin trong nhiu trng
hp khng soi r chi tit gc do gic mc ph.

13

- Th trng khng th o c trong cn glcm cp do cc mi trng trong

sut ph n nhiu, mt kch thch, chy nc mt.

Hnh 3,4. Glcm gc ng cn cp din

6.2.2. Glcm gc ng bn cp
Triu chng ch quan v du hiu thc th gn ging nh cn glcm cp tuy
nhin mc biu hin khng rm r.
Bnh thng biu hin bng nhng t tng nhn p, hay xut
hin v chiu ti, gy nhn m, nhn n c qung xanh , au nhc nh trong mt,
au u nhng t qua khi.
Gc tin phng ng.
a th v th trng thng b tn thng nhiu do ngi
bnh khng i khm pht hin bnh v iu tr kp thi.
6.2.3. Glcm gc ng mn tnh
- Biu hin lm sng m thm, gn ging nh glcm gc m nn nhiu ngi
bnh khi pht hin ra th bnh giai on nng. Ngi bnh thng c nhng cn
nhc u, nhc mt sau mt ngy lao ng mt nhc, cng thng.
- Nhn p thng tng va phi.
- Tin phng nng.
- Gc tin phng ng dn t nh gc. Soi gc tin phng: gc hp hoc ng.
- Lm a pht trin dn.
- Th trng tn hi c hiu ca glcm.
6.2.4. Glcm mng mt phng
L hnh thi glcm gc ng xy ra trn nhng ngi bnh c s bt thng
cu trc chn mng mt v th mi (pht hin bng soi gc v UBM). C ch gy
tng NA l do gc tin phng b nghn khi ng t gin.
Hay gp la tui 30 n 60 tui.
- Tin phng su trung bnh trung tm. Mng mt phng. Khng c biu hin
ca nghn ng t.
- Soi gc: chn mng mt bm dc gy hp hoc ng gc, np gp nhu m
ngoi vi ca chn mng mt dy. Tnh trng gc hp khng thay i sau khi lm laser
ct mng mt chu bin

14

- Chn on bng khm sinh hin vi siu m (UBM): np gp nhu m ngoi vi

ca chn mng mt dy, mng mt bm dch ra trc hoc v tr dch ra trc ca th
mi, khng nhn thy rnh th mi. Cc du hiu ny thy t nht hai gc phn t.
6.2.5. Glcm c tnh nguyn pht
- Biu hin lm sng ti cp.
- Nhn p tng rt cao.
- Du hiu c bit chn on phn bit: xp tin phng cc mc khc nhau.
- Mi trng trong sut ph n, mt kch thch nhiu nn thng khng soi c
y mt v khng lm c th trng.

Phn 2
IU TR BNH GLCM NGUYN PHT
1. MC CH
- Lm dng hoc chm li qu trnh tin trin tip ca bnh glcm
- Duy tr cht lng nhn, cht lng cuc sng cho ngi bnh.
2. CHUN B CC IU KIN
2.1. Nhn lc
Cc bc s, iu dng chuyn khoa mt c o to v cc phng php iu tr
bnh glcm.
2.2. Trang thit b
- Cc thuc h nhn p tra ti mt v dng ton thn.
- B dng c vi phu thut.
- My hin vi phu thut.
- My laser iu tr cng cc knh chuyn dng, my laser quang ng th mi.
2.3. a im
C s chuyn khoa mt cc tuyn y t qun/huyn, tnh, trung ng ty thuc tnh
trng trang thit b cn thit c ti c s.
- Nu c s khng c iu kin chn on xc nh bnh, khng c my hin
vi phu thut, dng c vi phu thut... Cn x tr cp cu h nhn p bng thuc, sau
chuyn ngay bnh nhn ln tuyn trn khm v iu tr.
- Nu c trang b hin vi phu thut, b dng c vi phu, c bc s c o
to v phu thut iu tr glcm th c th can thip phu thut h nhn p nhng
trng hp glcm xc nh chn on r rng nh glcm gc ng cp, bn cp
vi cc triu chng lm sng in hnh. Sau cn th gi ngi bnh ln tuyn

15

chuyn khoa mt c phng tin chn on hi chn ch iu tr, theo di

tip tc c hai mt.
3. Phc iu tr
Nguyn tc iu tr
- Ph thuc vo tng trng hp ngi bnh c th.
- iu tr ton din: h nhn p phi hp bo v, tng cng dinh dng cho th
thn kinh, iu tr bnh ton thn.
- Theo di nh k tnh trng nhn p, a th gic v th trng iu chnh ch
theo di v iu tr cho hp l.
- iu tr nhn p: NA cn iu chnh v mc bnh thng ca mt ngi Vit
Nam bnh thng (15 NA < 22 mmHg), dao ng nhn p trong 24 gi < 5 mmHg
(NA k Maclackov, qu cn 10g).
Tuy nhin mi ngi bnh c mc NA ch ring (mc NA khng gy tn hi tip
tc th thn kinh) m ngi thy thuc cn xc nh trong qu trnh iu tr v theo di
ngi bnh.
- i vi glcm giai on sm: NA ch 22 mmHg
- i vi glcm giai on mun: NA ch 20 mmHg
- i vi glcm nhn p khng cao: cn h khong 30% mc NA ban u.

3.1. iu tr glcm gc m nguyn pht

Phc iu tr glcm gc m nguyn pht
La chn u tin:
iu tr thuc tra mt h NA

Hiu qu

Tip tc
- iu tr thuc tra mt
-Theo di, nh k
kim tra a TG v TT

Khng hiu qu

iu tr
phu thut

Khng
hiu qu

iu tr laser

Hiu qu
- Theo di, nh k
kim tra a TG v TT

n nh

n nh
Khng n nh

- Ngay sau khi chn on xc nh bnh glcm: ch nh iu tr cp cu h

nhn p bng thuc tra mt v ton thn ( ung, tim, truyn).
- Sau khi nhn p h xung mc bnh thng: tip tc duy tr iu tr bng
thuc h nhn p tra ti mt.
- Nu iu tr thuc tra mt khng h c nhn p: chuyn iu tr laser.

16

- Nu iu tr bng thuc h nhn p tra mt v laser khng hiu qu: chuyn iu

tr phu thut.
- Nu ngi bnh khng c iu kin theo di hoc iu tr thuc lu di hoc c
s y t khng c my laser iu tr: ch nh can thip phu thut h nhn p sm.
iu tr thuc
Nguyn tc chn thuc
- Thuc c tc dng t v duy tr NA ch n nh lu di. Dao ng nhn p
trong ngy < 5mmHg ( vi NA k Maclakov).
- Dung np tt.
- Khng gy tc dng khng mong mun.
- Tin s dng ( t ln tra).
Nguyn tc ch nh thuc iu tr
- Bt u bng mt thuc vi nng thp nht.
- Nu cha t hiu qu hoc gy tc dng ph: thay mt thuc nhm khc.
- Nu vn khng t hiu qu: b sung thm thuc nhm khc hoc dng thuc
phi hp c nh.
Lu : Hng dn cho ngi bnh chia khong thi gian dng thuc hp l, cc
thuc tra cch nhau t nht l 5 - 10 pht.
Phn loi thuc h nhn p
- Cc thuc dng ton thn h nhn p
STT

Nhm thuc
c ch men CA

Mc % h
NA

C ch tc dng
Gim tit thu dch

Acetazolamid
250 mg

Acetazolamid
500mg/5 ml
-Glycerol 50%

40%- 50%

STT

-Ung 2-4 vin

-Tim TM 1 ng

Tng p lc thm
thu ca mu, to
mc chnh lch nng
gia mu v dch
knh lm rt nc t
dch knh ra

-Mannitol

Cch dng
( / ngy)

Liu cng
cao, a
vo c th
cng
nhanh
cng
h
NA c
nhanh,
nhiu

-Ngi ln: 1g-2 g/

kg / ln ung.Tr
em:
1g-1,5g/ kg cn
nng/ 1 ln ung

Chng ch
nh
- Tin nhim
acid
- D ng
sulfamid
- ang dng
nhm digitalis
- Ph n c thai
- T
- HA cao

-Tim TM 1,5g -2g/

kg

Cc thuc tra mt h nhn p

Nhm thuc

c ch men Carbonic
Anhydrase:
- Brinzolamide 1%

c ch -giao cm

C ch tc
dng
Gim tit thu
dch

Mc %
h NA

20%

Cch dng
( / ngy)
2-3 ln

- Dorzolamide 2%
2 ln

17

Chng ch
nh
-Tin nhim
axit
- D ng
sulfamid
- ang dng
nhm Digitalis
Timolol khng

- Khng chn lc: Timolol

0,25%; 0,5%
- Chn lc 1:
Betaxolol 0,25%,0,5%

Cng ph giao cm:

3

Pilocarpine 1%,2,3%, 4%,

Glaucostat 2%
Carbachol 1,5%;3%

Ch phm t Prostaglandin:
4

Latanoprost 0,005%
Bimatoprost 0,003%
Travoprost 0,004%

Cng v - giao cm:

5

Epinephrin 0,25%, 2%

Cng 2 - giao cm
6

Brimonidine 0,15%; 0,2%

c dng khi
c: bnh tim,
hen ph qun,
tc nghn phi
mn tnh, i
tho ng

20-25%

Tng
thot
dch qua vng
b
Tng
thot
dch qua MB
cng mc v
tnh mch
- Tng thot
dch qua mng
b o-cng
mc
- Gim tit thy
dch

20-25%

3 4 ln

- Cn th nng,
tin s bong
vng mc, vim
mng b o
- Mt mi m

25-35%

1 ln

- Vim nhim
mt

15-20%

20-25%

3-4 ln

2 - 3 ln

- Glcm gc
ng
-ang dng
thuc c ch
MAO
- Thn trng:
bnh nhn
mang thai, con
b, tr em

Thuc phi hp c nh:

Timolol v
+ Ch phm t Prostaglandin
(Ganfort, Duotrav, Xalacom,
Lacoma T)
+ c ch men Carbonic
Anhydrase (Cosopt)
+ Cng ph giao cm (Fotil)
+ Cng 2 - giao cm
(Combigan)

1 ln
C ch phi
hp ca 2
nhm

2 ln
2 ln
2 ln

iu tr laser
- c p dng nhng c s y t c trang b my laser iu tr.
- Loi laser c th s dng c trong iu tr glcm gc m: laser argon, laser
diode hoc laser YAG.
- Cn b thc hin: bc s chuyn khoa mt c o to v k thut iu tr
glcm bng laser.
- K thut: c thm Hng dn quy trnh k thut bnh vin .
a) t laser vng b: dng laser t trc tip ln vng b to ra nhng so co
ko c tc dng lm m rng cc l b xung quanh gip thu dch thm qua d dng
hn. Mi t iu tr lm trn 180o ca vng b, sau nu cn s lm nt 180o cn li.
b) t laser vng b chn lc s dng laser YAG Q-switched 532 nm. Nng
lng laser ch c cc t bo c sc t ca vng b hp th nn khng gy ph hu
vng b nhiu nh to hnh b theo phng php k trn.
3.1.3. iu tr phu thut
Ch nh:

18

- Sau khi iu tr bng thuc v laser m nhn p khng t ch hoc iu chnh

khng n nh, chc nng th gic tip tc bin i.
- Ngi bnh khng c iu kin iu tr bng thuc.
- Ngi bnh khng c iu kin i li khm theo di.
- Ngi bnh khng tun th tt ch iu tr thuc theo ch dn ca bc s.
K thut: c thm Hng dn quy trnh k thut bnh vin.
Cn b thc hin: bc s chuyn khoa mt c o to v cc phng php
phu thut iu tr glcm.
a) Phu thut l r
Phu thut l r (ct b, ct trc b, phu thut kt cng mc ...) c tc dng h
nhn p tt trong a s cc trng hp.
b) Phu thut ct cng mc su khng xuyn thng
Lp cng mc c lng n tn ng Schlemm, sau bc nt thnh trong ng v
lp b thnh. Do khng m thng vo tin phng nn trnh c hu ht cc bin chng
c th gp phi trong phu thut l r.
Lu : Trong iu tr phu thut trn nhng ngi bnh c nguy c ti pht cao do
to so x nh tui tr, phu thut l r tht bi... hn ch nguy c to so x sau
m nn kt hp vi thuc chng phn bo nh 5-fluorouracin hoc mitomycine C
dit cc nguyn bo x.
c) Phu thut t van dn lu tin phng: c ch nh trong trng hp phu
thut l r nhiu ln tht bi.
d) Laser quang ng th mi, in ng th mi, lnh ng th mi: l cc bin
php cui cng ch nh trong nhng trng hp mt m v au nhc.
3.2. iu tr glcm gc ng nguyn pht
Nguyn tc chung
- iu tr c 2 mt. Mt cha b ln cn tng nhn p cn iu tr d phng.
- Bt u iu tr cp cu bng thuc h NA, co ng t, chun b iu kin an
ton cho iu tr bng laser v phu thut.
- La chn phng php laser v phu thut da vo tnh trng gc tin phng:
Nu gc tin phng cn m chu vi: ct mng mt chu bin bng laser hoc
phu thut.
Nu gc tin phng ng chu vi: phu thut l r.
3.2.1. iu tr thuc
H nhn p cp cu bng thuc
- Co ng t bng thuc cng ph giao cm (pilocarpine, glaucostat, carbachol)
- B sung thm thuc h nhn p nhm c ch -giao cm (timolol, betaxolol)
hoc c ch men CA (brinzolamide, dorzolamide, acetazolamid), nhm tng thm thu
(glycerol, mannitol) tng thm tc dng h nhn p trong nhng trng hp nhn
p rt cao.
- Lu : thuc co ng t chng ch nh trong iu tr glcm c tnh. Thuc
cng -giao cm chng ch nh trong iu tr glcm gc ng.
Gim au.
An thn.
3.2.2. iu tr laser
- Ct mng mt chu bin bng laser: ch nh nu iu tr thuc NA iu chnh,
ng t co v gc tin phng cn m > chu vi ca gc.

19

- Laser to hnh gc tin phng: ch nh khi NA khng iu chnh sau iu tr

laser ct mng mt chu bin.
3.2.3. iu tr phu thut
Phu thut ct mng mt chu bin
Ch nh:
- Nh vi laser ct mng mt chu bin. Thc hin c s khng c my laser
iu tr.
Mng mt qu dy khng lm laser ct mng mt chu bin c
Phu thut ct b gic cng mc
Ch nh:
- Nhn p khng iu chnh c bng thuc.
- Sau iu tr bng thuc tch cc nhn p iu chnh nhng ng t vn b
gin do c co ng t b tn thng v gc tin phng ng dnh > chu vi.
- Nhn p khng iu chnh sau laser ct mng mt chu bin.
Phu thut ly th thy tinh, t th thy tinh nhn to hu phng
Vi glcm gc ng c km c th thu tinh gy nh hng nhiu n th lc:
- Nhn p iu chnh v cc mi trng trong tr li sau iu tr thuc h NA,
gc tin phng ng < chu vi gc: ch nh phu thut th thy tinh.
- Nu gc tin phng ng dnh > chu vi: ch nh phu thut phi hp th thy
tinh v ct b gic cng mc.
Phu thut th thy tinh phi hp ct dch knh, laser quang ng th mi ni
nhn: ch nh trong iu tr glcm c tnh.
Phu thut quang ng th mi, in ng th mi, lnh ng th mi: (Tng t
i vi glcm gc m).
3.2.4. iu tr mt s hnh thi glcm gc ng
a) iu tr cn glcm cp din
X tr cp cu bng thuc h NA ngay sau khi chn on bnh
Ti mt:
- Tra thuc co ng t pilocarpin 1%; 2% 15-20 pht / 1 ln n khi ng t co
v NA h. Liu duy tr 3-4 ln/ ngy.
- Tra phi hp nhm thuc h NA khc nh c ch - giao cm (timolol,
betaxolol) 2 ln/ngy hoc thuc c ch men AC (brinzolamide, dorzolamide) 2-3
ln/ngy tng cng tc dng h nhn p.
Ton thn:
Ung acetazolamid 0,25g x 2-4 vin / ngy.
Nu ngi bnh nn nhiu, thuc ung khng c tc dng: tim tnh mch
acetazolamid 500mg ( Diamox) x 1 ng.
Trong trng hp NA tng qu cao: c th phi hp tim tnh mch
acetazolamid 500mg v ung acetazolamid 500mg.
Ung b sung kali, thuc gim au, an thn.
Trong trng hp NA tng rt cao c th b sung cc loi thuc tng thm
thu nh truyn tnh mch nhanh mannitol liu 1-2g/kg cn nng (20% x 200ml) hoc
ung dung dch glyxerol 50% ( Ngi ln: 1g -2 g/ kg cn nng/ 1 ln, sau nu cn
thm liu 500mg/ kg cn nng/ 6 gi; Tr em: 1g-1,5g/ kg cn nng/ 1 ln, khi cn thit
liu nhc li sau 4-8 gi).
iu tr sau cp cu bng thuc

20

Sau khi ct c cn glcm cp ty vo tnh trng gc tin phng ch nh

phng php iu tr laser hay phu thut.
- Gc tin phng m > chu vi:
Nu gic mc trong: ct mng mt chu bin bng laser
Nu gic mc ph, mng mt qu dy: ct mng mt chu bin bng phu thut
- Gc tin phng ng> chu vi:
ng t co tt: laser ct mng mt chu bin phi hp laser to hnh gc tin
phng
ng t khng co hoc co na vi: phu thut l r (ct b)
b) iu tr glcm gc ng bn cp
- Gc tin phng m > chu vi: ct mng mt chu bin.
- Nu gc tin phng ng dnh nhiu, NA khng iu chnh sau laser ct mng mt
chu bin: phu thut ct b gic cng mc hoc m th thu tinh phi hp ct b.
c) iu tr glcm gc ng mn tnh
u tin cn ct mng mt chu bin gii phng nghn ng t.
Sau tip tc iu tr h NA bng thuc.
Trong qu trnh theo di cn ch tnh trng cc chc nng th gic.
Ch nh phu thut khi NA khng h c bng thuc.
d) iu tr glcm mng mt phng
- iu tr thuc cp cu h NA:
+ u tin: tra thuc co ng t.
+ Nu nhn p vn cn cao cn b xung thuc h nhn p nhm khc.
- iu tr laser sau khi iu tr h NA bng thuc: laser to hnh gc tin phng
phi hp vi laser ct mng mt chu bin.
- iu tr phu thut:
+ Khi nhn p khng iu chnh bng laser.
+ C s y t khng c my laser nhng ngi bnh khng c iu kin i ln
tuyn trn iu tr.
e) iu tr glcm c tnh nguyn pht
iu tr thuc
Tra thuc lit iu tit (atropin) gip gin ng t v gim tit thy dch vo bung
dch knh.
Tra phi hp thuc h nhn p nhm khc.
Lu : Tuyt i chng ch nh thuc gy co ng t.
iu tr laser
Laser ct mng mt chu bin kt hp bn thng mng hyaloid trc to ng
thot thy dch trc tip t bung dch knh vo tin phng.
iu tr phu thut
Ch nh khi iu tr thuc v laser khng hiu qu.
Ly th thy tinh, ct dch knh, ti to tin phng.
Trong nhiu trng hp nhn p qu cao cn phi hp thm quang ng th
mi ni nhn.

21

Glcm gc ng
nguyn pht

C nghn ng t
(cp, bn cp, mn tnh)

Khng nghn ng t
(glcm mm phng)

Thuc co ng t

Thuc co ng t

Thuc gim tit TD

Thuc gim tit TD

ng t co c
Gc ng < chu vi

ng t khng co c
Gc ng > chu vi

Laser ct MM chu bin

NA iu chnh tt

NA khng iu chnh tt

NA khng iu chnh tt

NA iu chnh tt

Theo di

22
Theo di

Laser to hnh MM
Laser ct MM chu bin

Ct b

Phn 3

THEO DI, QUN L NGI BNH GLCM

1. MC CH
Qun l, theo di lu di kim sot c qu trnh tin trin tip tc ca
bnh glcm, bo v c chc nng th gic cho ngi bnh.
2. I TNG
- Cc i tng c cc yu t nguy c cao sau khi c kim tra chuyn khoa
mt, cha loi tr c bnh glcm, cn theo di nh k tip tc theo lch hn ca y
t c s x hoc bc s chuyn khoa.
- Ngi bnh glcm ang theo di, iu tr ni khoa bng thuc h nhn p.
- Ngi bnh glcm tri qua t iu tr ni khoa, phu thut tuyn y t
chuyn khoa mt.
- c bit lu ti tuyn y t c s i vi ngi bnh glcm sc khe yu, neo
n, hon cnh kinh t kh khn khng c iu kin i li thm khm nh k ti cc
tuyn chuyn khoa.
3. CHUN B CC IU KIN
3.1. Nhn lc
- Cc bc s, iu dng chuyn khoa mt ca cc c s chm sc mt tuyn
qun/huyn, tnh c tp hun v phng php theo di v qun l bnh nhn
glcm.
- Cn c s phi hp cht ch gia cn b chm sc mt tuyn iu tr cc cp
vi cn b chuyn trch mt ca Trung tm y t v cc trm y t x, y t thn bn.
3.2. a im

23

3.2.1. Tuyn y t c s ( Trm y t x)

C th t chc qun l ngi bnh glcm di s ch o ca Trung tm y t huyn v
tuyn y t chuyn khoa cao hn.
Lp danh sch ngi bnh glcm, theo di qu trnh iu tr ca ngi bnh, nhc
nh ngi bnh i kim tra mt nh k theo lch hn ca bc s chuyn khoa.
T vn, tuyn truyn cch chm sc, phng chng m lo do bnh glcm trn a
bn qun l.
Khi cn iu tr th gi ngi bnh ti tuyn iu tr (Bnh vin huyn).
3.2.2. Cc c s chm sc mt tuyn qun/huyn, tnh, trung ng
T chc qun l, khm nh k, theo di ngi bnh glcm n khi tnh trng
bnh n nh s chuyn tuyn y t c s qun l, theo di tip tc.
3.3. Dng c, trang thit b
Cc trm y t x
- Bng o th lc.
- n pin
- Nu c cn b c o to bit s dng, c th trang b thm b dng c
o nhn p Maclakov.
Cc c s chuyn khoa mt
- Cc thit b phc v cho khm pht hin glcm nh bng o th lc, dng c
o nhn p, my soi y mt, sinh hin vi khm bnh, knh soi gc tin phng, my o
th trng ( nu c iu kin).
- c s chm sc mt tuyn tnh, thnh: nu c iu kin cn trang b cc thit
b chn on hnh nh: my o chiu dy gic mc, my chp nh a th gic, my
chp ct lp a th-vng mc....
3.4. H s qun l
3.4.1. Phiu theo di ngoi tr ngi bnh glcm
- Mi ngi bnh c mt phiu theo di ngoi tr vi y cc thng tin c
nhn (h, tn, tui, a ch ....), tin s, bnh s cc bnh v mt v ton thn, cc
phng php v ang iu tr, kt qu khm v chc nng th gic, cc bin i
thc th ca mt cc ln khm li.
- Phiu theo di c lu gi ti phng Qun l bnh nhn glcm c s y t
chuyn khoa mt v b phn qun l glcm ca trm y t x, sp xp theo th t
A,B,C...tn ngi bnh, ngy hn khm li.
3.4.2. S qun l ngi bnh glcm

Ghi danh sch ngi bnh glcm trong a bn c s.

3.4.3. S ghi chp tnh hnh ngi bnh khm li
- Thi gian khm.
- Tnh trng th lc, nhn p, a th gic, th trng.
- Phng php iu tr, ang iu tr.
- Ch iu tr tip theo.
- Lch hn kim tra li ca bc s.
3.4.4. S hn khm li
Mi ngi bnh c mt quyn s hn khm li gip cho ngi bnh nh ngy ti
khm ln sau, ng thi gip cho Phng qun l bnh nhn glcm nh gi c
ngi bnh c thc hin ng yu cu qun l hay khng.
3.4.5. Lch hn khm li

24

Do b phn qun l ngi bnh thit lp.

Ghi s h s hoc h tn nhng ngi bnh c hn ti khm li vo nhng
ngy n nh sn. n ngy hn, iu dng ly sn cc h s ch ngi bnh ti cho
bc s khm. Nu ngi bnh khng ti, ch vi ngy sau khng thy th gi th hoc
in thoi nhc ngi bnh ti kim tra li vo mt ngy gn nht.
Lch hn s gip cho vic qun l cht ch ngi bnh.
4. PHNG THC LM VIC
Ngy khm li: n nh vo 1-2 ngy ca tun tp trung ngi v chun b
h s chu o.
Nhng ngi bnh n khm v iu tr ln u tin hoc nhng ngi bnh
c qun l nay b cn tng nhn p, gim th lc phi c nhn khm ngay.
S ngi hn ti khm li mi ln tu theo kh nng x tr ca tng phng
Qun l ngi bnh glcm.
Thi gian hn ngi bnh khm li tu thuc bnh trng, mc iu chnh
nhn p, s tin trin ca bnh.
Ngi bnh cn i khm kim tra li ngay khi c xut hin cc triu chng
ca bnh nh au , nhc, nhn m nh qua mn sng m, cm gic cng tc mt.
Ngi bnh iu tr ni khoa bng thuc cn hn theo thi lng ca thuc
m bo iu tr khng b ngng v ht thuc.
Ngi bnh c nguy c cao mt chc nng th gic, nhn p giao ng, iu
chnh khng n nh, nghi ng bnh tip tc tin trin: hn khm nh k 1 thng 1 ln.
Ngi bnh c nhn p iu chnh n nh sau m: hn khm 3 thng / 1 ln
trong nm u, sau 6 thng /1 ln.
i vi nhng i tng nghi ng c bnh glcm: nu kt qu khm xt,
th nghim m tnh th hn ti khm li, tin hnh th nghim li khong na nm mt
ln. Ch phng xy ra kt qu dng tnh chm sau th nghim.
Sau 2 nm lin bnh glcm khng c xc nh th ngng qun l nhng phi
cn dn i tng i khm li bt k lc no khi c nhng du hiu ca glcm.
5. nh gi s tin trin ca bnh glcm
Bnh c coi l tip tc tin trin nu c mt trong cc biu hin sau:
Nhn p
- Nhn p khng iu chnh khi khm nh k
- Nhn p dao ng gia cc ln khm 5 mmHg ( NA k Maclakov).
- Tuy nhin NA c th cao ngoi gi khm bnh v gy nhng bin i tip tc
a th, th lc v th trng.
a th gic
- Da vo kt qu soi y mt trong mi ln khm li.
- Chn on hnh nh chp a th gic, kt qu OCT, HRT a th gic v lp si
thn kinh vng mc 6 thng mt ln.
- Nhng ca nng, nhn p iu chnh khng n nh, nghi ng bnh tin trin xu
i th phi kim tra sm hn.
- Cc ch s theo di bao gm:
+ a th gic, t l L/ (trc ng): lm a rng ra.
+ T l vin thn kinh/a th gic: gim.

25

+ B dy ca cc lp si thn kinh quanh a gim (s bin i c ngha nu

gim > 20m ): bnh glcm vn tip tc tin trin.
Th trng
So snh cc ln lm th trng da vo chng trnh phn tch s thay i v kt
qu in ra tng th.
- Th trng ng (Maggiore, Goldmann)
+ i vi cc giai on sm: th trng thu hp thm 10.
+ i vi cc giai on khc: th trng thu hp thm 5 - 10.
+ i vi giai on mun, th trng hnh ng (10 cch im nh th): th
trng thu hp thm 2 - 3.
+ m im m rng thm 5. Xut hin m im mi c rng 5.
- Th trng Humphrey
Cc tiu chun nh gi mc tin trin tn thng trn th trng da trn
kt qu ca 2 ln lm th trng lin tip thy:
+ Xut hin im tn hi mi (trn 1 vng trc khng c tn thng).
+ Tng mc tn hi vng tn thng c trc .
+ m im rng ra, tng s im tn hi.
+ Mt lan ta: khng do nh hng ca c th thy tinh trung tm hoc do
kch thc ng t.

MU H S QUN L NHUO BNH GLCM

Mu 1
B Y T
PHIU THEO DI BNH NHN GLCM
Bnh vin Mt ...

S lu tr:
M s :

I. HNH CHNH
Tui
1. H v tn:.. 2. Ngy sinh

3. Gii: Nam
N
..........................

4. Ngh nghip:

5. Dn tc:.
6. Ngoi kiu:
..........................
7. a ch: S nh . Thn, ph .. X, phng
. Huyn (Qun, th x) ........
Tnh (thnh ph) ...........................
8. Ni lm vic: ................... 9. i tng: 1.BHYT
2.Thu ph
3.Min
4.Khc
10.BHYT gi tr n ngy thng nm 20.. S th BHYT:
.................................
11. H tn, a ch ngi nh khi cn bo tin:
................................................

26

. S in thoi lin lc:

....
12. n khm bnh lc ...... gi..... pht ngy ... thng ..........nm
20............
13. Chn on ca ni gii thiu: ...............................................
.
II. L do i khm:
1. Nhc mt:
d di
va
nh
khng
2. Nhn: m t ngt
m tng lc
sng m
khng m
m tng dn
nhn thu hp
qung tn sc
3. S nh sng, chy nc mt: c
khng
4. mt:
c
khng
5. Ton thn:
au u
nn
bun nn
khng
6. Cc triu chng khc: ...
.
III. Qu trnh bnh l
1. Thi gian xut hin bnh:
..
2. C s y t khm v iu tr: Huyn
Tnh
Trung ng
Khc
3. Phng php iu tr:
Phu thut Thuc Laser
4. Phu thut thc hin:
Ln 1

Mt phi
Ln 2 Ln 3

Ln 4

Ln 1

Mt tri
Ln 2 Ln 3

Ln 4

Loi phu thut

1. ct b CGM 2. ct b+CCH 3. ct CMS 4. ct CCM+CCH 5. ct MM ngoi vi 6.
van dn lu 7. quang ng TM 8. lnh ng TM 9. sa so bng 10. kt cng mc

Thi im p.thut
Ni phu thut
1. bnh vin huyn 2. bnh vin tnh 3. bnh vin trung ng 4. ni khc

5. Thuc h nhn p dng:

ung
1 thuc

tra mt
2 thuc

tim
3 thuc

thuc
Mt

Tn thuc

Liu dng

27

Thi gian
dng

Ghi ch

6. Cc thuc khc:
...
7. Tin trnh iu tr: .
.............................................
IV. Tin s cc bnh mt khc
Cn th

Vin th

Chn thng

Vim mng b

o
Vim phn trc nhn cu
Tc TMTTVM
PT mt (Ghi r) : .........................................................................................
Bnh khc (Ghi r).........
Tin s dng corticosteroid ko di. Tn thuc: ...............................................
Thi gian s dng:...
- ng dng:
Tra mt Tim mt
Ton thn
- Theo ch nh ca bc s
Bnh nhn t dng thuc
V. Tin s bnh ton thn
Tim mch Huyt p (cao, thp)
i ng
Thn kinh
( T., ngoi vi)
R ng mch cnh - xoang hang
Bnh khc (Ghi r )..........................
VI. Tin s bnh glcm trong gia nh
ng, b
b, m
anh, ch, em
c, d, ch, bc

VII. Khm mt
Mt phi

Mt tri

Th lc vo
.
vin:
Khng knh .
C knh
Nhn p

mmHg
Sng n mi mt
C
Khng
Kt mc
- Cng t
- So m
c
- Bng d

C
Khng
C
Khng
tt dt x mng qu
pht

28

.
.

mmHg
C

Khng

C
Khng
C
Khng
tt dt x mng qu
pht

Gic mc
- Tnh trng
trong sut
- Ph n,
bng biu m
- dy gic
mc
- Ta ( s
lng, v tr)
- ng knh
gic mc
Cng mc
- Dn li
- So m
Tin phng
- su
(p.p Smith)
- P.p Herick
Gc tin phng

Du hiu khc:
Mng mt
- Mu sc
- Tnh trng
thoi ho
- Tn mch
ng t
- ng
knh
- Vin sc
t
- Phn x
Th thy tinh

Dch knh

trong so lon dng

C
Khng
.
.
.

C
C

Khng
Khng

trong so lon dng

C
Khng
.
.
.

C
C

Khng
Khng

..................................................mm
<1/4. 1/4.1/2.GM

..mm
<1/4. 1/4.1/2.GM

C
Khng
C
Khng

C
Khng
C
Khng

trn
mo
.
.
bnh thng gim mt

trn
mo
.
.
bnh thng gim mt

trong
c
nhn v di bao ton
b
trong
c
.........................................................

trong
c
nhn v di bao ton
b
trong
c
...............................................
..........

y mt:
- Vng mc .
- Hong
.
im
C
Khng
- Tn mch
C
Khng
- Xut
huyt
a th gic
- Vin thn
bnh thng bt thng

29

.
.
C
Khng
C
Khng

bnh thng bt thng

(di trn mi thi dng)

kinh
- Mu sc
- C/D
- Mch mu
- Xut huyt
- Teo cnh

... ...

bnh thng chuyn hng gp
gc

C
C

gai
Vn nhn, lc
Nhn cu

(di trn mi thi dng)

Khng
Khng

bnh thng chuyn hng gp

gc

C
C

bnh thng dn li to
nh

Khng
Khng

bnh thng dn li to
nh

Hc mt

VIII. Cc xt nghim cn lm: ...............................................................................................

IX. Chn on:
1. Bnh chnh
- Mt phi:..................................................
- Mt tri:...............................................
2. Bnh km theo: ................................................
..
3. Bnh ton thn: ...............................................
..
X. Ch nh iu tr: .............................................................

.......................................................
XI. Tin lng: ..............................................................
................
Ngy .. thng .. nm 20....
Bc s lm bnh n

H v tn...........................................
NGY
GI

XT
NGHIM

DIN BIN BNH

30

Y LNH

Mu 2

PHIU THEO DI BNH NHN GLCM .....

( Ti BVK huyn, BV Mt tnh nm 20..... 20.....)

M: ... / ... /... /

A. THNG TIN CHUNG

H v tn:
Tui:
Gii:

1. Nam.

2. N

BHYT: 1. C.

Khng

31

2.

a ch:
in thoi:

NR:........................

D.........................

Thi gian b bnh glcm: ...................................................................................................

Ni pht hin glcm u tin: 1. TYT x 2.BV huyn
Ni iu tr glcm:

1. TYT x 2.BV huyn

3.BV tnh 4. TW 5. Khc ..

3.BV tnh 4. TW 5. Khc

Thi gian iu tr:

Phng php iu tr:

1. thuc

2. laser

3. PT

4. TD.

MP MT Chn on:
MP MT Ch theo di:
Ti TYT x: o TL, NA

thng / 1 ln.

Ti BVK huyn: o TL, NA, soi y mt, th TT s b

Ti BV Mt tnh:

thng / 1 ln

..............................................................................................................

Ti k.Glcm BVM TW:

a im theo di: BVK ..............................

BV Mt tnh ............................ Khoa Mt BVK tnh .............................

B. KT QU THEO DI
Ngy
khm
Tnh
trng
bnh nhn

MP
Triu
chng

MT

32

TL
NA
a th

MP
MT
MP
MT
MP
MT
MP

TT

MT

Th

MP
MT

nghim

Ch nh

Xc nhn ca Bnh vin

Bc s theo di

Mu 3

PHIU THEO DI BNH NHN GLCM .....

( Ti TYT x nm 20.... 20....)

M:..//

A. THNG TIN CHUNG:

A1 - H v tn:
A2 - Gii:

Tui:

1. Nam.

2. N

A3 - a ch:
A4 - in thoi:

NR:........................

D.........................

A5 - Thi gian b bnh glcm: ...................................................................................................

A6 - Ni pht hin glcm u tin: 1. TYT x 2.BV huyn 3.BV tnh 4. TW 5. Khc

A7 - Ni iu tr glcm: 1. TYT x 2.BV huyn 3.BV tnh

33

4. TW 5. Khc

A8 - Thi gian iu tr:

A9 - Phng php iu tr:

1. thuc

2. laser

3. PT

4.

TD.
Thuc ang iu tr: MP:. MT..
Phng php laser iu tr: MP:

MT:

Phng php phu thut iu tr: MP MT A10- Chn on:

MP:
MT:
A11- Ch theo di:
Ti TYT x:

....................................................................................................................

Ti BVK huyn:

Ti BV Mt tnh:

..............................................................................................................

Ti k.Glcm BVM TW:

A12 - a im theo di: Trm Y t x ..............

B. KT QU THEO DI:
Ln
khm

Ngy
khm

Triu
chng

Th lc
MP

MT

Nhn p
MP

1
2
3
4
5
6
7
8
9
10
11
12
13

34

MT

Ch
TD,
iu tr

Lch
hn
KL

Ghi ch

14
15
Trng trm Y t x

Cn b CSMB ca Trm Y t

Mu 4
BNH VIN..............

- KHOA ...........
S HN KHM LI
(Bnh nhn glcm ngoi tr)

H tn:
Nam
N
a ch lin lc:

Tui
SBA:

S in thoi:
Chn on:
G

GM
Khc
iu tr:
MP:
Ct b
Ct MM bng laser, PT Thuc
Ct CMS Quang ng TM

Van DLTD
MT:
Ct b
Ct MM bng laser, PT Thuc
Ct CMS
Quang ng TM
Van DLTD
Phng php khc (Ghi r):.........................................................
Ln

Ngy khm

Lch hn khm li

35

BS khm

TI LIU THAM KHO

1. Nguyn Trng Nhn (2006): Tuyn tp cc cng trnh nghin cu tp 1,
Nh xut bn Y hc
2. Nh Hn, Nguyn Ch Dng ( 2009): Bo co tng kt cng tc phng
chng m la Vit Nam nm 2008-2009, K yu tm tt cc cng trnh
nghin cu nm 2009.
3. Hi Nhn khoa M (1993-1994): Bnh Glcm, Tp 10. Ti liu dch ca
Nguyn c Anh ( 1994) t sch Basic and Clinical Science Course, Section
10: Glaucoma, American Academy of Ophthalmology, Nh xut bn i hc
quc gia H ni.
4. T chc Y t th gii (2006): Th gic 2020: quyn c nhn thy Ti liu
Hi tho v Th gic 2020
5. T chc Y t th gii (2008): Communicable and non-communicable causes
of blindness Report on IAPB conference, Argentina 2008
6. Deborah Pavan-Langston (2008) Manual of Ocular Diagnosis and
Therapy, Williams and Wilkins, p.259-285
7. Hodapp E., Parrish R.K., Anderson D.R. (1993): Clinical decisions in
glaucoma. St.Louis, Mosby
8. Shields M B., Allingham R.R, Damji K.F., Freedman S, Moroi S.E.,
Shafranov G. (2005): Shields Textbook of Glaucoma, 5th Edition, Lippincott
Williams and Wilkins
9. (2007): , , -, .
253-271
10. (2008): , ,

36