NHUNG TON THI/ONG 0 PHAN SAU NHAN CAU

1. BONG VONG MAC

Bong v5ng mac co bieu hien dac trufng tren sieu am ve vi
tri cung nhiZ mute do 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 do cao cua be mat vong mac va ke do la
mot khoang trong am bieu hien dich dv/di vong mac.

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Hinh minh hoa cac tinh trang vong mac. (Day hinh ben trai) Cac bieu
do sieu am B do I6p hcic vong mac bj dciy len di/oc hien thj v6i do
nhan cam he thong toi da (A) va do nhay cam he thong di/pc tem
giam (B); Bong vong mac toan the dang pheu (C) va Bong vong mac

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xep nep ngoai bien (D). ( Day hinh ben phai) Cac bieu do sieu am A
do 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 do sieu am B, diidc do dat mot cach chinh xac tren
sieu am A khi lam giam do 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, trong 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 do
sieu am A co thiidc do diidc yeu cau de do do phan chieu cua
nhiing cau true mang trong mat dtfa tren do phan chieu cung
mac lam chuan. Bong vong mac thiidng tao ra nhiing tin hieu
manh dac hieu.

Vdi bieu do sieu am chuan hoa, bong vong mac co the phan
biet diidc vdi mang dich kmh dam dac vdi do chinh xac tren
98% (bong vong mac khong ro nguyen nhan) hoac 96% (bong
vong mac phiic tap chang han bong vong mac trong cac triidng
hdp cat dich kinh). Khoang diidi vong mac co the danh gia diidc

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mot cach dang tin cay bang sieu am A ma co the phan biet
diidc thanh dich, mau tiidi, can lin g, tinh the cholesterol va
nhiing to chiic ciing.

Bong vong mac co nay va van due dich kinh

 Bong vong mac diidc phau thuat cat dich kinh. that dai va
bctm silicone theo thiet do theo true triidc sau va sd do 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 do
sieu am.

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 Bong silicone ap sat toan ctfc sau nhan cau.an sat vao ph&n
trtfdc nhan cau. Hinh anh “mang” nam doc tren bieu do 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 do
a. 6 gid
b. Dien dtfdi
c. 9 gid.
d. Dien mui
e. 12 gid
f. Dien tren

g- 3 gid
h. Dien thai dtfdng

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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 trong giong nhi/
vong mac. Trong sieu am dinh khu thi bong den day cua mong m it
la dSc trimg cho bong dich kinh

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 Bone vdne mac dai diCdne

Thiet do thing ddng chinh giu'a va thiet do khao sat phan tren
Co nhiing mane triidc vong mac, ciing, keo va khong di dong

a. Thiet do khao sat kinh tuyen di qua hoang diem va thiet do

khao sat kinh tuyen thang goc vdi kinh tuyen tren
b. Co cac mang djch kinh, hut am manh, khong di dong d cue sau

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 M a n g vong m ac thiidng gap d mdt can thi nang (phan biet
vdi bong vong mac).

Thiet do ngang Thiet do doc

2. BONG HAC MAC

Cac dau hieu am hoc cua bong hie mac la vi tri, hinh
dang va do 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 ngay ca trong 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.

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 k i f

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c 1 1 a

c kk.

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Hinh minh hoa bong hac mac (C). Liru y nhumg xung day dinh doi
tren cac bieu do sieu am A va that vay ngay ca mot bong hac mac
sau rong cung khong dinh vao dTa thj tren bieu do sieu am B

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 Hinhanh tren sieu am B cua bong hac mac tai vung ora seratta
cho den goc tien phong day la diem phan biet vdi BVM.

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 Boris hac m ac va bong vong mac pho'i hdp

Cat theo true triidc sau Cat theo hiidng thai diidng - mui
Bong hac mac
Thiet do cat theo true va thiet do khao sat ctfc dif6i.

Vip.m noi nhan kem vdi cac benh ly khac:

Viem noi nhan la benh ly tram trong tai mat do nhieu tac
nhan vi khuan di kem vdi chan thiidng xuyen thung hoac phliu

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thuat. Tren sieu am B co the phat hien diidc cac benh ly noi
nhan du cho cac moi triidng trong suot deu bi v&n due
Khong co thuy tinh the tai vi tri gidi phau va viem mu noi nhan

Bong vong mac va viem mu noi nhan

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3. LOM GAI THj TRONG BENH GLAUCOM

G f

Hinh minh hoa cac bieu (Jo sieu am B cua mot mat co lom gai
glaucom toan bo (A,B,C) va mot mat binh thi/dng (D, E,F) di/oc ghi
nhan vdi do nhan cam he thong tdi da (A,D) va vdi do nhan cam he
thong giam xuuong 10db (B,E) va vdi do nhan cam he thong giam
xuong 20db (C,F). Lom gai toan bo cua dla thi diroc quan sat tot
nhat vdi do nhay cam he thong giam xuong dan tCr cao xuong thap.

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 Lom gai tren thiet do ngang

4. n h Qn g k h o i u c u a v o n g m a c

4.1. U nguyen bao vong mac (Retinoblastome)

Co tan so m&c benh la5 /100.000, thay doi tuy theo cac
nU6c khac nhau, u nguyen bao vong mac thiidng gap d tre em.
Tuoi trung binh cua loai u nay la vao khoang 13 thang tuoi.
Theo Reese, Haye 85% triidng hdp gap triidc tuoi len 3. Khoi u
gap ca hai ben mat chiem 18-30% triidng hdp va 80% triidng
hdp mang ti'nh chat gia dinh. Ngiidi benh cang nhieu tuoi thi
mac d hai mat cang It hdn. Mat thii hai co the mac benh tic
khac hay nhieu thang sau khi khoi u nguyen thuy xuat hien.
Khi khoi u xay ra ca hai ben thi moi mot khoi u tien trien
theo cach cua no. Tan so" cua nhiing triidng hdp co tinh chat gia
dinh la 3%. Sii lan truyen diidc thiic hien theo kieu the nhiem
sac thiidng troi.

4.1.1. Ve lam sang

U nguyen bao vong mac bieu hien bdi tinh trang dong tii
trang (Leucocorie): anh dong tii mau trang bong. Dau hieu
dong tii trang bong nay con co the la do nhieu benh khac nhau,

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lanh ti'nh dUdc tap hdp diidi danh tii la gia ung thii vong mac.
Chan doan u nguyen bao v5ng mac diidc khang dinh bang cach
kham day mat dudi gay me. Kham sieu am diidc yeu cau de
chan doan phan biet
- Trong muc di'ch chan doan khi kham day mat khong ro
hay khong the thiic hien diidc vi ly do co mot xuat huyet tien
phong, xuat huyet dich ki'nh hay due thuy tinh the. Sieu am
khang dinh hay bac bo chan doan u nguyen bao vong mac vdi
do chi'nh xac cao tren 95%.
- Trong muc di'ch tien liidng benh nham phat hien sii lan
toa cua khoi u vao thi than kinh, vao hac mac va vao hoc mat.
Viec xam lan vao nao chi diidc phat hien b&ng chup CT
scanner. Can phai danh gia diidc dien ti'ch vong mac bi ton hai.
- Trong sii theo doi tien trinh dieu tri nham phat hien sii
tai phat tai cho sau qua trinh dieu tri hay sau khi 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 nhau (Hinh 4.1 va 4.2), cau true sieu am
khong dong nhat the hien tren mot mat co kich thiidc binh
thtfdng, ca khi nhan cau to ra.

H inh 4.1 H inh 4.2

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 Khoi u la rat gay am vang v6i nhtfng vung tang am ttfng
dam v6i hinh chop cua hong liing ttfdng tfng vdi nhtfng dam
calci hoa.
Nhtfng dam calci ho;i
nay co the la rat min, rai
rac trong khoi u (Hinh
4.3, 4.4). Doi khi ngtfdi ta
co the tim thay nhtfng
vung it gay am vang
ttfdng tfng vdi mot vung
hoai ttf cua khoi. Cac bd
cua khoi u khong deu.
Phtfdng thtfc A cho phep
danh gia tinh chat mach
mau cua cac khoi u.
Kham nghiem phai danh
gia kich thtfdc cua moi
khoi u va vi tri cua u
cung nhtf tim nhtfng dau
hieu di kem chang han:
xuat huyet dich kinh Hinh 4.3: Khoi U nguyen bao to:
(Hinh 5.4): Bong vdng
mac hay nhieu khoi u rai
rac trong dich kinh.

Hinh 4.4

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 Sieu am chuan hoa la mot bd sung lam sang quan trong
trong viec danh gia nhan ciiu vdi dong tii trang. U nguyen bao
vdng mac tao ra cac bieu do sieu am dac trtfng trong hdn 95%
trtfdng hdp. Cac net dac trtfng am hoc cua u nguyen bao vong
mac la co do ttfdng phan cao ro ret va bong tdi dam tren cung
mac va nhiing cau true hoc mat phia sau u. Trong bieu do sieu
am A chuan hoa, ung thtf nguyen bao vong mac tao ra 100%
dinh xung cao (chieu cao dinh xung ngang b&ng vdi chieu cao
hien thi) dtfdc gop lai thanh nhtfng chuoi xung dac trtfng.
Chieu cao cua nhtfng dinh xung cung mac va hoc mat theo sau
nhtfng tin hieu u bi giam dang ke, khi dtfdc so sanh vdi bieu do
sieu am binh thtfdng hoac nhtfng bieu do sieu am d nhtfng mat
ttfdng ttf dtfdc ghi nhan khi chum song am di ngang qua khoi
u. Trong bieu do sieu am B, ung thtf nguyen bao vong mac tao
ra nhtfng tin hieu tap trung, sang, sap xep theo kieu dac trtfng
khi stf dung do phan giai he thong cao. Ngay ca khi giam do
phan giai nhieu thi nhtfng cham nho ddn doc van hien thi tren
man hinh nhtf nhtfng tin hieu u. Stf tao bong tdi cua khoi u gay
ra nhtfng khiem khuyet tren bieu do hoc mat va cung mac, ma
co the de nhan biet, tuy nhien chi khi lam giam do phan giai
he thong.
Nhtfng dau hieu am hoc nay, dac trtfng cua ung thtf nguyen
bao vong mac, dtfdc tao ra bdi nhtfng can lang calcium trong
khoi u ma co tmh chat giong nhtf nhtfng di vat nho nhieu.

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 o H

Hinh 4.5: U nguyen bao vong mac. (T: kieu dang u; S: Cung mac; O:
To chtfc hoc mat. (A) Bieu do sieu am A ghi di/dc d do nhan cam to
chtfc tCf mot khoi co bong li/ng manh (shadowing tumour), bi calci
hoa, dam dac, I6n; (B) Bieu do sieu am A ghi diroc d do nhan cam to

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chtfc tu" mot con mat bi benh ti/ong ttf nhi/ 6 hinh (A) ma co chum
song am di xuyen qua khoi u (li/u y si/ khac nhau ve chieu cao cua
cac xung hoc mat trong (A) va (B)); (C) khoi u co bong li/ng rong, co
nhieu diem calci hoa lan toa (don docu, cac xung u rat cao); (D) Bieu
do sieu am B ghi di/pc d do nhan cam he thong toi da ttf khoi u hut
am nhe, nho; (E) Khoi u hut am manh, I6n; (F) Khoi u giong nhi/ d E,
nhung hien thi d do nhan cam he thong dupe giam (Li/u y si/ hien
dien cua nhumg tf hieu manh do nhumg lang dong calci ben trong uL);
(G,H) Cac bieu do sieu am A cua u nguyen bao vong mac nho ghi
nhan di/pc d do nhan cam to chtfc va nhung cai dat de lam giam do
nhan cam ro ret. (Li/u bong li/ng cua u the hien ro bdi chieu cao
dinh xung cua to chtfc hoc mat bj giam d do nhan cam to chtfcL, va
chieu cao nho cua xung cung mac khi so sanh v6i nhtfng xung u 6
do nhan cam bj giam)

4.1.3. S u lan trim ra hac mac

Hinh 4.6. U nguyen bao vong mac

Khoi calci hoa 0 trung tam khoi u

tao nen mot chop bong li/ng hien len d
khoang sau cua nhan cau.
Kham nghiem thtfc hien 0 do
khuyech dai yeu, mdi thay di/dc
nhtfng dam calci hoa rat nhieu va nho
rai rac d trong khoi u. Ton hai cua nhtfng cau true nay thi/dng
la do di can gap trong nhtfng khoi u cd ldn.

4.1.4. Sis lan trim den thj than kinh

Thi/dng rat d i phat hien do co stf hien dien cua ttfng dam
calci hoa ldn, kem theo hinh chieu cua chop bong li/ng tren thi
than kinh (Hinh 5.5, Hinh 5.6) vi stf lan tran cua u lam cho
tien li/png nang hdn. Stf xam lan vao phan trong hoc m it cua

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thi than kinh do stf tang the tich cua no. Thi than kinh thtfdng
la giam gay am vang nhtfng doi khi co the tang gay am vang
do co stf calci hoa cua thi than kinh. Can phoi hdp vdi chup CT
scanner.

Hinh 4.7. Ung thtf nguyen bao vong mac co nhieu o kem theo stf lan
toa ra gai thj. Co mot mang dich kinh noi hai khoi u. Gai thi loi lan ra
vung dau cua thj than kinh co bien chtfng xuat huyet dich kinh.

Thiet do tham do dien phia dtfdi.

Thiet do tham do thi than kinh.
Khoi U bi calci hoa dong thanh mang va tao ra hinh chop
bong ltfng phfa sau lam che khuat thi th&n kinh sau nhan cau.
Nhtfng am vang trong nhan cau la di dong va ttfdng tfng vdi
mot xuat huyet trong dich kinh. B in g cach thay doi goc tdi cua
chum sieu am, dam calci hoa khong che thi than kinh sau
nhan cau ntfa, no xuat hien binh thtfdng.

4.1.5. S ii lan trAn ra hoc mat

Day la mot qua trinh lan ra ben trong hinh chop lam giam
am vang doi vdi ldp md bao boc thi than kinh. Co the gap

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nhtfng khoi u rat ldn choang toan bo hoc mat va dan den loi
nhan cau thtfc stf (Hinh 5.6). De danh gia chinh xac mtfc do lan
toa ra hoc mat nhieu khi gap kho khan bdi co nhtfng dam calci
hoa to nam ben trong khoi u, nen tao ra nhtfng hinh chop bong
ltfng phfa sau d trong hoc mat.

Hinh 4.8. U nguyen bao vong mac kem

theo loi mat.

Thiet do true.

Hinh 4.9. So do giai thich:

Khoi u ldn choang toan nhan cau va hau nhi/ bi calci hoa hoan
toan, xam chiem hoc mat ttfng dam.

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 Stf khac biet ve cau true sieu am cua stf lan toa trong hoc
mat nay. Thi than kinh la tang am vang vi no bi calci hoa. Stf
xam chiem cua 16p md d sau nhan cau la giam gay am vang vi
khong con nhieu mat phan gidi.
Chup CT Scanner la rat quan trong de xac dinh stf lan toa
sau nhan c iu va d trong so cua khoi u. Cung cian khao sat
nhiing hinh thai mo hoc cua loi mat de danh gia chinh xac sii
lan toa cua ton thtfdng.
Tien ltfdng luon luon la tien ltfdng song chet nhtfng cung la
tien ltfdng ve chtfc nang trong trtfdng hdp ton thtfdng d ca hai
mat. Nhtfng yeu to" tham gia vao viec tien ltfdng la:
- Tuoi: Benh nhan cang tre tien ltfdng cang xau.
- Ton thtfdng mot mat thtfdng tot hdn hai mat, nhtfng ton
thtfdng cua mot ben mat co the lan sang mat thtf hai.
- Ton thtfdng qua mot ntfa vong mac la tien ltfdng rat xau
ve mat chtfc nang.
- Stf lan toa cua khoi u vao thi than kinh co tien ltfdng rat
xau anh htfdng den stf song.
- Ban chat mo hoc cua khoi u: u te bao vong mac
(retinocytome), u biet hoa co tien ltfdng tot hon loai u nguyen
bao vong mac.
- Stf tien trien: Stf xuat hien cua tai phat tai ch6 hoac lan
truyen sang mat thtf hai cua khoi u hoac di can xa co the xay
ra cham hdn.
Reese da dtfa ra mot phan loai dtfa tren so" u va dtfdng
kinh cua nhtfng u nay so v6i dtfdng kinh gai thi, vi tri cua
nhtfng u nay doi vdi xich dao, viec co hay khong co stf rai rac
cua cac khoi u trong dich kinh.
Nhom 1:
a. Khoi u ddn doc co dtfdng kinh < 4 lan dtfdng kinh gai thi
nam d sau xich dao.

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 b. Nhieu khoi u co dtfdng kmh < 4 lan dtfdng ki'nh gai thi.
Nhom 2:
a. Khoi u co dtfdng ki'nh ttf 4 - 10 lan dtfdng ki'nh gai thi, u
doc nhat, n4m d phia sau xi'ch dao.
b. Nhtfng khoi u co dtfdng ki'nh ttf 4 - 10 lan dtfdng ki'nh
gai thi, nhieu khoi u, nam d phi'a sau cua xi'ch dao.
Nhom 3:
a. Mot hay nhieu khoi u nam d phi'a trtfdc cua xich dao.
b. Khoi u co dtfdng ki'nh gap 10 lan dtfdng ki'nh gai thi, u
ddn doc, nam d phi'a sau xi'ch dao.
Nhom 4:
a. Nhieu u ma co mot so" u co dtfdng ki'nh >10 lan dtfdng
ki'nh gai thi.
b. U n&m rai ra trtfdc vtfng oraserrata.
Nhom 5:
a. Khoi u xam chiem hdn 1/2 cua vong mac.
b. Cac khoi u n&m rai rac trong dich kmh.

4.1.6. Chan doan phan biet

Nhtfng ton thtfdng khac gay dong ttf tr&ng ma co the nghi
ngd nhtf u nguyen bao vong mac chang han nhtf xd san sau
thuy tinh the, qua san dich ki'nh nguyen phat, benh COATS,
viem mu noi nhan va loan san vong mac, cho thay dac ti'nh am
hoc hoan toan khac vdi dac diem am hoc cua u nguyen bao
vong mac. Nhtfng ton thtfdng nay bieu thi mot cau true ben
trong dang mang va ngoai trtf nhtfng giai doan cuol cua m&t
teo nhan, khong tao nen bong ltfng. Mac dau trong nhtfng giai
doan sdm cua u gia gliome co the dtfdc chan doan phan biet
vdi cac loai benh ly khac ve mat sieu am, nhtfng d giai doan

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teo nhan thi khong the. 6 nhiing m it teo, cac nep gap cung
mac va dac biet la sii tao xiidng co the gay nen nhiing bong
liing khac thiidng ma thiidng hiem khi xay ra trong u nguyen
bao vong mac.
Ngoai ra de gop them vao chan doan ban dau cua u nguyen
bao vong mac, bieu do sieu am chuan hoa do diidc sU nho len
cua u mot cach chinh xac va vi vay rat quan trong de theo doi
hieu qua dieu tri ca d mat due moi triidng trong suot va nhiing
mat co moi triidng trong suot con tot.
Chi 50% nhiing triidng hdp dong ttf trang (Leucocorie) la do u
nguyen bao vong mac. Nhieu benh khac, lanh tinh, tap hdp dii6i
ten chung la gia ung thii vong mac co the the hien tren lam sang
bdi dau hieu dong tii trang. Sieu am la phiidng phap tot nhat de
phan biet u nguyen bao vong mac vdi nhiing triidng hdp gia ung
thii vong mac. Trong nhiing benh do chung ta can liiu y:
a. Benh xd san sau the thuy tinh: La sii hinh thanh mot
mang xd d phan triidc dich kinh. Benh nay cang ngay cang
hiem tii khi ngiidi ta biet rang no
xay ra d nhiing tre sd sinh de non
do thd oxy nhieu qua. No xuat
hien tren nhiing mat nho (54%).
Benh thiidng xay ra d ca hai ben
mat. Ngiidi ta khong tim diidc
nhiing o Calci hoa. Benh co the
co bien chO£ng bong vdng mac.
b. Tang san dich kinh nguyen
thuy: Chinh la sii ton tai cua mot
bo xd tiidng iing vdi sii ton tai cua
dich kinh nguyen thuy va cua
dong mach dich kinh va nhiing
nhanh bi teo. Tren sieu am B cho
Hinh 4.10. Tang san djch
thay mot mang gay am vang yeu,
ki'nh nguyen thuy
it hay nhieu bi day len cong queo

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xuat phat tii gai thi va hudng ve mat sau cua the thuy tinh.
That kho khan de phat hien ro mang nay tren chi mot thiet do.
Rat nhieu am vang trong dich kinh khong dongnhat va co
xuat huyet trong dich kinh nhieu kem theo to chiic hoa.
c. Loan san vong mac cua Reese: Benh co ti'nh chat gia
dinh xay ra d nhiing tre em sinh du thang, thiidng gay ton
thiidng d ca hai ben mat ket hdp vdi ton thiidng cua he thong
than kinh trung lidng va ton thUdng d cac bo phan khac. Benh
xay ra tren nhan cau nho.
d. Viem mang bo dao gid ung thii vong mac xay ra khu tru
sau viem mang bo dao d tre em.
Tre em tii 2 - 5 tuoi, the ti'ch cua nhan cau to len 20%. Vdi
sii gia tang kich thiidc cua tien phong, the thuy tinh co ki'ch
thiidc nho, co nhiing thanh rat gay am vang kem theo due the
thuy tinh. Nhieu am vang trong dich ki'nh cua nhiing mang do
viem mang bo dao.

Hinh 4.11. Viem mang bo dao gia ung thi/vong mac.

153
 Co bong vong mac day, rat gay am vang va xuat huyet cl
khoang dtfdi vong mac
e. Benh xd hod vong mac tiing dam d tre em (Reese): Benh
bieu hien dtfdi hinh thai cua mot dam mau xam trang nhat cl
trong dich kinh kem theo xuat huyet trong dich kinh. Benh
xuat hien it lau sau khi sinh ra.
f. Bong vong mac: Viec chan doan sieu am la de dang,
nhtfng ckn phai chan doan nguyen nhan.
g. Benh Coats: Day la tinh
trang viem vong mac co mach
mau, viec chan doan phan biet
rat kho. Benh luon d mot ben
mat va phoi hdp v6i mot bong
v5ng mac day, xuat huyet trong
dich kinh va xuat huyet d
khoang dtfdi vong mac (Hinh
5.8). Benh thtfdng gap d nhan
cau nho. Nhtfng o calci hoa deu
rat hiem. No la do to chtfc hoa
cua xuat huyet tao thanh.

Hinh 4.12. Viem vong mac cua Coats:

Thiet do thSm do dien phi'a trtfdc kinh tuyen 6 gid..

4.2. Nhumg khoi u than kinh cua vong mac

Nhtfng khoi u cua vong mac thuoc ve benh Bourneville va

cua benh u xd than kinh cua Recklinghausen. Chi nhtfng khoi
u ldn nhat cd the phat hien bang sieu am. Chung luon d canh
gai thi hay d tren gai thi. Cac khoi u nay hau nhtf luon co d hai
ben mat. Cac khoi u nay deu gay am vang hay rat gay am vang
ma khong co dac tinh rieng biet (Hinh 4.13).

154
 Ttfng dam d thanh ctfc sau, khong dong nhat, chtfa mot
dam calci hoa ttfdng tfng vdi mot xuat huyet d thanh ctfc sau.

Hinh 4.13: U than kinh trong benh

Bourneville.
Ttfng mang co gidi han
khong deu, rat gay am vang,
xuat phat ttf v5ng mac. Hac
mac va cung mac d dtfdi do la
binh thtfdng..

4.3. NhCmg khoi u mach mau cua vong mac

Nhtfng khoi u do xay ra thtfdng nhat trong khuon kho cua
benh Von Hippel - Lindeau. Benh u mach co the la benh cua
vong mac hay benh cua nao - vong mac. Thoat dau day la mot
khoi u rat gay am vang. Benh luon bi tai phat bdi nhtfng xuat
huyet va co the bi calci hoa (Hinh 4.14). Ve sau co the xuat
hien bong mac hay glaucom.

H inh 4 .1 4 . Benh Von Hippel - Lindeau.

155
 Thiet do tham do dien phia tren.
Thiet do tham do kinh tuyen 12 gid.
Mot khoi nho len, hinh cau tang gay am vang vdi hinh
chop cua bong ltfng phu hpp vdi tiing dam calci hoa cua mot u
mach v5ng mac.

5. n h Qn g k h o i u c u a h A c m a c
Nhiing u hac to" cua hac mac:
Cac u hac to" chiem 80% nhiing u cua mang bo dao. No xay
ra 0 tren ngtfdi ldn tuoi ttf 40 - 60 tuoi.
Tren sieu am B, day la mot khoi u chac co bd ro, kich thtfdc
thay doi.
- Stf khong bao hoa (vung hoan toan vo am) no ttfdng tfng
vdi stf giam manh me cua nhtfng am vang trong chieu sau cua
ton thtfdng.
- Lom hac mac bieu hien bdi mot khuyet gay giam am
vang co gidi han ro ret va deu dan d gitfa cua hac mac. No
ttfdng tfng vdi vung khoi u cat qua vung nay it gay am vang
hdn vung hac mac binh thtfdng d sat do.
- Bong ltfng chieu len khoang md sau nhan cau ttfdng tfng
vdi stf giam nang ltfdng cua cac song sieu am bdi khoi u.
Cung vdi phtfdng phap soi day m it va chup mach ky
huynh quang bang fluoresceine, phtfOng phap sieu am hien
nay co mot vi tri tfu the trong viec tham do nhtfng khoi u cua
mat nhd stf phoi hdp gitfa phtfdng thtfc B, giup khu trtf ton
thiidng va tim ra nhtfng dau hieu phoi hdp vdi phtfdng thtfc A,
gitfp xac dinh ban chat dich thtfc cua khoi u va do chinh xac
chieu day va do cao cua u.

156
 Hinh 1a,b. Khoi u 6 mong mat, the mi

Nhiing khoi u cua mong mat va cua the mico the kham
diidc day m it diidc de dang, nhiing nhiing khoi u d ban phan
sau doi khi tham kham day mat kho khan vi co kem xuat
huyet trong dich kinh, bong vong mac hoac due thuy tinh the.
80% nhiing khoi u cua mat d ngifdi ldn la nhiing u hac to"
ac tinh. Nhiing di can cua mat khong phai hiem. Tien hanh mo
tii thi tren nhiing benh nhan bi ung thii thi co khoang 10% co
ton thiidng d mat. U mach mau cua hac mac thi rat hiem.
Nhiing ton thiidng u khac thi han hiiu mdi co.

Hinh 2a, b.

157
5.1. U cua mong mat va cua the mi
Trong nhiing khoi u nay thi sieu am diidc can den trong
hai triidng hdp:

Hinh 3a, b.
- Chan doan phan biet giiia mot khoi u ran chac vdi mot
khoi u dang nang, nhat la khi co due cac moi triidng trong suot
(Hinh 4a, b).

Hinh 4a, b. Nang cua mong mat

158
 Thiet do cat theo kinh tuyen mot gid.
Thiet do thang goc vdi thiet do tren.
Lam r5 mot cau true khong gay am vang, gidi han r6 rang.
Nhiing thanh cua ton thiidng khong thay diidc vi ban chat d
the long cua ton thiidng.
- Phat hien sii lan toa ve phfa sau cua loai u nay, dac biet d
vong nep gap the mi (Hinh 5a, b). Tham do sieu am de mot
phan la nghien ciiu ve phan triidc nhan cau theo diidng d phia
triidc, phan khac de nghien ciiu mong mat va nhiing nep gap
the mi bdi diidng cat xuyen qua dich kinh bang cach nghieng
diu do tdi da. Liiu y doi vdi nhiing dau do co tan so qua cao
(20MHz) thi co the cho hinh anh gia nang d mot ton thiidng
ran. Trong triidng hdp nay can bo sung tham do vdi mot dau do
co tin so" thap hdn (8-10MHz).

Hinh 5a, b. U hac to ac tinh cua mong m it rai ra cho

den nep gap the mi.

Thiet do cat qua nhan cau theo kinh tuyen 4 gid 30.
Thiet do cat qua dich kinh tham do dien d mui dtfdi. Mang
rln xuat hien nhtf la chan khong cua am vang bang tham do
qua nhan cau.

159
 Thiet do cat qua dich ki'nh bang cach nghieng toi da dau
do de tham do vung chu bien cua nhan cau. Nhiing mang gay
am vang chac, khoang cach goc
cua dau do ngan can thay dtfpc
lom hac mac.

Hinh 6. U hac to co the tich

trung binh.

5.2. U h ie to lanh tinh

Nhtfng nevi det khong nhin
thay ro tren sieu am. Doi khi b ln g phtfdng thtfc B, ngtfdi ta co
the ghi dtfdc stf khong deu cua thanh vong mac ttfdng tfng v6i
cho day len cua hac mac do khoi
u hac to"lanh ti'nh (Hinh 7). Cho
nho len nay thtfdng dtfdi l mm.
Dtfdng kinh cua ton thtfdng la
dtfdi 5mm, trong trtfdng hdp ay
khong co stf noi ro cua 15m hac
mac hoac stf noi ro bong ltfng
am va cung khong noi ro khong
bao. Dang nay khong phai la
dac diem cua no. Can phai phoi
hdp kham bang den soi day
mat, chup mach ky huynh
quang va sieu am deu dan la
can thiet. Hinh 7. U h§c to lanh tinh
cua hac mac

160
5.3. U h lc to ac tinh

Hinh 8a, b.
Mot trong nhtfng nhiem vu quan trong nhat cua chan doan
sieu am la phat hien va phan biet nhtfng khoi u noi nhan. V6i
bieu do sieu am chuan hoa, u hac to" ac tmh cua h&c mac va the
mi co the diidc phat hien mot cach dang tin cay, cho thay do
nho len cua u so vdi cung mac it nhat la 0,75mm (trong hac
mac) hoac 1,5mm (trong the mi). U hac mac co the dtfpc phan
biet vdi nhtfng ton thtfOng khac v6i do chinh xac tren 95% neu
stf nho len cua chung ttf be mat cung mac phfa trong ft nhat la
1,5mm (h^c mac) hoac 3mm (the mi). Nhtfng dau xac dinh
chuan am hoc cua u hac to" ac tmh la:

1) Cau true ben trong dong deu (cac dinh xung cua ben
trong u bieu hien mot chieu cao ttfdng ttf nhau hoac giam d&n
do cao ttf trai sang phai).
2) Dp phan chieu trung binh cho den thap (chieu cao cua
nhtfng xung trong khoi u la ttf 50-60% chieu cao hien thi).
3) Nhtfng dinh xung cua u co dam dp dac khong thay doi
sau di dong nhan cau.

161
 4) Stf tan mach hoa (hdn 90% u h ie to ac ti'nh bieu hien
dau hieu bieu do sieu am cua tan mach hoa la co mot stf di
dong cua nhiing dinh xung trong u ddn doc, theo chieu doc, lap
loe, lien tuc, ttf nhien, nhanh). Bon da'u hieu chu yeu nay la
tieu chuan cua sieu am A, nhtfng sieu am B cung rat htfu dung
trong viec thu thap nhtfng hinh anh nhtf dang nam cua mot sd
u hac to. Vdi sieu am A chuan hoa, stf tham nhiem cung mac
va mot stf keo dai cd ngoai nhan nho co the dtfefe phat hien, vdi
ca hai phtfdng phap sieu am A va sieu am B, ca toan bo hoc
mat cung khao sat dtfdc.

Hinh 9. U s ic to ac tinh cua h ie mac. Hai hinh tren dtfoc ghi nhan til
mot u h ie to ac tinh nho len 5mm so vdi be mat phang; Hai hinh dtfdi
bieu hien mot u hac to ac ti'nh dang hinh nam nho cao hdn nhieu.
Ltfu y stf khac nhau ve nhtfng tin hieu be mat (R) dac trtfng cho hai
kieu hinh dang u. (T: u sac to ac ti'nh h ie mac; S: Cung mac)

162
 U hac to" ac tinh cua hac mac

Hinh 11a, b
Ngtfdc lai vdi u hac to ac tmh, carcinoma di can den hac
mac se bieu hien bang cau true ben trong u khong dong deu
hoac do ttfdng phan cao hdn (chieu cao dinh xung dat 80-95%)
hoac ca hai. U mau cua hac mac bieu hien vdi do ttfdng phan
rat cao (chieu cao dinh xung 95-100%). Stf thoai hoa dang dla
cua hoang diem bieu hien 2 hoac 3 dinh xung cao cach nhau
mot khoang trong hep ttfdng doi vdi nhtfng be mat cua vong
mac, bieu mo sac to va hac mac. Nevi va u te bao hac to cung
bieu hien do ttfdng phan cao hdn va nhtfng cau trtfc ben trong
u khong dong deu hdn u hac to" ac tinh (hinh 12).

163
Hinh 12. Si/ khac nhau ve bieu do sieu am gii/a (A) U h ie to ac tinh;
(B) Thoai hoa hoang diem dang dla (gia u); (C) U mach mau hac
mac (hemangioma); va (D) U bieu mo di cSn (carcinoma). (M: u hac
to; D: Ton thi/ong dang dTa; H: U mach mau; C: Kieu dang xung
khong deu cua u bieu mo di cSn; R: Be mat khoi u; S: Cung mac.

Trong khi do, nhiing xuat huyet hac mac mdi co the co
nhiing cau true ben trong va do tiidng phan tiidng tii nhii trong
u hac to ac tinh, nhiing tinh trang nay co thay doi sau di dong
nhan cau va vi vay khong diidc nham lan vdi nhiing u dac.
Trong nhiing triidng hdp ma tieu chuan am hoc nam d ranh gidi
(thiidng la nhiing ton thiidng rat nho) thi cac kham nghiem theo
doi can than thiidng lam ro tinh trang tien trien hay thoai trien
cua ton thu'dng hoac chuyen thanh mot bieu do sieu am dien
hinh hdn.

164
Hinh 13: Bieu do sieu am kham theo doi 3 benh nhan. (A,B,C) La cac
bieu do sieu am bieu hien cho si/ kham ban dau, vdi nhumg dau hieu
khong ro rang (A,B) va chan doan sieu am cua mot ton thi/ong dang
dia (C). (D, E, F) La nhumg bieu do sieu am ghi di/oc sau 1 thang (F)
va 5thang (D, E); Cac bieu do nay giup xac dinh chan doan u hac to
ac ti'nh (D,E) va xac djnh chan doan thoai hoa hoang diem dang dla
(F). Li/u y si/ khac nhau ve cau true ben trong va do hoi am (xung tir
trung binh den cao va khong deu trong hinh A va C so vdi xung thap
va deu dSn a hinh D va E trong 2 tri/dng hop u hac to ac tinh, ngoai
ra, con co si/ tien trien cham trong suot qua trinh theo doi) va si/ giam
nho len cua cac xung trong thoai hoa hoang diem dang dTa.
 Hinh 14a,b.
Thiet do c it ngang qua dich kinh theo phiiOng thtfc B.
Tham do dien thai diiOng.
Thiet do cat ngang qua dich kmh theo phiiOng thtfc A.
Tham do kinh tuyen 3 gid.
Ton thiidng it gay am vang. Tren sieu am A cho thay hinh
anh lom hac mac va khoi u co do ldn trung binh.
,
9 ^
0 phiidng thtfc A do la mot khoi u gay am vang trung binh
(10-60% nhtfng dmh nhon cung mac) va nhtfng am vang trong
cung mac deu min va deu khong giam am vang cua khoi u cua

166
vong mac ve phia cung mac, hoac la chung ta co the ghi mot
dang hinh chfl V cua nhiing am vang trong khoi u phu hdp vdi
sii lan tran cua khoi u ra cung mac. Co the thay sii giam cua
nhiing am vang trong khoi u cua vong mac ve phia cung mac
dan den mot sii giam dang ke cac am vang theo chieu sau.

a b

Hinh 15 . U h§c to ac ti'nh cua hac mac

a. Thiet do cat ngang dich kinh theo phiidng thuo B co khuyech
dai (gain) to chifc.
b. Thiet do cat qua djch ki'nh bang phiidng thifc B co khuyech
dai (gain) cao.
c. Thiet do cat qua dich kinh bang phiidng thifc A co khuyech
dai (gain) to chifc.

167
 Dieu nay ttfdng tfng vdi stf khong bao hoa quan sat dtfdc d
phtfdng thtfc B. Hdn ntfa con co th§ ghi dtfdc mot stf giam am
nhieu cua nhtfng am vang sau nhan cau, dieu nay ttfdng tfng
vdi nhtfng bong ltfng quan sat dtfdc theo phtfdng thtfc B. (Hinh
14a,b) Cd mot stf dao dong cua nhtfng am vang trong khoi u d
gan cung mac phu hdp vdi tmh chat mach mau cua khoi u.
Hien ttfdng nay cung cd the thay dtfdc d phtfdng thtfc B.

To’n thtfdng la l't gay am vang, dong nhat. Lom hac mac rat
rd net. Khi cd gain cao, khoi U hinh nhtf gay am vang.

Kham sieu am dong thdi phai tim nhtfng dau hieu phoi
hdp nhtf la: xuat huyet trong dich kinh; bong vong mac, stf
xam nhap cung mac hay la hoc mat.

Phan loai theo kich thtfdc cua u, nhtfng u hac to cd nhieu

dang khac nhau:

5.3.1. U hac to ac tinh cd kich thudc nho

Do la nhtfng khoi u cd dtfdng kinh ttf 5 - 7mm va chieu

day ttf 1,5 - 2,5mm (Hinh 16). Nhtfng khoi u nay gay am vang,
ngtfdi ta ghi nhan cd lom h&c mac nhtfng khong cd bong ltfng
am cung khong cd khong bao. Theo doi b&ng sieu am deu dan
de tim stf tang len ve the tich cua khoi u, cua stf xuat hien mot
lom hac mac la can thiet. Khi to°n thtfdng hdn 6mm dtfdng kinh
va hdn 1,5mm chieu day thi ngay ca khi khong thay rd lom hac
mac, nhtfng khoi u nay van dtfdc nghi la ac tinh. Can theo doi
deu dan, phai do that chinh xac kich thtfdc cua khoi u de co
lieu phap dieu tri thich hdp.

Ton thtfdng d thanh nhan cau khong cd tinh chat am dac

biet. Khong cd lom hac mac.

168
Hinh 17. U hac to ac ti'nh co kich
thirdc nho. Ton thifong nho 6 thanh
nhan cau phia chu bien do dirge
6mmdi/dng kinh la 1,6mmchieu day.

5.3.2. U hac to ac tmh cd kich thuoc trung binh

Khoi u thtfdng khong lam vd mang Bruch va co hinh dang

cua mot thau kmh hai mat loi va chu vi rd, deu (Hinh 5.24).
Ngtfdi ta tim thay lom hac mac va khong bao.

Hinh 18. U sac to ac tinh cua hac mac: khoi u co mot hinh dang thau
kinh 2 mat loi. Hien ttfdng lom hac mac thi thay ro. Cau true sieu am
ben trong cua u h ie to la rat it gay am vang.

169
 d. Nhiing u hac to" co the tich ldn: Khoi u pha vd mang
Bruch va co dang co dien (hinh nam) (Hinh 19) Doi khi chung
co the rat to va chiem gan het phan sau nhan cau. Nhiing
dtfdng vien cua khoi u kha ro net va deu dan. Khong nhat thiet
phai co stf khong bao hoa. Cau true am ben trong cua khoi u la
luon luon khong deu dan ttfdng dtfdng vdi mot vung bi hoai tii.
Lom hac mac doi khi kho phat hien vi cotf kich thtfdc nho so
vdi the tfch cua ton thtfdng trong nhan cau.

Hinh 19. U hac to ac ti'nh khoi

li/ong I6n cua hac mac: khoi dtfdc
danh dau (*) u co cau true sieu am
deu. Nhtfng dau mui ten ghi nhan
nhumg dau hieu cua khong bao va
lom h ie mac u (■*). Ltfu y co hinh
anh bong vong mac 6 chu bien cua
khoi u. ( ^ ) k6m xuat huyet cua
khoang dtfdi vong mac.

De phan biet mot ton thtfdng cua mot bong hac mac xay ra
sau phau thuat vi bieu hien cd nhieu tui d chu bien. Viec chan
doan kho khan hdn khi khong chi cd mot tui bong h ie mac ma
con khong thay rd khong bao hoa va cung khong ro lom hac
mac va cau true sieu am cua khoang dtfdi hac mac la khong
dong nhat.

170
 Hinh 20a,b. U hac to ac ti'nh the tich ldn
a. Thiet do cat ngang djch ki'nh d lan kham benh dau tien
b. Thiet do cat ngang djch kinh thtfc hien mot nam sau lan kham
benh dau tien.

Benh nhan da tu: choi moi phtfdng phap dieu tri. Khoi u
thoat dau rat ldn, no lam vd mang Bruch, co hinh anh “Nu co”
(Boutn de col). Tren hai thiet do, cau true sieu am ft gay am
vang, vdi mot vung rat ft am vang ttfdng dtfdng vdi mot vung
hoai tii trong khoi u. Tren bieu do ngtfdi ta thay ro stf lan tran
ra cung mac theo dau mui ten.
Chan doan phan biet giiia mot u hac to" khong lo cua nhan
cau va mot xuat huyet trong dich kmh to chtfc hoa doi khi kho
khan. Nhtfng am vang trong khoi u thi min hdn va deu hdn
(Hinh 21, 22). Con nhtf nhtfng am vang cua mot khoi xuat
huyet trong dich kmh thi khong deu va tho hdn (Hinh 23).
Viec lam rd hdn nhtfng am vang nho cd tmh hoi am do cd hien
dien td huyet lam nghi den mot xuat huyet nhieu hdn.

171
 Hinh 21: U hac to khong lo cua h ie mac
a. Thiet do true
b. Thiet do benh ly giai phau dai the
Khoi u chiem ca phan sau cua nhan ciu . Khong co the
thuy tinh 6 vi tri giai phau. Khoi u giam am vang va khong
dong nhat dau mui ten chi. Thi than kinh tang the tich ro ret.
Sieu am khong phan biet dufOc nhiing te bao u t, manh s ic to
den va nhiing vung xuat huyet.

Hinh 22. Xuat huyet timg dam chiem

tat ca phan sau.
Ton thirong ti/ong doi gay am vang
va khong dong nhat. Lull y nhumg vung
gay qua am vang tirong di/ong v6i
nhCimg cuc to huyet.

172
 Hinh 23. U h ie to “khong lo"
cua hac mac.
U hac to" choan tat ca phan sau
nhan cau tdi ngang mtfc vdi bao sau
cua thuy tinh the. Khoi u da lam
nghen stf tuan hoan tinh mach trd
ve tao nen mot cho day len rat nhieu
cua thanh nhan cau. Cau true sieu
am ben trong cua khoi u deu va gav
am vang nhe.
Trong trtfdng hop kho khan can phai chup CT scanner.
e. Nhiing u hac to" cua vung hoang diem: nhiing khoi u nay
la rat hiem (Hinh 24) can phai chan doan phan biet vdi nhiing
thoai hoa xuat huyet gia u cua hoang diem va nhiing bong bieu
mo hac to". Nhiing thoai hoa thiidng phoi hop vdi sii go len cua
vdng mac do cd xuat huyet diidi vong mac, thtfdng ton thtfOng
nay cd d 2 mat.
Trong trtfdng hop chan doan phan biet vdi thoai hoa hoang
diem, can phai lam sieu am de theo doi stf giam the tfch cua
ton thtfOng va cd hinh dang khong deu, khong dong nhat.
Nhtfng bong thanh dich hay bong cd xuat huyet cua bieu mo
sac to" thi van de chan doan rat kho khan.
Thtfc the" doi khi de nham lan vdi gia lom hac mac. Chung
luon luon khu trtf d vung hoang diem cd hinh anh mot vung
chan khong cua am vang d sau ldp bieu mo bi tach ra.

173
 Hinh 24. U hac to cua vung hoang diem

Khoi u co hinh thau kinh 2 mat loi. Ltfu y hien ttfdng lom
hac mac va cac vung ti dich d ldp bieu mo sac to" vong mac

Hinh 25a,b. Thoai hoa xuat huyet gia u cua hoang diem

a. Thiet do cat ngang nhan cau th5m do kinh tuyen tCr 10gid.
b. Thiet do th in g goc vdi thiet do noi tren.
Ton thtfOng rat rong, rat gay am vang va nhat la rat khong
dong nhat. Bd trtfdc cua ton thtfOng la khong deu, khong cd
hien ttfdng lom hac mac.

174
 Hinh 26. Bong thanh djch cua
bieu mo s ic to.

Ton thiidng rat rong, rat

gay am vang va nhat la rat
khong dong nhat. Bd triidc cua
ton thiidng la khong deu, khong
co hien tiidng lom hac mac.
f. Nhiing u h ie to" tien trien d in lam tang the tich cua khoi
u trong nhan cau, lan tran ra cung mac va xam lan vao hoc
m it (Hinh 27). Sii lan toa sau nhan cau cua cac u hac to d m it
thi hiem va bieu hien nhii hiing ton thiidng sau nhan c iu giam
gay am vang, khong dong nhat hap thu manh me chum song
sieu am. Can chup CT scanner trong cac triidng hdp nay de
danh gia sii lan tran d p h in sau nhan c iu va de phat hien
nhiing di can vao nao co the xay
ra sau khi dieu tri bao ton bang
tia xa.

Hinh 27. U hac to ac tinh cua hac

mac lan rong ra hoc mat phi'a sau
nhan cau gay loi mat . Hoc mat to
giam gay am vang. Ton thi/ong
trong nhan cau thay rat ro, gay am
vang trung binh. Co hinh anh bong
vong mac nho d ria cua khoi u. Si/
khac nhau ve cau true sieu am
giC/a khoi u trong nhan cau va si/
lan tran 6 phfa sau nhan cau lam
noi bat hinh anh cua khoi u nay doi
vdi vung xung quanh.

175
 Khoi u trong nhan cau cung vdi dich kinh khong gay am
vang. Khoi u sau nhan cau cung vdi ldp md sau nhan cau, qua
gay am vang.

a b
Hinh 28. U hac to ac ti'nh cua hac mac.
Tien trien sau khi di/oc dieu tri bang tia xa.

a. Ton thi/ong luc ban dau

b. Hinh thai cua ton thirong 15 thang sau khi dieu tri bang tia.
Ngi/di ta nhan thay mot si/ det xuong dang ke cua ton thi/ong.
Nhi/ng dtfdng ki'nh cua ton thi/ong khong thay doi, cau true sieu am
thay doi vdi nhtfng vung tang gay am vang ttfong dtfong vdi nhCfng
vung xuat huyet dang calci hoa.

Sieu am cho phep theo d5i stf tien trien cua ton thtfdng va
d day cho thay stf giam the tich cua khoi u. Neu dtfdng kinh
cua u khong thay doi thi chieu day cua no giam mot cach dang
ke. Dong thdi cau true sieu am cang trd nen khong dong nhat
do co nhiing thay doi do xuat huyet.

176
5.4. NhCrng di can cua h lc mac
Nhiing di can nay khong phai la hiem, di can tu! ung thii
cua vu chiem 75% triidng hdp. Ngoai ra con do di can cua phoi,
cua gan, cua bo may tieu hoa hay cua cac tuyen noi tiet. Khi
ton thiidng co kich thiidc nho thi cau true cua am la gay am
vang va khong dong nhat. Khi ton thiidng co kich thtfdc ldn
(Hinh 29) thi viec chan doan phan biet la rat kho khan vdi mot
u hac to" cua hac mac. Thiic the cau true sieu am co the la gay
am vang trung binh va dong nhat , lom hac mac thiidng it gap
hdn. Chan doan diidc gdi y tii mot ung thii da biet.

a b

Hinh 29. Di c3n hac mac cua mot ung thtfvu.

a. Ton thi/ong ban dau cua u
b. Kham nghiem thtfc hien 5 thang sau khi dieu tri being hoa chat.
Thoat d iu ton thiiOng ldn, gay am vang trung binh, khong
co hien ttfcfng lom h ie mac. Cau true am vang ben trong dongil
deu. Viec theo doi sau dieu tri cho thay ton thiiOng mat gan
het. Ngiidi ta ghi nhan mot tinh trang bong vong mac va hac
mac khong dong nhat vdi nhiing vung calci hoa.

177
5.5. U mach mau cua hSc mac
Day la mot khoi u hiem khi xuat hien til 10 - 20 tuoi. Khoi u
la tang gay am vang, dong nhat, khong co lom hac mac cung
khong co khong bao (Hinh 30). Theo phtfdng thuc A nhtfng dinh
nhon cua khoi U dat 80-100% so vdi nhtfng dinh xung nhon cua
cung mac. Nhtfng am vang trong khoi u la khong deu.
Ton thtfdng dtfdi hoang diem tang gay am vang, khong co
lom hac mac. Cau true am vang ben trong la deu, song xuat
hien rat tho. Ngtfdi ta cung ghi nhan rang co mot xuat huyet
nho d trong dich ki'nh phoi hdp.

Hinh 30. U mach mau cua hac mac

178
5.6. Nhi/ng Melanocytome cua gai thj
Khong co u hac to" cua gai thi. Khi phan biet bang sieu am
giiia mot Melanocytome la mot u lanh ti'nh cua mat va mot u
hac to" d canh gai thi lan ra phi'a triidc cua gai thi. Trong 2
triidng hdp deu co mot cho noi len cua gai thi gay am vang.
Trang thai d day mat va tien trien giup cho chan doan phan
biet. Nhiing khoi u nay phan biet de dang vdi cac drusen (u det
co sac to) cua gai thi.

5.7. U xifdng h lc mac

Van de chan doan kha de
dang, co mot qua trinh xam
chiem thanh nhan cau tang
gay am vang vdi mot hinh
chop cua bong liing the hien
mot khoi u calci hoa (hinh 31).
Nhiing khoi u xiiOng hac mac
co the co d 2 ben mat.

Ton thiiOng n im trong

dien thai diiOng tren T, tiidng
doi phing, tang gay am vang, Hinh 31. U xi/Ong h ie mac
keo theo mot hinh chop cua
bong liing, the hien sii calci
hoa cua ton thiiOng nay.

5.8. Nhumg u hiem: Benh u than kinh xd cua hac mac la rat
hiem. Thiidng la benh Recklinghausen. Bieu hien la mot cho
day len, lan toa, xO cua hac mac.
+ Benh limphosacome: thiidng gap khu tru d h ie mac, cua
mot benh limphosacome da biet, mot benh leucose limphoid,
hay la Myeloid, hoac mot leucose cap.
+ U than kinh va U schwannome ac tinh thinh thoang mdi gap.

179
 KHOI HOC MAT

Vdi sieu am chuan hoa, hon 99% cac ton thtfOng hoc m it
kem theo nhtfng dau chtfng va trieu chtfng deu co the dtfdc
phat hien. Khoang 80% nhtfng ton thtfdng dtfdc phat hien co
the chan doan phan biet vdi 60 loai ton thtfOng khac nhau hoac
nhtfng nhom bat thtfOng vdi do chinh xac 80%. Do nhay va do
chinh xac cua sieu am chuan hoa trong viec chan doan phan
biet cac tinh trang cua hoc mat phu thuoc phan ldn vao loai
ton thtfOng chang han nhtf do dong tinh mach ltfu thong
nhanh, hoac tao nen nhtfng kieu m lu nang dang da (cyst
dermoide) tren bieu do A dac trtfng ma co the nhan biet dtfdc
trong moi trtfdng hop rieng biet. U mau xoang hang d dang
trtfdng thanh dtfOc chan doan vdi do chinh xac 96%, tuy nhien
nang dang da thi do chinh xac chi 63%, va kho chan doan phan
biet nhat vdi mot vai ton thtfOng khac. Ngay ca trong so" nang
dang da, do chinh xac cua sieu am cung khac nhau tuy thuoc
vao noi dung ben trong cua nang: nhtfng nang thanh dich tao
ra nhtfng kieu dang dac trtfng, nhtfng nang chtfa cholesterol
hoac nhtfng nang cd chtfa chat nhtf “pho mat” cd the de bi
nham lan vdi nhtfng u te bao vo mach, khong cd vo boc, hdi
tron (ch in g han gia u)
Trong hoc m it, sieu am A chuan hoa cung cap thong tin
chan doan chinh xac nhat. Mac du sieu am B va sieu am
Doppler doi khi cd the cung cap nhtfng thong tin bo sung co gia
tri. Sau day la nhtfng ton thtfOng mach mau, nhtfng ton
thtfdng u va cac di dang, dtfdc xem nhtf la nhtfng vi du trong
viec ap dung sieu am chuan hoa de chan doan nhtfng ton
thtfOng hoc mat, ton thtfOng than kinh thi giac va cac tinh
trang cua cd ngoai nhan.

180
 Phiidng thiic B cung cap chu yeu la khai niem ve hinh thai
cua no va co the cho mot y niem ve cau true sieu am cua no;
phiidng thiic A cho khai niem ve ban chat cua cau true do.
Khoang khong gian 3 chieu phai diidc thiet lap lai diia tren
thong tin lien tiep cua nhiing thiet do khac nhau thiic hien
trong mot hoac nhieu binh dien cua khong gian. Sieu am co
the cho ngay lap tiic nhiing thiet do trong bat ky binh dien nao
cua khong gian. NgUdi lam sieu am phai nhd nhiing dinh luat
lan truyen cua bo sieu am trong nhiing moi triidng sinh vat
dac biet cua hoc mat va cac bo phan chiia trong do: Hinh chop
xiidng co dinh d phia sau, ma day thi choang bdi nhan cau,
canh ciia so am thiic sii cho phep nghien ciiu nhiing qua trinh
d phia sau nhan cau. Co nhiing nghien ciiu khac nhau da diidc
tien hanh de so sanh giiia sieu am va chup CT scanner khi
khao sat nhiing khoi cua hoc mat. Sieu am ft thanh cong hdn
la chup CT scanner. Dieu nay la do sii de doc cua mot so ngiidi
khong chuyen khoa. Bdi sii doi lap d be ngoai ma cung mot
ngiidi cam thay triidc mot xet nghiem sieu am. May scanner
lam cho moi lien he giiia qua trinh vdi toan bo nhiing cau true
cua m&t va so; sieu am cd mot thi giac chia thanh tiing phan
nhd hOn. Nen phoi hop hai phiidng phap de dat diidc toi da
nhiing chi dan chan doan tren hinh thai va ban chat cua
nhiing ton thiiOng tham do.
Ve phiiOng dien ky thuat, kham nghiem phai chinh xac,
phai thiic hien nhiing thiet do cat qua nhan cau, qua dich
kinh, va ben canh nhan cau, cua nhiing thiet do di qua true ldn
cua to’n thiiOng va nhiing thiet do vuong goc vdi true nay,
nhiing thiet do chi ro nhiing quan he cua ton thiidng vdi nhiing
cau true giai p h iu hoc hoc m it: Nhan cau, than kinh thi giac,
cac cO van dong nhan cau, thanh xiidng, nhiing thiet do trong 3
binh dien cua khong gian de cho phep mot phep do chinh xac
cua ton thiiOng.

Kham nghiem phai cho thay nhiing khao sat ve nhiing yeu
to" chi diem tinh nhii hinh thai, vi tri, va nhiing gidi han cua

181
ton thiidng va nhiing chi dan dong nhii do hoi am cua no, sii
giam dan va ti'nh chat dong deu hay khong vdi mot do khuyech
dai cao hoac thap nhat.
Sii nen diidc, sii ciing ran hay sii mem mai cua mot ton
thiidng, nhiing sii thay doi ve the tich tuy theo nhiing tii the
(tii the nam sap) hay theo nhiing nghiem phap dac biet nhii
(Valsalva).
Can phoi hdp doi chieu cac bieu hien tren sieu am vdi cac
trieu chiing lam sang de nghien ciiu ti'nh chat lam sang cua
mot loi mat, liet van nhan, hoac roi loan thi liic hay thi triidng.
Sieu am cho phep phat hien mot khoi hoc m it trong 98%
nhiing triidng hdp; trong do 80% triidng hdp cd the diidc phan
biet hdn 25 loai ton thiiOng cua khoi u. No cd the nghien ciiu
hinh thai, vi tri, nhiing gidi han cua ton thiiOng, cung nhii sii
giam nhe am, cau true, mat do, tinh didong cua mot luong mau
d giiia khoi u. Sieu am cung khao sat mot each ky liidng nhiing
cau true khac cua hoc mat, cung ben va doi ben.
Sieu am la hiiu dung trong viec theo doi tien trinh dieu tri,
nhat la khi ton thiiOng don thuan d hoc m it va khi lieu trinh
dieu tri do la b in g thuoc hay la xa tri. Chiia co mot cach phan
loai “logic” nao de nghien ciiu nhiing khoi u hoc m it khac
nhau, nhiing d day chung ta se thifa nhan mot cach phan loai
theo thii tii dinh khu va nghien ciiu lan liidt:
• Benh hoc cua day than kinh thi giac.
• Nhiing khoi manh mau
• Nhiing khoi u phan triidc nhan cau xam lan.
• Benh hoc CO
• Nhiing khoi trong hay la / va ngoai chop cd

182
1. BENH HOC CUA DAY THAN KINH THj GIAC
. Do day cua than kinh
thi giac co the do dac danh
gia bang sieu am chuan hoa
vdi do chinh xac khoang tii ±
0, 3mm d khoang khong sau
nhan cau den ± 0, 5mm d
hoc mat sau (hinh 1). Trong
khi do sieu am khong the
hien thi do day cua than
kinh thi giac binh thiidng
trong dinh hoc mat, cac ton
thiidng th in kinh thi giac co
the diidc phat hien ro rang
trong hau het cac vi tri d hoc
mat sau. neu no ldn hdn 3mm

M
i»

• L

183
Hinh 1. Do dac be day cua day than kinh thi giac. (A) Oat dau do
gan xich dao phia thai di/ong va hirdng chum am di xuyen qua ca
true trong va xuyen qua cac phan khac nhau cua day than kinh thi
giac. (B, E) Cac bieu do sieu diroc ghi nhan theo 4 hiidng chum am
di/oc mo ta d hinh A. (M: Co tri/c trong; N: than kinh thi giac). De do
be day toi da cua day than kinh thi giac, cac bieu do sieu am D va E
hien thj be day cua than kinh thi giac d sau nhan cau va phan xa sau
hoc mat.
Vdi sieu am A chuan hoa, mot sii phan biet cd gidi han cua
nhiing ton thiiOng th in kinh thi giac la cd the dtfOc (hinh 2).
Cac bieu do sieu am cho thay hoac la do day cua nhiing cau
true than kinh do sii phong len cua nhiing thanh p h ln thin
kinh cua day than kinh (chang han, trong viem day th in kinh
thi giac) hoac la do sii day len nhiing bo sdi th in kinh thi giac
(nhii trong benh ly mat Grave) hoac la do dich diidi nhen bao
quanh th in kinh tang len (ngiidi ta tim thay mot "kieu dang
dich” trong nhiing trUdng hdp nhii vay khi cd tang ap liic noi
so lanh tinh). Thiidng rat kho chan doan phan biet giiia phong
day th in kinh thi giac vdi nhiing gliome nhd, hoac giiia sii day
len cua nhiing bd scfi th in kinh thi giac vdi u mang nao nhd.
Ngay khi cd sii phong len hoac day len tang qua 100% hoac trd
nen khong deu va khong doi xiing (day hon ve mot phfa cua
day than kinh) la chiing to cd sii hien dien cua khoi u. Sieu am
chuan hoa cho phep chan doan phan biet nhiing gliomas vdi
cac u mang nao tren co sd vi trf cua chung va kieu phat trien
cua chung. Tuy nhien, sii phan biet cua nhiing u ma diiOc gidi
han tai dinh hoc mat la khong the thiic hien diiOc. Teo thin
kinh thi giac diiOc dac triing bdi nhiing “kieu dang dich” dien
hinh (tai cho noi tiep vdi nhiing diidng kmh th in kinh nhd
hon) nhiing cac diidng kinh toan the cua kieu dang th in kinh
thi giac thi binh thiidng.

184
Hinh 2. Cac bieu do sieu am A bieu thi sir phong len cua day than
kinh thj giac (A) va cac thd spi than kinh bi dan cSng do (1 djch (B).
(N: Day than kinh thi giac; F: la mat phan gidi giura day than kinh thj
giac va mang nhen. Cac mui ten chi vi tri ma be mSt day than kinh
thi giac bj tach ra khoi mang nhen bdi dich.
Trong phan nay chung ta chi nghien ciiu benh hoc cua day
than kinh thi giac doan sau nhan cau va doan trong hoc mat.
Phiidng thiic B va phiidng thiic A cho phep nghien ciiu niia
triidc cua day th in kinh thi giac sau nhan cau. Ngiidc lai, day
than kinh thi giac d dinh hoc mat chiia diidc nghien ciiu day du
ve sieu am. Nhiing ton thiiOng nho cua p h ln sau diipc nghien
ciiu ro hdn bdi phiidng phap chup CT scanner hoac MRI.
Neu phiidng thiic B cho phep phat hien mot sii tang the
tich cua day th in kinh thi giac thi phiidng thiic A cho phep sat
nhap sii tang the tich nay vdi mot sii phong len cua day th in
kinh tii no (nhii trong viem thi th in kinh), hoac mot sii day len
cua nhiing vo boc mang nao (nhii trong benh Basedow) hay la
d mot sii tang the tich cua nhiing khoang diidi mang nhen (nhii
trong tang ap liic noi so hinh 3).

185
 Hinh 3 a, b, c
Neu chi tang vtfa phai (< 100%) thi rat kho phan biet mot
benh hoc lanh tinh, hay mot khoi u. Mot day than kinh co the
tich ben ngoai binh thtfdng kem theo tang the tich khoang dtfdi
mang nhen lam nghl den mot teo thi than kinh.

1.1. NhCimg u than kinh dem cua day than kinh thj giac
Nhiing u than kinh dem thtfdng xay ra trtfdc 30 tuoi; trong
do 75% trtfdc 10 tuoi va 90% trtfdc 20 tuoi. Rat hiem nhiing
trtfdng hdp xay ra d nhiing ngtfdi co tuoi. Khoi u co the d bat ky
vi tri nao doc theo cac dtfdng thi giac. Nhtfng ton hai cua giao
thoa thi giac va d mot hay hai day than kinh thi giac thi
thtfdng xay ra hdn. Co mot moi lien quan gitfa nhtfng u than
kinh dem cua day than kinh thi giac va u xd than kinh cua
benh Recklinghausen. Nhtfng dau hieu lam sang rat khac
nhau tuy theo do la mot u th in kinh dem trong hoc mat hay la
trong so. Stf giam thi ltfc la dau hieu dau tien thtfdng xay ra

186
nhat. O tre em, no co the bieu hien bdi mot tinh trang lac hoac
giam thi liic. Nhiing u than kinh dem trong hoc m it nhanh
chong dan den loi mat thang true, viia phai. Nhiing u than
kinh dem cua giao thoa thi giac co khuynh hiidng dan den
nhiing roi loan ve chOfc nang true diidi doi - tuyen yen. Con
nhiing dau hieu tang ap liic noi so, loi mat la hiem hdn va xay
ra cham hdn.
Tom lai sieu am co the chan doan mot khoi u than kinh dem
trong hoc m it nhung CT scanner va MRI co kha nSng chan doan tot
hon, nhat la de chan doan sii phat trien ra sau cua khoi u.

a b

■ iiiillllllll“ iii||‘||i|tl|:“ |||lt“ i--

Hinh 4. U than kinh dem cua day than kinh thi giac
a. Thiet do true, phifong thifc B
b. Thiet do qua xirong tran, phi/ong thifc B
c. Phiidng thifc A

187
 Day than kinh thi giac to hon ro ret, no bi gay khuc d
khoang 1/3 trtfdc cua hoc mat. Stf tang the tich 6 phan sau
nhan cau cua day than kinh thi giac dan den stf bat thtfdng ve
dtfdng cong cua day th in kinh thi giac.
Tren thiet do sieu am A cho thay mot day than kinh thi
giac tang the tich 7mm, giam gay am vang.
Nhtfng dau hieu sieu am cua mot u than kinh dem cua day
than kinh thi giac gom:
- Mot stf tang the tich cua day than kinh thi giac va tien
trien den mtfc co the chiem ca khoang sau nhan cau ben trong
hinh chop.
- Mtfc do hoi am trung binh, vdi nhtfng dinh nhon giao
dong gitfa 40% va 60% cua dinh nhon cung mac.
- Ton thtfOng cd gidi han rat ro.
Trong nhtfng trtfdng hpp the tich tang khong dang ke, cau
true sieu am la dong deu vdi nhtfng dinh khft khao ttfOng doi
dai. Doi khi cd nhtfng xung dinh ndi rong ra noi bat hon, ngay
d in g sau cua nhan c iu (Hinh 4)
- Gidi han rat ro cua nhtfng u th in kinh dem cua hoc m it
doi vdi khoang md sau nhan c iu the hien ro rang tren sieu am
B va bieu hien bang mot dinh xung doi nhon tren sieu am A.
Do la do mang ctfng, gidi han khoi u vdi stf tang sinh mang
nhen phan tfng d ngay dtfdi do. Doi khi khoi u rat to. Ngtfdi ta
thtfdng thay trong nhtfng trtfdng hdp do co nhtfng vung co
nang, thoai trien, gidi han ben trong cua khoi u.

1.2. Nhiirng u mang nao cua bao day than kinh thj giac
- Nhtfng u nay thtfdng gap nhat d nhtfng ngtfdi trtfdng
thanh ttf 40 den 60 tuoi va philn ldn la phu ntf (90%). Nhtfng
co nhtfng trtfdng hdp tre em dac biet 10 tuoi cung mac benh.
Vdi nhtfng dau hieu lam sang tai mat va giam thi ltfc.

188
 - Liet van dong nhan cau va nhiing roi loan cua cam giac
giac mac deu xay ra cham trong qua trinh nhiing u mang nao
lan ve phia sau.
- Tren binh dien sieu am cua day than kinh thi giac u co
the khong deu, tho hay hinh thoi, to hay nho. U mang nao bao
ton nhiing spi than kinh, nen co the thay day than kinh thi
giac binh thiidng d giiia khoi u. Dieu nay khong phai la dac
biet va co the thay trong mot so" hinh thai gia u (hinh 5).
Khoi tap trung tren day than kinh thi giac. Viia thiet do
true viia thiet do qua tran, ngiidi ta co the lam noi ro thi than
kinh ft gay am vang giiia nhiing ton thiiOng giam gay am vang
bao boc xung quanh no.
Trong triidng hdp khoi u to khong the thay diidc ciic sau cua
khoi u gan ong thi giac. Co the co nhiing nhan calci hoa the hien
bdi nhiing vung rat gay am vang cao tao ra nhiing hinh chop
cua bong liing. Nhiing nhan nay phai diidc phan biet vdi sdi cua
tinh mach. Doi khi ngiidi ta cd the lam noi ro len mot o calci hoa
thanh khoi cua u day than kinh thi giac. (hinh 5).

Hinh 5. U mang nao calci hoa cua nhiing lao cua day than kinh thi giac
a. thiet do true.
b. thiet do tran.

189
 Tren thiet do true co mot vung tang gay am vang sau nhan
cau theo sau la mot hinh chop cua bong ltfng. Tren thiet do
tran vdi do khuyech dai giam, ngtfdi ta lam noi ro nhiing bao
cua day than kinh thi giac bi calci hoa bao quanh day th&n
kinh thi giac cd the tich binh thtfdng.
Khi khoi u cd kich thtfdc nhd d dinh hoc mat, thi sieu am
khong the phat hien dtfdc ma chi cd chup CT scanner mdi phat
hien dtfdc hoac ca khi phtfdng phap sieu am phat hien mot
khoi u cua day than kinh thi giac d dinh hoc mat thi no khong
the chtfng minh tinh chat dac thu cua benh. CT scanner theo
doi sau dieu tri thtfdng tot hdn theo d5i b&ng sieu am.

1.3. NhCrng ton thi/dng viem gia u co the lam tang the tich cua
day than kinh thi giac vdi cac bd khong deu. O thiet do tran,
ngtfdi ta cd the thay mot cach khong ro rang day than kinh d
gitfa mot vung it gay am vang, khong dong chat. Viec chan
doan doi khi khong the thtfc hien dtfdc tren nhtfng hinh anh
chi vdi mot u mang nao hay mot u than kinh dem. Trong qua
trinh dieu tri bang corticosteroide, viec giam khoi ltfdng cua
khoi u la yeu to nghl den ton thtfOng viem gia u (hinh 6).
Thtfdng kem theo ton thtfOng cua cung mac va / hay cua mot
hoac nhieu cO va / hay la cua tuyen le.
Ton thtfOng viem gia u gay ton thtfOng cho day than kinh
thi giac lam noi ro mot khoi bao quanh day than kinh thi giac.
d gitfa khoi nay, day than kinh dtfdc bao quanh bdi mot vong
qua gay am vang. Cd mot cho day len cua thanh nhan ciiu.
Stf tang the tfch cua day than kinh thi giac gay am vang cd
the thay dtfdc trong benh Leucemie cap bdi stf tham nhiem cua
nguyen bao vao nhiing bao mang nao.

190
 Hinh 6
Nhiing nang bam sinh vdi nhiing cho khuyet cua day than
kinh thi giac deu the hien ro tren sieu am (Hinh 7)

Hinh 7

Cho thay nang hoc mat

phoi hop vdi mot tat nhan cau
nho va co mot khuyet cua thi
than kinh. Nhieu tui chat long
trong hinh chop bao quanh
mot day than kinh thi giac co
kich thiidc nho.
Ton hai cua day than kinh thi giac do khoi u cua mat lan
truyen sang.

191
2. n h u n g k h o i m a c h m a u

2.1. Trtfdng tmh mach hoc m it: (hinh 8) La mot trong so

nhiing ton thiiOng mach mau thiiOng gap hon 0 vung nay.
Nhiing tieu chuan am hoc cua chung la (1), Mat do rat mem, vi
the ngay ca mot ap liic nhe nhat cua dau do cung se lam xep
tinh mach triidng va diidng bieu dien cua no bien mat tren
bieu do sieu am hoc mat. (2), Phinh ldn ro ret khi lam nghiem
phap VALSALVA va (3), Thieu dong chay cua mau.

Hinh 1: Trifdng tmh mach hoc m it. Ca cac bieu do sieu am bieu
hien rong hon binh thiidng nhung yeu dan de cho thay mot sii thieu
hut (goc khuyet) ban dau cua nghiem phap Valsalva (hinh d tren),
tuy nhien ca hai hinh cho thay mot sii thieu hut (goc khuyet) trong
suot qua trinh cung nhii la sau khi thiic hien nghiem phap Valsalva
(hai hinh di/di).

192
 Ltfu y rang stf khiem khuyet trong bieu do sieu am A dtfOc
phat hoa sac net (thanh mach mau) va co cac xung thap (dich
mau) ma doi khi bi md (khong co mau trong long mach).

2.2. Do dong tmh mach (hinh 9) hoac doi khi ‘’lan rong vao”
trong hoc mat, tao ra nhtfng bieu do sieu am dien hinh do stf
phinh ldn dang ke (>100%) mot tinh mach hoc mat, thtfdng la
tinh mach mat tren va nhtfng nhanh noi thong cua no vdi tinh
mach goc.
Nhtfng lo do "chay nhanh” tao ra nhtfng phan cua bieu do
sieu am hoc mat ma dtfcfc phat hoa ro net bdi cac dinh xung be
mat len va xuong mot cach doc sau (cac thanh mach mau) va
chtfa mot chuoi nhtfng dinh xung thap va rat thap (2 - 20%
bien do hien thi); tat ca nhtfng dinh xung mau cho thay stf
chuyen dong theo chieu doc nhap nho nhanh, lien tuc, ttf
nhien, bieu thi dong chay cua mau kieu dong mach ben trong
tinh mach dan. Hien ttfOng sieu am A dong nay phan biet ro
rang do dong tinh mach vdi trtfdng tinh mach, ma giong nhtf
cac loai do bieu hien hinh dang va stf lan rong dien hinh cua
tinh mach hoc mat tren sieu am A - B.
He thong mach mau dan cang; co hinh anh thong dong
tinh mach; lam sang nghe tieng thoi
Stf phan biet nay phai dtfcfc thtfc hien trtfdc khi lam
nghiem phap VALSALVA, la nghiem phap rat htfu dung trong
chan doan cac trtfdng tinh mach nhtfng nguy hiem khi ap dung
doi vdi cac loai do. Dtfa tren viec lam tang ap ltfc bdi d&u do,
tinh mach dan dau tien bieu hien ctfng, nhtfng roi xep di khi
ap ltfc dtfOc stf dung vtfOt qua ap ltfc mau cua no. Nhtfng loai
do dong tinh mach "chay cham” tao ra bdi canh lam sang dac
trtfng cua stf tf mau (nhtfng mach mau thtfOng cung mac xoan
lai va nd ldn), khong the phong ldn cac tinh mach hoc mat du
de lam nhan ra chung tren cac bieu do sieu am. Nhtfng lo do
nhtf vay gay nen ctfOng tu ket mac va vi vay lam stfng phong

193
lan toa miic do viia cua nhiing cau true hoc mat nhii mo md,
cac dai than kinh thi giac va cac cd ngoai nhan. Cung chung
vdi boi canh lam sang cua cac tinh mach thtfdng cung mac
xoan va dan ldn, nhiing dau hieu nay it nhat cho thay co do
dong tinh mach chay cham trong noi so.

Xl >
V ■v

I \\ ■
m m
IV J ^m 9

''if' iffl
Hinh 9. Do dong tTnh mach. Tinh mach m it tren bj do vdi dong mach
va bj dan ldn (V) hien thi nhtf mot chd khuyet sau tren bieu do sieu
am A (A) va nhir mot cho khuyet hoi rong tren cac bieu do sieu am B
(C,F). Phan do di chuyen ti/ vj tri mui (C) den cac vj tri thai dirong
(D,F) bdi vi chum am dtfdc nang len ttf phia trtfdc di vao phan sau
tren cua hoc mat (bieu thj dudng di cua tTnh mach). Dong mau chay
nhanh trong mach mau lam md cac xung djch mau thap tren bieu do
sieu am A (A), xac djnh chan doan. (B) Bieu do sieu A hoc mat binh
thtfdng (chum am di ngang qua cac mach mau bj dan). (M: Cac tin
hieu nhap nhd bieu hien stf hoi am cua cac xung sieu am gitfa thanh
trtfdc va thanh sau cua nhan cau)

2.3. Nhumg tat dj dang tTnh mach

Tren lam sang khi phai tim kiem mot di dang tinh mach la
co mot loi mat tting cOn xuat hien trong mot so ttf the hay tinh
huong. Khi tham do bang sieu am nhtfng di dang phai dtfdc
lam di lam lai vdi nhtfng thao tac (ttf the nam sap, Valsalva).
Nhtfng dau hieu co the la rat km dao nhtfng co the phat hien
bang mot ttf the nam don gian. Nhtfng benh nhan thtfdng la tre,
nhtfng co khi phat hien tinh cd d mot ngtfdi gia, phai so sanh
hoc mat dang khao sat vdi hoc mat
ben doi dien. O ttf the nam trang
thai co the la hau nhtf binh thtfdng
hoac chi cho thay mot vai khoang
trong nho khong gay am vang gidi
han kem doi vdi ldp md 0 trong hoc
milt (Hinh 10).
Sieu am la hoan toan htfu ich
de phat hien nhtfng di tat d phia
trtfdc, ma CT scanner co the
khong phat hien dtfdc.

Hinh 10. Dan tTnh mach to cua hoc m it

195
 Thiet do cat qua dich kinh tham do dien tren, trong ttf the nam.
Lam r5 nhtfng khoang nho it gay am vang, gidi han kem doi
vdi dam md hoc mat nam ke dtfdi. Mot so khoang thi gay am
vang va ttfOng dtfOng vdi nhtfng cho (tac tinh mach) huyet khoi
Ltfu y rang hinh anh sieu am cua ldp md trong hoc mat la
do nhieu mat phan gidi gop lai. Doi khi co mot khoi khong gay
am vang, it hay nhieu loi lom thay doi hinh the do stfc de cua
dau do.
Viec chan doan ttfOng doi de dang khi co nhtfng soi tinh
mach, do la dac diem cua nhtfng dan tinh mach hoc mat va
nhtfng u mach hang. Thtfdng gap trong 60% trtfdng hop cua
dan tinh mach.
Tren sieu am, no bieu hien bdi nhtfng vtfng tron qua gay
am vang rat manh tao ra mot hinh chop cua bong ltfng ro. Chi
dien tich phia trtfdc hinh tron la thay dtfdc. Mat sau thi hap
thu trong hinh chop cua bong ltfng.
C) ttf the nam sap hay sau thtf nghiem Valsalva di dang trd
nen ro rang hon (Hinh 11).

Hinh 11. Dan tTnh mach hoc mat

196
 a. Thiet do cat qua dich kinh tham do dien mui dtf6i d tii
the nam ngtfa.
b. Thiet do cat qua dich ki'nh tham do dien mui dtfdi 6 tii
the nam sap.
Do la mot khoi khong gay am vang nhieu, deu, rat gidi
han, lom xuong, mem va doi khi co nhiing ngan trong do.
- Di tat co the hoan toan 6 trong hinh chop, hoac viia d
ngoai va viia d trong hinh chop tuy theo he thong tinh mach
mat tren va mat diidi.
O tii the n im ngtia, ngiidi ta lam noi bat nhiing khoang sau
nhan cau ft gay am vang, gidi han kem. O giiia chung co hai
vung qua gay am vang tiiOng ting vdi nhting vien sdi tinh mach.
0 tii the n im sap, khoi tang the tfch mot cach dang ke.
Nhiing soi tinh mach co biet hoa ro rang hon vi chung no co 0
giiia khoang khong gay am vang.
- Tuy tinh tinh hudng can thiet ma sti dung sieu am
Doppler de danh gia, tuan hoan dang tinh mach d ben trong
cua di dang.
- Chup CT scanner la can thiet de phat hien nhting di
dang mach mau khac phoi hop. Ngay nay phiiOng phat chup
tinh mach hoc mat chi co chi dinh khi dtf tmh phau thuat.

2.4. Nhiimg u mach hang

U mau xoang hang d the trtfOng thanh (hinh 12) la trong
so" nhting ton thtfOng u dau tien 6 hoc mat dtfOc phat hien va
chan doan phan biet b&ng sieu am. Nhting tieu chuan chfnh ve
mat am hoc la:
1) Cau true dang to ong (mot chuoi nhting dinh xung cao
va thap dien hinh cho nhting be mat hoi am cua nhting khoang
trong xoang hang va mau bi tac nghen, rai rac ft trong cac
xoang.

197
 2) Do hoi am cao (chieu cao dinh xung chiem den 80 - 95%
bien do hien thi).

3) SiJ bien doi am vita phai (goc Kappa co kich thtfdc trung
binh).
4) Mot vo boc u mong v6i be mat hoi p h in g (de nhan biet,
doi khi co nhiing dinh xung be mat hai dinh la bieu hien cua
nhiing chuyen dong ngo&n ngoeo len xuong that thtfdng trong
khi chum song am dang quet ngang qua khoi u).
5) Khu trtf trong chop cO phia thai dtfOng so vdi than kinh
thi giac (Tuy nhien nhiing khoi u ldn se lan rong ve phi'a thai
dtfOng vtfOt qua ca chop cO).

6) Do dac ctfng khong co stf thay doi ttic thi ve chieu rong
cua bieu do sieu am khi ton thtfOng dtfcfc om chat giiia nhan
cau va thanh xtfOng hoc mat thi bang cach an dau do sieu am
A chat vao nhan cau theo htfdng khoi u thi co stf giam dang ke
ki'ch thtfdc cua u va be rong cua bieu do sieu am khi ton
thtfOng dtfOc an chat trong hon 30 giay trong qua trinh sieu am
dong nhtf vay. Khoi u bieu hien trtfdc tien la ctfng bdi vi no
chtfa day mau ma khong the bi chen ep mot cach nhanh chong
bdi vi long mach nho, ap ltfc tang dan trong khoi u. Sau do se
dan den stf tong mau d vi vay lam giam the tich khoi u.
7) Khong co hinh anh dong chay cua mau trong khoi u ca
khi kham bang sieu am A dong hoac kham b&ng sieu am
Doppler (stf khac nhau gitfa dtfdng ki'nh toan the ldn cua cac
xoang mach trong u mau xoang hang vatf nhtfng dtfdng kinh
nhd hon cua nhtfng mach mau nuoi voicm mach li ti tao nen stf
tf mau trong khoi u, ttfOng ttf nhtf ntfdc trong ho boi dtfOc do
day va dtfOc hut ntfdc b in g ong thoat nho.

198
199
Hinh 12. U mach mau xoang hang (the trtfdng thanh). (I: Xung dau
tien bieu hien dinh dau do hoac be mat nhan cau; S: Cung mac; H: U
mach mau; B: Xuong hoc mat; Mui ten: Be mat cua u; M: Co true
ngoai). (A) Sieu am A xuyen nhan cau d do nhan cam to chtfc; (B)
Sieu am A canh nhan cau d do nhan cam to chtfc; (C,D) Cac bieu do
sieu am A dupe ghi nhan trong cung mot chum hudng am d mUc do
nhan cam do dac thap; (E,G) Cac bieu do sieu am B 6 do nhan cam
he thong toi da va d do nhan cam he thong giam xuong 23db; (F,H)
Cac bieu do sieu am ghi nhan dupe trUdc khi ep (F) va 60 giay sau
khi ep (H)( Luu y stf giam ro ret cua be ngang cua khoi u, dieu nay
cho thay rang mau da dupe tong xuat bang phuong phap dong hoc)

Nhiing u mau xoang hang d the nhi hoa rat khac vdi the
trtfdng thanh (hinh 13). Chung thtfdng chtfa ca mao mach va
nhtfng ph&n xoang do vay se hien thi mot cau true ben trong
khong dong nhat (vdi ca stf ttfOng phan cao va thap 0 nhtfng
ph&n khac nhau). Chung thtfdng thieu mot cai bao de nhan
biet nen hinh dang it ro rang hon the trtfdng thanh cua u mau.
Chung thtfdng mem va co the bi ep xep de dang va nhanh
chong trong suot qua trinh sieu am dong. Dong mau chay dang
ke trong khoi u dtfpc phat hien vdi ca sieu am A dong va sieu
am Doppler. Dong thdi, u mau xoang hang the nhi hoa thtfdng
dtfpc phat hien d nhtfng vi tri rat khac vdi the trtfdng thanh,
nghla la, u n&m ngoai chop co d hoc mat trtfdc. Nhtfng u mau
xoang hang cung nhtf nhtfng u mau don gian, u noi mac mach
mau nhd (hemangio-endotheliomas), u mach chu bao (u ngoai
mac mach - hemangiopericytomas ) la co stf phan bo' mach mau
ngheo nan va chtfa chu yeu la cac mo te bao ctfng. Ngtfpc lai
vdi u mau xoang hang d the trtfdng thanh nhtfng ton thtfOng
nay co do ttfOng phan thap.

200
Hinh 13. U mach mau xoang (the nhi hoa). (H: U mach mau; Mui
ten: Be mat cua u). (A) Phan u co do hoi am cao ro ret v6i cac dau
hieu cua cac khoang khong xoang; (B) Phan u co do hoi am thap ro;
(C) Bieu do sieu am cho thay ca cac phan co do hoi am cao va dp
hoi am thap; (D) Bieu do sieu am B cung cho thay cau true khong
dong deu cua khoi u nay; (E,F) Cac bieu do sieu am A ghi nhan
di/pc tren be mat khoi u tri/Pc khi ep bang dau do (E) va trong khi ep
bang dau do (F). (Liru y sp giam ro ret be ngang cua khoi u do bdi
mat do mem cua u mach mau ma bao gom ca cac phan mao mach
cimg va ca phan xoang mem; cung can lull viec xuat hien nhumg
dinh xung u mo la do dong mau chay nhanh trong ton thi/ong u)

201
 Nhiing u mach mau nay tien trien tii tii d nhiing ngiidi tre
dan den mot loi mat am 1. Ton thtfdng luon d trong hinh chop
nhtfng doi khi co the xam chiem khoang ngoai hinh chop. Dieu
nay giai thi'ch rin g nhiing thiet do cat qua dich kinh the hien ro
ton thtfdng hdn nhiing thiet do canh nhan cau. Do khuyech
dai khong nen cai dat qua cao de khong “che khuat” ton thtfdng.

Hinh 14. U mach mau the hang

a. Thiet do cat qua djch kinh tham do kinh tuyen tii 6 gid den 12 gid.
b. Thiet do cat qua djch ki'nh tham do dien dtfdi.
c. Phtfong thCrc A.

202
Hau het ton thtfOng la tron, co nhtfng dtfOng ki'nh giong nhau
trong nhtfng htfdng khac nhau trong khong gian. PhtfOng thtfc
B phan tich nhtfng mdi lien quan vdi cac cau true cua chop cO;
day than kinh thi giac co the bi day ltfi, co hinh cung. Khoi u
tach biet vdi ldp mO trong hoc mat vi no bi boc bdi mot ldp vo.
Khoi u gay chen ep nhe, kin dao ctfc sau cua nhan cau. No
hoan toan dtfOc gidi han doi vdi ldp mO hoc mat d dtfdi va d
thanh hoc mat, gay am vang dang ke d phan trtfdc va keo theo
mot stf giam dang ke cua chum sieu am. Tren sieu am B hien
thi mot hinh thai sam mau cua ton thtfOng d phan sau. Tren
sieu am A bieu hien mot do nghieng giam dan cua nhtfng am
tin hieu khoang 45°.
Ton thtfOng dtfOc gidi han bdi nhtfng dinh xung nhon rat
cao. Khoi u cd mat do ctfng, phai dung mot ltfc ep manh va keo
dai mdi lam thay doi ve hinh thai. Nhtfng u mau the hang co
kich thtfdc nhd co the di dong nhe nhang va co mat do mem.
Khoi u co cau true am vang ben trong, deu, vdi mot do hoi am
cao. Nhtfng dinh xung cao ttfOng tfng vdi nhtfng bo xO, bao
quanh nhtfng khoang it hoi am ttfOng tfng vdi ho mau. Nhtfng
hinh thai nay (tang ong) da dtfOc mo ta nhtf mot hinh thai cua
nhtfng u mach the hang (Hinh
14). Ngtfdi ta co the khao sat dtfOc
d ben trong khoi u nhtfng thay
doi lam chay mau (Hinh 15) va
nhtfng sdi tinh mach (Hinh 16)
ma thtfdng it gap trong nhtfng
dan tinh mach hoc mat.

Hinh 15

203
 U mach hang kem theo chay mau. Khoi u co gidi han
khong ro rang doi vdi ldp md hoc m it. Co nhtfng vung ft gay
am vang ben trong cac ton thtfOng.

Hinh 16. U mach the hang

Thiet do cat qua dich kmh tham do dien dtfdi mui. Khoi u
gidi han rd rang, cd mot cau true am vang deu. Ltfu y sdi tinh
mach gay tang am vang vdi hinh chop cua bong ltfng.

2.5. U mach mau dang mao mach

H iu nhtf trai ngtfOc vdi u mach the hang, u mach mau
dang mao mach thtfdng dtfcfc phat hien luc mdi sinh ra hay
trong nam dau sau sinh. U ttf thoai trien sau 18 thang. Tren
sieu am khoi u thtfdng cd gidi han rat ro, doi khi ft gay am
vang, va khong dong chat. U luon de nen dtfOc vi ban chat
mach mau cua chung, va no phu thuoc vao vi tri cua he thong
dong mach canh trong hay dong mach canh ngoai. Tren thiet
do canh nhan c iu u thtfdng la 0 phfa trtfdc, nong, doi khi tien
trien ra phfa sau nhan cau. Can sii dung nhtfng dau do cd tan
so"cao. (Hinh 17, 18).

204
 Hinh 17. U mach mau dang mao mach.
Thiet do khao sat kinh tuyen 11 gid, thiet do canh nhan
cau tren.
Ton thtfOng lien he chat che vdi nhan cau va thanh xtfOng,
ton thtfOng mem de lom xuong, khong dong chat.

Hinh 18. U mach mau dang mao mach tien trien ra phia sau nhan
cau. Khoi u co ranh gidi so vdi ldp mo hoc mat phia dtfdi. Khoi u rat
mem, de lom xuong dtfoc.

205
2.6. Nhung u mach mau the phoi hdp dang mao mach va hang
Cac u nay thiidng gap d tre em tuoi thieu nien. U tien trien
cham hdn, dan den loi mat, va gay dau ddn. Khdi u co ranh
gidi khong ro rang nhii trong nhiing loai u 0 ngiidi ldn. Cau
true am vang la khong dong nhat, kho de nen xuong diiOc va
hau het nam d phan triidc - tren cua hoc mat, doi khi kho chan
doan phan biet vdi mot u lim pho bao, cd the gay bien chiing
chay mau.

2.7. Nhung u bach mach (Lymphangiomas)

TifOng tii nhiing u mau xoang hang, u bach mach tao ra
nhiing bieu do sieu am dien hinh (hinh 19). Nhiing khoang
trong mach mau cua
nhiing u bach mach diiOc
lap day bdi chat dich dong
nhat hon la mau khong
dong nhat trong cac u mau.
Vi vay, co nhiing dinh xung
rat cao tren bieu do sieu
am A va nhiing diidng dam
net tren hinh anh sieu am
B the hien cho nhiing be
mat trOn lang cua nhiing
khoang khong xoang, diiOc
tach biet ra bdi nhiing cho Hinh 19: U bach mach. Ca hai bieu
khuyet sau cua chieu cao do sieu am A va sieu am B cho
xoang tren bieu do sieu am thay nhiing khoang khong mach
A, tiiOng ling vdi nhiing mau rong va hoi am thap. Mot so
vung khong co tin sieu am cac xung cua mang mach bieu hien
tren bien do sieu am B. hai dinh (moi dinh tirong ung vdi
TiiOng phan vdi nhiing u mat triidc va mat sau cua mang)
mau xoang hang the triidng cho thay be day cua chung (cac
thanh, u bach mach thiidng dau mui ten)

206
co bd bao boc khong deu va mem. Cung khong giong nhif
nhiing u mau xoang hang the nhi hoa. Tren sieu am A dong va
ca sieu am dopper, u bach mach khong phat hien dtfdc dong
mau chay. U bach mach la mot trong so nhiing ton thtfdng hoc
mat rieng le rat it dtfdc nhan biet tren sieu am A va sieu am B.
U bach mach la nhiing khoi u ldn, thtfdng gap d ngtfdi tre
va tien trien ttf ttf. Sieu am chd thay mot khoi gidi han khong
ro, it gay am vang chtfa nhtfng nang dtfng chat long khong gay
am vang, ngan cach bdi nhtfng vach day. Chung luon nam d
ngoai nhan cau va trong hinh chop. Chay mau co the den dot
ngot ben trong u bach mach, nhtfng nang “chocolat” , dan den
nhtfng cuc mau dong to hay nho
Ton thtfdng trong hinh chop va ngoai hinh chop phia tren,
cau trtfc am vang khong dong nhat. Khoi trtfdc -tren chtfa
nhtfng vung chat long khong gay am vang.

a b e

Hinh 20. U bach mach.

a. Thiet do tham do kinh tuyen 3 gid.
b. Thiet do tham do dien mui di/6i.
c. Thiet do canh nhan cau trong.

207
 Ton thiidng to trong hinh chop va ngoai hinh chop phi'a
diidi trong. Ton thiidng it gay am vang, mem co nhieu vach
ngan. Tren bieu do noi ro nhiing vung khong gay am vang
tiidng ilng vdi nhiing cho chay mau.

2.8. Nhtfng hinh thai khac cua u mach mau

Nhtfng hinh thai nay it gidi han la u ngoai mac mach
Pericytome (u mach chu bao), u noi mac mach (u huyet quan
noi mo - hemangio-endotheliome), hay u cd trdn mach mau
(leiomyome vasculaire). Van de la nhtfng ton thiidng nay it gay
am vang, thiidng khong dong chat. Doi khi bieu do sieu am A
lam ro mot luong mau nhanh dan 0 ben trong nhtfng khoi u
bang chtfng la co nhtfng am vang md di do di dong 0 ben trong
ton thiidng (Hinh 21).
Nhiing do dons mach canh - tinh mach hang:
Do la nhtfng noi thong gitfa mot dong mach vdi dam roi
tinh mach hang. Ngiidi ta phan biet:
* Nhtfng ro dong mach canh trong ddn thu&n do co vet
rach cua dong mach 6 doan xoang nong; cac ro dong mach
thiidng la co nguon goc chan thiiOng. Dan liiu toan bo nhtfng
nhanh tdi (chu yeu la tmh mach mat tren va xoang tinh mach
da diidi) cua xoang tinh mach hang ctfng ben va / hay la ben
doi dien.
* Nhtfng ro dong mach canh ngoai don thuan va nhtfng ro
hon hop thiidng la tii phat. Dan liiu di ve he thong mat tren.

208
 Hinh 21. Di dang dong - tTnh mach trong hoc mat

a. thiet do true .
b. phirong thCrc A.

Ton thtfdng ldn tiep xuc vdi thanh trong cua hoc mat.
Nhiing am vang md trong ton thtfOng bieu hien luong mach
mau nhanh dan.
- D in ltfu tinh mach cua nhiing rd dong mach canh - tinh
mach hang thay doi tuy theo hinh thai X quang - giai phlu hoc:

209
 Phai phan biet nhiing ro co liiu liidng ldn va liiu liidng be.
Nhiing ro co liiu liidng ldn chu yeu la de chan thiidng, gay bien
doi huyet dong hoc d phfa diidi cua rd.

a b

Hinh 22. Ro dong mach canh -

tTnh mach hang
(fistule carotico- cave rneuse).
c
a. Thiet do true tren.
b. Thiet do dtfng doc giOfa.
c. Thiet do canh nhan cau trong.
Tinh mach mat tren di tii phan
triidc trong cua hoc mat va di ve
phfa dinh hoc mat. Tinh mach bi
gian, thiet do diing doc giiia, phan trong hinh chop xuat hien 6
tren cua thi than kinh.
Thiet do canh nhan ciu , phan ngoai hinh chop la ngoan
ngheo. Nhiing ro chan thiiOng co dac diem nhii:
* Loi mat co nhip dap, ciiOng tu mau ket mac va phu ket mac.
* Co tieng thoi va cam giac “sd rung” cua nhiing tinh mach
dong mach hoa.

210
 * Dan tmh mach vong mac, va tang ap liic mat.
* Liet van dong nhan cau.
Bieu hien lam sang thiidng dien ra muon hang tuan hoac
hang thang sau chan thiidng.
Nhiing nhutng dau hieu co the km dao hdn nhat la trong
triidng hdp ro tii phat.
+ Tang ap liic mat nhe, tham lang.
+ Ciidng tu mach mau nho 0 ket mac.
Sieu am cho thay mot gian tinh mach mat tren (H. 22). Do
la mot cau true hinh cung co mat 15m vao trong 0 phfa trong
tren binh dien tren so vefi binh dien cua day than kinh thi giac.
Doi khi tinh mach mat tren dan ra that 16n. Nhiing thiet do
trong cac binh dien khong gian co the cho thay tinh trang
ngoan ngeo 0 phan sau cua hoc mat. Mat do cua nhiing cho
dan lefn do la mot khoi mem. Tren phiiOng thiic A bieu hien
tuan hoan dong mach 0 trong tinh mach mat tren bi dan ra.
Hinh 23 cho thay nhiing am vang trong, deu, rat di dong
tren sieu am Doppler cho thay nhiing dau hieu dac biet cua
mot sii tu&n hoan dong mach. Doi khi dau hieu sieu am la am
tmh do sii dan cua tinh mach la km dao, hoac do dan tinh
mach 0 phfa sau hoac khong dan tinh mach mat tren.
 Hinh 23. Ro cfong mach canh - tTnh mach hang.

a. Thiet do dirng doc giufa.

b. Thiet do thSm do kinh tuyen 10 gid 30.
c. Phi/ong thCfc A
Mot khoi u to 0 phan tren hoc mat, day lui nhan cau. Tren
thiet do tham do kinh tuyen 10 gid 30, ngtfdi ta lam noi bat len
nhiing doan ngoan ngheo 0 phia sau cua ton thtfOng. PhtfOng
thtfc A tren mot hinh anh dong de lo nhtfng am vang md trong
ton thtfOng chtfng to luong mau dong mach 0 ben trong cua
tinh mach mat tren, nen tmh mach bi dan ra mot cach ky la.
- Kham nghiem hoc mat ben doi dien phai dtfOc thtfc hien
co he thong.
Can phai chup X quang dong mach co he thong ve dong
mach canh trong va cac nhanh cua dong mach canh ngoai ca hai
ben. Phai danh gia vi tri, stf thoat ltfu tinh mach va tieng vang
huyet dong hoc cua rd. No cho phep dat ra nhiing chi dinh dieu
tri can thiep mach mau (Hinh 24).

212
 Hinh 24. Ro dong mach canh tTnh mach hang sau dieu trj.

Tinh mach mat tren chiia day am vang.

Phong dons tinh mach : La mot di dang hoc mat hiem gap
ma rat khac ve mat sieu am vdi triidng tmh mach chu yeu la vi
tri khu tru va dang u cua no. Phong dong tmh mach co the
diiOc phan biet vdi triidng tinh mach do bdi dong mau chay lien
tuc, nhanh. Mac du hoi cufng hon, dong nhat hon va dac hon.
Di dang mach mau nay thiidng gap trong u mau xoang hang
the nhi hoa (mat do tiiOng doi mem va co nhiing dac diem
huyet dong hoc). Trong nhiing di dang dong tinh mach vai tro
cua sieu am dopper la khong the thieu diiOc de chan doan phan
biet cac ton thiiOng u d hoc mat (hinh 25).
Hinh 25. Cac bieu do sieu am Doppler cua phong dong mach hoc
mat (A) va hoc mat ben kia binh thi/dng (B), di/pc ghi nhan blng
phiiOng phap loc tan so. Do hinh ben trai di/oc ghi nhanitong qua
trinh lam nghiem phap Valsalva. Li/u </ si/ khac nhau ve bien do (van
toe mau chay) gii/a hai hoc mat trong giai doan dau. 6 nhi/ng to
chirc binh thi/dng, toe do mau chay nhanh va gon khi b it dau lam
nghiem phap Valsalva (mui ten), tiep theo dong chay cua mau giam
dan (bdi vi hoc mat bi cang cCmg). Tuy nhien trong phong dong mach
thi toe do dong chay cua mau tang lien tuc trong suot qua trinh lam
nghiem phap Valsalva (bdi vi mau chay xuyen qua cho noi thong
(shunt) dong tTnh mach vdi toe do tang.

Nhting khoi mau tu (Hematome):

Nhiing khoi mau tu bieu hien bang mot loi mat, gay dau
nhiic xuat hien dot ngot. No co the thoai trien tii nhien tii ti/,
nhiing cung co the tai phat. No thong vdi mot ch6 vd cua mot
dan tinh mach, hoac cua mot u mach mau the hang hay mot u
bach mach, hoac do mot chan thi/Ong hoc mit. Khoi mau tu co
the 0 trong hinh chop, co hinh dang tron hay nhieu thuy, bao
quanh day than kinh thi giac (Hinh 26). Khoi mau tu d ngoai
hinh chop co hinh dang det hon, thiidng “chom” vao trong hinh
chop. Hinh thai sieu am cua khoi mau tu thay doi tuy theo
tinh trang mdi hay cu.

214
 Nhiing khoi mau tu mdi, co do hoi am trung binh, hoac
giam va co cau true am dong nhat hpp vdi nhiing mat phan
cach cua nhiing te bao mau

Hinh 26. Khoi mau tu hoc mat.

a. Kham nghiem lan dau.

b. Kham nghiem thifc hienl thang sau.
d. Kham nghiem thifc hien 6 thang sau.
Thoat dau co mot khoi trong hinh chop to, tron, nhieu
thuy, bao quanh thi than kinh. Cau true sieu am cua chung la
gay am vang trung binh, dong chat. Theo thdi gian, khoi do
giam the tich, cau true am vang cua no cung giam di.

215
 Kho chan doan phan biet giiia khoi mau tu vdi nhiing u
thuoc nhom u bach mach, u lien ket va gia u. Nhiing vdi benh
sii bi chan thiidng va nhat la nhiing dau hieu tien trien theo
hiidng thoai trien trong nhiing ngay va nhiing tuan tiep theo
deu la nhiing yeu to dinh hiidng cho viec chan doan la khoi
mau tu (Hinh 27). Sieu am la phiidng phap tot nhat de theo
doi sii giam kich thiidc cua mot khoi mau tu.
Do hoi am cua chung trd nen yeu hon phu hop vdi sii huy
fibrin. Tuy theo co mot hoac nhieu khoi mau tu ma tren sieu am
A xuat hien nhiing dinh nhon tren mot dien rong hon va ro hon.

Hinh 27. Khoi mau tu diidi mang xuong cua tran hoc m it.

a. Kham lan dau tien, tham do kinh tuyen 12 gio.

b. Kham nghiem tham do cung mot kinh tuyen 1 thang sau.

Thoat tien co mot khoi u to canh thanh tren cua hoc m&t
va day lui, de det cO thang tren ( —>•). Mot thang sau, khong
dieu tri, kich thiidc ton thiiOng da giam dang ke. Cau true am
vang la giong nhii nhau. Co thang tren trd lai kich thiidc binh
thiidng.

216
3. NHIJfNG KHOI U 6 PHAN TRlfCJC NHAN CAU XAM LAN
VAO PHAN TREN HOC MAT VA VUNG MAT

Chung bao gom nhiing nang dang da (kystes dermoide),

nhiing khoi u 0 vung ho' le, nhiing u nhay (mucoceles), nhiing
khoi u cua mi mat va cac u mach mau (u mach mau dang mao
mach - angiome capillaires, triidng tinh mach - varices). Day la
nhiing khoi u nhin thay diidc, sd diidc, phan tich diidc tren lam
sang. Sieu am chu yeu la de tim nguyen nhan, xac dinh kich
thiidc cua ton thiidng va gidi han cua ton thiidng nhat la doi
vdi nhiing ton thiidng kich thiidc nho. Viec nghien ctiu ton
thiidng xiidng thi can den chup CT scanner. Nhiing khoi u
nhay se nghien ctiu 0 phan sau. d day chung ta nghien ctiu
nhiing nang dang da, nhting khdi u thuoc tuyen le cung nhii
nhting khdi u cua mi mat.

3.1. Nhumg nang dang da

Do la nhting khoi u lanh tmh co nguon goc tti bao thai, co

the xay ra d bat ky ltia tuoi nao, nhat la 0 tre em va ngiidi tre.
Chat chtia ben trong khoi u phan ldn la md doi khi cd nhiing
cau true, gdi lai nhting mam cua long hay cua rang. No luon
luon 0 ngoai hoc mat thiidng nam 0 goc ngoai (cuol duoi chan
may) hay hiem hdn d goc trong mat.
- Khoi u cd the do ra da. Kham sieu am, chi ra mot ton
thiidng tron, gidi han rat ro bdi mot nang, cau true am vang
thay doi tuy theo sii dong nhat cua chat chtia ben trong.
Chung co the gay am vang thap vdi mtic do hoi am yeu, hay
ngiipc lai hoi am kha, deu. Doi khi co mot cau true am vang
khong dong chat vdi nhting cau true ben trong (nhii m&m rang)
nen qua gay am vang. Mat do cua chung co the la tiiOng doi
mem hay ngiidc lai rat cting va thay doi tuy theo kich thiidc
cua nang (Hinh 28).

217
 a b c
Hinh 28. Nang dang da.

a. Thiet do canh mat hiidng giufa trung tuyen

b. Thiet do canh mat hi/dng thai diiong tren.
c. Thiet do cat qua dich ki'nh thSm do dien thai diiong tren.

Nang kha to, gidi han r5 rang. Cau true am vang cua no la
khong dong chat, toan the nang co gay am vang trung binh, d
trung tam co nhiing vung giam gay am vang. Thiet do cat qua
dich kmh khao sat vung canh nhan cau. Lpi fch cua sieu am la
phat hien phan phinh ra d phia sau cua ton thiiOng. Nhiing ton
thiiOng kich thiidc nho nhiing phia sau lai to phinh ra, choan
ph&n ldn hoc mat kem theo phan ting cua xiiOng doi khi con
pha huy xiiOng, ma chi thay ro khi chup CT scanner (Hinh 29).

218
 t i 1' ' 0 'I

M
i

Hinh 6.26. Nang dang da to 6 hoc m it.

a, b. Thiet do cat qua djch kinh.

c. Phi/ong thCrc A.
Ton thifOng hoc mat 0 ngoai hinh chop “chom” len tren hoc
mat va ho" thai dtfOng ngoai. Do phan giai xtfOng dtfpc nhin
thay ro (—»). Nhin ro cO thang ngoai bi day lui, day than kinh
thi giac cach xa ton thtfOng. Cau true am vang cua ton thtfOng
la hoan toan dong nhat.

3.2. Nhumg khoi u cua vung tuyen le

Nhiing kho'i u vung tuyen le thtfOng thay ro tren lam sang,

sd dtfpc u 0 goc tren - ngoai cua hoc m&t, thtfdng phat trien tii
tuyen le hay vung bao quanh tuyen le roi xam lan hay th&m

219
lau vao tuyen le. Mot niia nhiing u cua tuyen le co nguon goc
bieu mo (nhiing khoi u hon hdp lanh tinh va nhiing khoi u ac
tinh). Mot niia kia gom nhiing ton thiidng viem gia u va nhiing
u bach mach. Nhiing khoi u d vung tuyen le co the co nhieu
kieu loai u. Nhiing ton thiidng u gia viem, nhting u bach mach,
u limphd (lymphome), nhting u di can, nhting u hach bach
huyet, nhting nang dang da.
Sieu am cho phep phan biet nhting nhom u khac nhau.

3.2.1. Nhung nang cua tuyen le

Hinh thai thiidng xay ra nhat la “u nang tuyen le” , ben

trong nang chtia chat long, co the rach ra khi can thiet.

3.2.2. Nhung khoi u hdn hop Idnh tmh

Do la nhting khoi u thiidng xay ra nhat, thiidng gap 0 dan

ong, u tien trien tti tti va gay ra loi mat, day nhan c&u xuong
diidi va day lui cd thang ngoai ve phia trong. Tuyen le phinh to
ra, nhin thay ro tren nhting thiet do canh nhan cau va thiet do
cat qua dich kmh. Khoi u co gidi han rat ro, co mtic dp hoi am
cao. Nhting tieu chuan nay doi khi diipc nhin thay ro d mot do
khuyech dai yeu hon. Cau true am vang ben trong cua khoi u
la deu dan vdi nhieu mat phan cach.
 Hinh 30. Khoi u hon hop lanh ti'nh cua tuyen le.

a. Thiet do tham do kinh tuyen 2 gid.

b. Thiet do cat qua dich kinh tham do dien thai diiong tren.
c. Phi/ong thtic A.

Khoi u ldn 0 ho" le lam bien dang cua thanh xiiOng canh
ben. Ton thiiOng rat co gidi han, kem theo bien dang kin dao
cua nhan cau, cau true am vang deu. Ngiidi ta lam noi ro
nhiing dinh nhon, deu, tiiOng ting vdi nhting mat phan cach.

3.2.3. Nhung khoi u ac ti'nh: Thiidng gap nhat la nhting ung

thii bieu mo dang tuyen (adenocarcinoma). Do la nhting khoi u
to, khong co vo boc, luon tien trien nhanh, gay dau ddn, vdi sii
pha huy nhting thanh xiiOng gan do, xam lan, tham lau ra
chung quanh. Ton thiiOng co do hoi am manh, co cau true am
vang khong dong nhat va doi khi co mot dang chti “V” ... nhiing
cac dac triing nay (pathognomonique) khong the thay diiOc
trong mot so" triidng hop Abces cua tuyen le. Sii ton tai cua
nhting o calci hoa la rat thuan loi cho qua trinh ac tinh hoa
(Hinh 31).

221
 Hinh 31. Ung thirbieu mo dang tuyen cua tuyen le.

U to cua vung tuyen le gidi han kem, kem bien dang cua
thanh xiiOng ben canh. Cau true cua u gay am vang khong
dong nhat, xen ke nhiing vung it gay am vang vdi nhiing vung
rat gay am vang va ca nhting o calci hoa (—>). Toan bo nhiing
dau hieu do la thuan loi cho qua trinh ac tmh hoa.
Khoi u hon hop lanh tinh hay ac tinh doi khi tai phat sau
khi da cat bo khoi u va nhat la neu bi lam vd bao cua u trong
qua trinh lam phau that hay lam sinh thiet. Thiidng rat kho
khan khi tach mot trong nhting cO cua khoi u.

3.2.4. Nhung gia u va nhung u limpho

Nhting u nay it bien doi tren bieu do sieu am, co mat do

cting, co do hoi am thap, mot cau true deu, ton thiiOng thiidng
co gidi han ro va co the la each biet hay la phoi hop vdi nhting
ton thufOng khac (Hinh 32).

222
 Mot ton thiiOng ca hai ben mat co the la mot sarcome ft
hay mot hoi chtfng M ikulicz (Hinh 33).

Hinh 33. Hoi chtfng Mikulicz.

a. Thiet do canh nhan cau cua tuyen le trai.

b. Thiet do canh nhan cau cua tuyen le phai.

223
 Tuyen le tang the ti'ch d ben phai va ben trai. Cau true am
vang la dong nhat. Ben trai ngiidi ta lam noi ro mot nang nho
d ben trong cua tuyen le.

3.2.5. Nhung khoi u cua mi mat

Van de la mot ung thii bieu mo (epithelioma), hoac u

limpho (lymphoma) hay mot u sac to den, Kham lam sang co
the phat hien sii lan ra phi'a sau hoc mat. (Hinh 34).

Hinh 34. Ung th ii bieu mo di can vao ciic sau nhan cau

4. BENH HOC CO

4.1. Cac roi loan cua cd ngoai nhan

Sii day len cua cac cO triic co the do diidc v6i do chi'nh xac
den ± 0, 3mm gan noi cO true bam tan vao nhan cau, den ±0,
5mm 0 cho bung cO trong khoang trong hau nhan cau. Cac cO
cheo co the hien thi va do dac diidc chi khi chung day len

224
nhieu. De tim cac cd cheo tai cho
bam tan vao nhan cau theo htfdng
rong roc va thanh xtfdng hoc mat
dtfdi mot cach tuan ttf. Ngtfdi
kham ap dung mot ky thuat quet
ttfdng ttf nhtf ky thuat dtfdc dung
doi vdi cac cd trtfc nhtfng vdi
htfdng quet khac, nghia la chum
am dtfdc htfdng doc theo cd cheo ttf
phi'a thai dtfdng den phi'a mui hdn
la theo htfdng trtfdc sau nhtf dtfdc
ap dung doi vdi cd thang.

Hinh 35. Stf do dac co trtfc trong. (A) Dau do dtfdc dat gan xich dao
phi'a thai dtfOng va htfdng chum am di qua cac phan khac nhau cua
co trtfc trong. Htfdng chum am 0 vj tri 3 la toi tfu de hien thi be day
toi da cua co. (B-E) Cac bieu do sieu am cua co trtfc trong ttfOng ung
vdi 4 htfdng chum am dtfOc djnh vi d hinh A. (M; Co trtfc trong)

2 25
 Sieu am co the that bai trong viec xac dinh benh ly hoc mat d
ben diicfi va chi cho phep noi len don gian, nhii la “ sii day len viia
phai cua cd triic ngoai ben trai” (day toi da la 4,8mm) hoac la sii
day len ro ret cua ca hai cO triic tren (day toi da la 5, 2mm 0 hoc
mat ben phai vaO 5, 8mm 0 hoc mat trai. Sieu am A chuan hoa
thiidng hiiu dung trong viec phan biet nhiing tinh trang khac
nhau nam ben diidi cac cO ngoai nhan bi day len. Sieu am khong
chi noi len so liiOng va loai cO bi anh hiidng trong mot hoac ca hai
hoc ma t, ma con phat hien ra nhiing thay doi dong thdi khac
trong to chiic hoc mat. Chang han sii phinh len cua tuven le, sii
day len cua than kinh thi giac...
Hinh 36. Cac bieu do sieu am A cua co triic trong binh thiidng (A-C)
va sii day len ro ret cua cua co triic trong do ung thif bieu mo di can
den co (D-C). Cac hi/6ng cua chum am di/oc hi/dng vao cho bam
tan cua co vao nhan cau (A,D) va vao cho bung co ngay sat sau
nhan cau (B,E), va vao phan sau hon cua co (C,F).(M: co triic trong
binh thi/dng; C: co bj tham nhiem ung thtf bieu mo di can; Cac mui
ten: Cac bo co)

Chan doan sieu am cua benh ly mat Grave Basedow diia

tren sii phat hien do day lan toa cua mot so" co ngoai nhan
trong ca hai hoc mat. Chan doan nay co the diicfc bo sung bang
dau hieu sieu am cho thay sii phinh len cua to chiic mo, sii day
len cua nhiing bao than kinh thi giac va quanh hoc mat. Hiem
khi sii phinh len cua to chiic mO hoc mat la dau hieu chinh ma
khong kem theo sii phinh len dang cua cac cO ngoai nhan.

jf-

227
 B D

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Hinh 37. Cac bieu do sieu am cua co cheo dirdi bj day len ro ret
(benh ly m it Graves).(A) Bieu do sieu am B cat theo chieu doc (kinh
tuyen 6 gid) hien thi phan cat doc cua ch6 bam tan cua co triic diidi
(mui ten) va phan bat cheo cua co triic diidi bj day len (l).(B) Bieu do
sieu am B cat theo chieu ngang cua hoc mat di/di, hien thj phan bat
cheo cua co triic di/6i (mui ten ben trai) va mot phan bat cheo cua co
cheo diidi bi day len chong len tren (mui ten ben phai). Cac bieu do
sieu am A (C-E) bieu thi cac phan bat cheo khac nhau cua co cheo
diidi tai cho bam tan cua co vao nhan cau (C) den cac phan bi day
len tiiong doi (D) va nhumg vung dan rong toi da (E)

Trong benh ly mat Grave Basedow mtic do phong len co

the rat khac nhau cua mot cO nay doi vdi mot co khac d cung
mot mat, hoac co the thay doi rat khac nhau giiia cac c0 giong
nhau d mat ben kia, nhii da diiOc phat hien d mot so" benh
nhan da diiOc kham va theo doi tren nhieu benh nhan Grave.

228
Ngoai ra, nhtfng nguyen nhan hiem gap hdn lam day len cua
cac cd ngoai nhan trong ca hai hoc mat la u limpho
(Lymphoma), va benh he thong lien ket (Sarcoidosis). Ngtfdc
lai vdi benh ly mat Grave, cac benh nay thtfdng kem theo
nhtfng ton thtfdng u d ca hai hoc mat, nghia la, phi dai tuyen
le, tham nhiem thtfdng cung mac va nhtfng khoi u khac d ngoai
hoc m^t hoac trong hoc mat. Ttfdng ttf, d benh nhan ung thtf,
cac cd ngoai nhan d ca hai hoc mat co khuynh htfdng dan rong
hdn binh thtfdng .
Trong trtfdng hdp khong the xac dinh ro tinh trang cu the
cua "benh ly cd” thi sieu am se cung cap nhieu thong tin de
chan doan, hoac it nhat la chi ra nhtfng benh ly 6 ben dtfdi CO.
Viem cO cap tinh khong chi bdi co cac dau hieu va trieu chtfng
lam sang cua phong mi mat, do da, dau ma con cho thay
nhtfng dau hieu sieu am cua phu hoc mat va viem thtfOng cung
mac hoac benh ly xoang 0 gan noi cO bi ton thtfOng. Mot so tinh
trang nhtf viem xoang man tinh, loan san xO, u mang nao cua
tran hoc mat va cac tinh trang ac tinh quanh hoc mat (chang
han: u bieu mo cua xoang - carcinoma) co the gay nen stf day
len nhe hoac vtfa phai cua cac co ngoai nhan lan can ma khong
tham nhilm vao cac to chiic hoc mSt. Phu hoc mat va viem
thtfdng cung mac thtfdng khong xuat hien trong viem cd man
tinh. Stf phong len lan toa nhe hoac trung binh cua tat ca cac
cau true cua mat bao gom cac co ngoai nhan, cac bao soi than
kinh thi giac, to chiic md, di kem nhtfng dau hieu xung huyet
ket mac m it la dien hinh cho cac do dong tinh mach 0 nao. Loi
mat dot ngot mot ben mat do stf phong ldn cua mot cO ngoai
nhan don doc bieu hien u mau d trong cac bao co. Dieu nay co
the xay ra sau chan thtfOng hoac khong bi chan thtfOng. De xac
dinh chan doan nay benh nhan phai dtfOc tai kham sieu am
trong mot vai ngay sau do. Chan doan u mau dtfOc chiing minh
khi do day cua cO giam nhanh chong trong mot thdi gian ngan.
Neu khong co thay doi hoac neu do day cua cd tang len trong
qua trinh theo doi thi u mau bi loai trii.

229
 Nhiing tinh trang khac chang han nhii gia u. u xd than
kinh, u mang nao than kinh thi giac, u bieu mo (carcinoma) di
can den nhiing to chtic hoc mat mem, u cd van ac tinh
(rhabdomyosarcoma) co the gay nen day mot hoac nhieu cd
ngoai nhan trong hoc m it. Bang cach phat hien va dinh ro tinh
trang hoc m it ben diidi, sieu am giup lam ro sii day cd nhii vay.
Trong liet cd ngoai nhan keo dai, sieu am se phat hien teo cd.
Nhting cd thang diidc phan tich theo phiidng thtic B va
theo phiidng thtic A tren thiet do doc va thiet do tran vdi dieu
kien la do khuyech dai khong diidc qua cao. Chung it gay am
vang va gidi han ro doi vdi ldp md cua hoc mat va thanh hoc
m it. Nhting cd cheo cung thay diiOc dac biet neu chung tang
the tich. d ngang dinh hoc mat rat kho phat hien cO.
Khi kham sieu am thay ro tang the tich cua mot cO nao do
thi phai kham co he thong nhting cO cua hoc mat ben kia va
tim benh ly cua nhting cau true khac d hai hoc mat nhii: tuyen
le, day than kinh thi giac, khoang md sau nhan cau trong hinh
chop, thanh cua nhan cau. Sii tang the tich cua cO mot ben mat
co the gap trong benh Basedow, hoac mot ton thiiOng viem gia
u tii phat, hoac mot khoi u co, hay tham lau cua mot benh
mau, hay la di can cua mot u ac tinh, hoac nang ky sinh trung.
Trong hoc mat co hinh anh tang the tich cua tuyen le va
cua co thang ngoai. Cau true am vang cua hai thiiOng ton nay
la rat thap.
Tang the tich cua nhieu co d mot ben mat co the gap trong
benh Grave Basedow, mot ton thiiOng viem gia u, hoac ro dong
mach canh - tinh mach hang mot ben.
Tang the tich cua nhieu c0 d hai ben mat it hay nhieu, doi
xting hay khong doi xting, co the gap trong benh Basedow, mot
u limpho, hoac u tuy, hiem hon la benh sarcome, hoac ro dong
mach canh - tinh mach hang.

230
4.2. Benh ly m it GRAVE - BASEDOW

Loi mat la mot trong nhiing dau hieu chu yeu cua benh
Grave - Basedow. No la do sii tang the tich cua ldp md trong
hoc mat va nhutng cd van nhan. Viec chan doan tren lam sang
luon de dang vdi trieu chiing loi mat hai ben kem theo co rut
cua mi mat tren va nhiing xet nghiem chiic nang tuyen giap
deu la diidng tmh. Kham sieu am co vai tro theo doi sii tien
trien cua benh trong hoc mat theo qua trinh dieu tri.
Viec chan doan lam sang kho khan hon khi loi mat xay ra
d mot ben va nhiing xet nghiem chiic nang tuyen giap khong
dac hieu cho chan doan. Ngiidi ta doi hoi sieu am xac dinh
chan doan va loai trii cac nguyen nhan khac, dac biet la u, doi
v6i loai loi mat Grave- Basedow. Can phai khao sat tu in tii
tiing cO thang va cac cO cheo cua moi mot hoc m it. Moi mot co
phai dtfoc nghien ciiu theo chieu doc va chieu thang goc. Cung
phai do kich thiidc cua day than kinh thi giac va lam mot thiet
do true cua moi mot hoc m it de danh gia the tich cua ldp md
trong hoc m it. Kham nghiem cho thay co tang the tich cua mot
hay nhieu cO trong ca hai hoc mat. Sii tang the tich thay doi
khac nhau giiia CO nay so vdi co khac, ty le ton thiiOng cua cac
cO thiidng la: co th in g trong 53%, co th in g diidi 46%, co th in g
tren 33%, cO th in g ngoai 24%, cO cheo ldn 6%. Cau true am
vang cua cO la binh thiidng hay tang len (Hinh 38). Gidi han
cua ldp md hoc m it 1 la khong ro rang so vdi binh thiidng.
Phai tim nhiing dau hieu phoi hop nhii: tang the tfch cua ldp
md hoc mat sau nhan cau, hoac sii day len cua bao day than
kinh thi giac (H6.32); phat hien bien chiing nhtf: phu gai thi
do chen ep day than kinh thi giac bdi nhiing cO phinh to ra 0
dinh hoc mat.

231
 Hinh 38. Benh Basedow
Thiet do tham do cO thiing trong. Co thang trong tang the
tfch 0 phan bung c0. Co co cau true am vang trung binh va
dong nhat.

Hinh 39. Benh Basedow

a. Thiet do tham do co th in g di/6i
b. Thiet do tham do co th in g tren
Co thang dtfdi va thang tren day len va ldp mO hoc mat
tang the tfch. Stf rong ra cua day than kinh thi giac.
Hiem khi trong benh Basedow chi co mot dau hieu la tang
the tfch cua ldp mO hoc mat (7%). Doi vdi loi mat nhieu, doi khi
c£n phai can thiep bang phau thuat de lam giam ap ltfc hoc
m&t, thi can phai chup CT scanner. Sieu am luon can thiet de
theo doi stf tien trien cua dieu tri ve stf giam the tfch cua cac CO.

232
4.3. Viem cd cap tinh

Viem cd thiidng kem theo nhiing dau hieu lam sang nhii:
phu mi mat, do da, dau. Co tang the tich toan bo kem theo
thiidng ton cua gan co cau true am vang giam. Phai tim nhiing
dau hieu viem thiidng cung mac va / hay cua viem xoang ke
sat vdi cd bi ton thu’dng.

4.4. Nhumg u cd van ac tinh (Rhabdomyosarcome)

Do la nhiing khoi u ac tinh, ldn rat nhanh, co the cham vao

mot hay nhieu cd. U xay ra dot ngot d tre em vdi chu yeu hai
thdi diem, mot la d nhiing tre sd sinh, hai la bat dau d tuoi vi
thanh nien.
Co sii tang the tich dang ke cua mot hay nhieu cd. Doi khi
khoi u co gidi han ro, tiep can vdi mot cd d cho bat dau cua khoi
u. Khoi u doi khi xam lan vao tuyen le. Khoi u ciing, rat ft gay
am vang (Hinh 40). Sii xam lan vao thanh xiidng va nhiing d
cau true lan can can phai danh gfa bang chup CT scanner.

Hinh 40. Sac com co van cham vao co thing tren.

a. Thiet do tham do kinh tuyen 12 gio
b. Thiet do tham do dien tren.

233
 Sieu am co the chan doan phan biet gitia mot saccom cd
van, mot khoi u ac ti'nh khac vdi mot ton thtfOng u gia viem.
Khoi u phat trien tti cd thang tren gan cua cd binh thtfdng.
Cau true giam gay am vang. Khoi u rat ran, khong de bep
dtfdc. Lam bien dang cua thanh xtfdng tai cho ton thtfdng.

5. NHIJNG KHOI U BEN TRONG HAY / VA NGOAI HINH CHOP

5.1. Nhung khoi u ac tinh

No co the la nhtfng kho'i u ac tinh nguyen phat hay thti

phat (chu yeu la u vu hay u phoi). Ngoai nhting dac diem cua
nhting saccom van cd. Tat ca nhting khoi u ac tinh khac khong
co hinh dang sieu am dien hinh. Thtfdng bieu hien la nhting
khoi u co gidi han khong ro rang vdi tham lau vao nhting cau
true hoc mat lan can, va doi khi vao xoang (hinh 41). NgtfOc lai
co nhtfng ton thtfOng co gidi han ro lam chan doan nh&m vdi
mot ton thtfOng lanh tmh.

5.1.1. U x o md bao (Histocytofibrome)

Hinh 41. U xo mo bao (Histocytofibrome).

234
 Lam noi ro mot khoi u hoc mat rat to, cting, gay bien dang
dang ke nhan cau, chen ep day than kinh thi giac sau nhan
cau. Cau true am vang cua u la giam gay am vang, rat khong
dong chat.

5.1.2. U hac to ac tmh nguyen phat cua hoc mat

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Hinh 42. U hac to ac ti'nh nguyen phat cua hoc mat

a. Thiet do tham do kinh tuyen 7 gid 30.

b. Phirong thCrc A.
Tren sieu am B, ton thtfOng co dang hinh trtfng, hai thuy,
gidi han ro doi vdi ldp md cua hoc mat, gay chen ep. Ltfu y co
mot stf day len dang ke cua thanh nhan cau, khoang dtfdi bao
Tenon dan rong.
Cau true am vang cua khdi u la khong dong chat xen ke
vdi mot phan dong chat, nen tren bieu do sieu am co mot phan
khong gay am vang va mot phan khac gay am vang hon. Trang
thai khong dong chat cua ton thtfdng lam thuan ldi cho qua
trinh ac tinh hoa.
Do hoi am ldn, giam am dang ke (hinh 42). Stf khong
thu&n chat cua tap hop te bao va gidi han kem cua khoi u doi

235
khi tao ra mot mot dang chtf
stf bat dong cua chung la do
can. Doi khi lam nhan cau
nguyen phat hay nhtfng ton
can (Hinh 43).
“V” . Mat do cua chung 0 rat cting,
tham lau cua nhting cau true lan
bat dong, co the la mot ung thtf
thtfdng thtf phat lam nghi den di

Hinh 43. Di can hoc mat cua mot ung thtf 6 phoi.
a. Thiet do canh nhan cau dtfdi.
b. Thiet do cat qua djch ki'nh, tham do trtfdng phi'a dtfdi.
c. Thiet do cat qua djch ki'nh tham do kinh tuyen 3 gid.

236
5.2. Nhurng benh mau va nhung ton thUdng viem gia u

Ton thiidng cua hoc m&t khong co tinh dac hieu tren sieu
am trong nhiing benh ung thii he tao mau (Leucemie), nhiing
u limpho va nhiing u lien vong ac tinh (Reticulosarcom- sacom
liidi). Day la nhiing khoi ft hay nhieu co gidi han ro, ciing, ft
gay am vang, doi khi 0 ca hai ben.
Nhiing ton thiiOng u gia viem tii phat la nhiing benh co
nguon goc khong ro, nhiing co the co nguon goc mien dich.
Tren lam sang co trieu chiing loi mat dau nhiic kem theo liet
van nhan, co hoac khong co giam thi liic. NgiiOc lai, vdi u lim
pho ngiidi ta nhan thay co th&m lau monoclonale con trong
nhiing ton thiiOng u gia viem co tham lau lim pho tiiOng bao
Polyclonale.
Nhiing u limpho co the xam lan vao tuyen le, cac cO, va mi
mat (Hinh 44), ket mac, hay chen vao giiia nhiing thanh xiiOng
va nhiing cO hay choan toan bo hoc mat (Hinh 45).
Ton thiiOng anh hiidng den mi diidi va khoang trong hinh
chop, giam gay am vang, gidi han kem doi vdi ldp md hoc mat
gay tham lau doi vdi thi than kinh va cO thang trong: Ton
thiiOng toan bo nhiing cau true hoc mat kem theo sii bat dong
hoan toan cua nhan cau.
Cac gia u th&m lau theo ty le tuan tii nhii sau, chu yeu la
vao tuyen le, ke den la cac cO, roi den cung mac va sau cung la
than kinh thi giac. Tat ca nhiing cau true hoc mat deu cd the
bi ton thiiOng.
Tat ca nhiing ton thiiOng nay deu ft gay am vang va ciing.
Do hoi am bien do cua chung deu thap. Nhiing gia u xO deu rat
ft gay am vang va rat ciing. Tren bieu do sieu am, rat kho
nhan biet, diia tren nhiing tieu chuan am hoc don thuan de
chan doan phan biet vdi nhiing u limpho vdi nhiing ton thiidng
viem gia u.

237
 Hinh 44. U lim pho cua mi diidi.

Khoi u co gidi han rd, giam gay am vang cua mi diidi.

Nhiing tiiOng quan cua nhan cau diiOc lam noi ro len.
- Nhiing tieu chuan theo doi sau dieu tri (lieu phap
corticosteroide, lieu phap tia xa va mien dich lieu phap) la rat
quan trong de nghien ciiu.
Nhiing ap xe, tren lam sang ngiidi ta phai lii y den benh sii
cua viem mo te bao va sii cd mat cua nhiing dau hieu viem hoc
mat va quanh hoc mat. Nhiing ap xe hoc mat deu tron neu
chung 0 trong hinh chop, det hon khi chung 0 ngoai hinh chop.

238
 Hinh 45. U limpho hoc mat.

a. Thiet do cat qua djch ki'nh tham do dien tren.

b. Phuong thiic A.

Nhin tren thiet do tong quat, co cho day len cua ket mac,
co cho day len cua cO thang tren, khoi sau nhan cau co cau true
rat it gay am vang.
- Nhiing ap xe mdi deu kem gidi han va cd do hoi am trung
binh. Sau mot thdi ky tien trien nao do, nhiing ap xe co mot vo
day, do hoi am giam dan. Sieu am cd the chan doan phan biet
mot khoi mau tu hay mot khoi u loai u limpho, hoac u sacom,
hoac gia u. Chup CT scanner la rat c&n thiet de phat hien ton
thiiOng nhiing cau true quanh hoc mat.

239
 Hinh 45. Ton thi/ong viem gia u.
a.Thiet do true.
b. Thiet do canh nhan cau tham do vung tuyen le.
c. Thiet do tham do kinh tuyen 9 gid.
d.Thiet do tham do mat phang ti/ong Cmg.
 Thi than kinh tang kich thiidc. Khoang diidi bao Tenon
day len, khong gay am vang. Tuyen le tang kich thiiclc, giam
gay am vang. Nhiing cd van dong nhan cau day len ldp md hoc
mat sau nhan cau giam gay am vang.

5.3. Nhumg khoi u nang hoa

Chung ta da nghien ciiu nhiing nang dang bi, nhiing u

quai (Teratome) nhiing nang phoi hdp vdi mot tat mat nho,
nhiing khoi mau tu, nhiing boc niem dich, nhiing nang ddn
thuan, nhiing nang ky sinh trung, nhiing thoat vi d iu
(Cephalocele).

5.3.1. Nhung boc nhay (Mucocele)

Do la nhiing ton thiidng lanh tinh phat trien “ chom “ tren

mot xoang khong khi va hoc mat, tien trien tii t£f, kich thiidc
thay doi. Do la nhiing ton thiidng ran, gidi han ro vdi mat phan
cach cua thanh xiiOng. Chat chiia d trong la it gay am vang
dong chat, tiiOng diiOng vdi tich tu cua chat nhay. Doi khi
ngiidi ta ghi nhan diiOc 0 trong cua mot ton thiiOng khong gay
am vang, long, cd mot vung it gay am vang, dong chat, tron, di
dong theo cac tii the cua benh nhan. Trong triidng hop boi
nhiem, chat chiia 0 trong trd nen gay am vang hon, khong
dong chat.

5.3.2. Nhung nang don thuan (Kyste simples)

Do la nhiing nang do ii dong, cd kich thiidc nhd, phat trien

tii nhiing tuyen cua ket mac (H. 47). Nang do the vui
(inclusion) bieu mo cd the rat to. Chung phat trien sau mot
chan thiiOng hay mot can thiep bang phau thuat. Do la nhiing
khoi gidi han rat ro, cang mong, cd chiia diing chat long.

241
 Hinh 47. Boc dich xoang
sang tri/dc.

Mot khdi u nhd cd p h in trtfdc / trong cua hoc m it. Coquan

he vdi thanh xtfOng rat ro cung nhtf vdi nhan cau. Chat chtfa
dtfng ben trong la khong dong chat.

242
 Hinh 48. Boc djch xoang sang trirdc kha to.
a. Thiet do canh nhan cau tham do kinh tuyen 3 gid.
b. Thiet do canh nhan cau trong.
c. Thiet do canh nhan cau trong, vdi ttf the nam sap.
Stf phan cach cua boc dich vdi thanh trong hoc mat va
nhan cau trong rat ro. Cau true am vang cua boc dich la khong
gay am vang vdi phan doc xuong, mot vung gidi han ro, giam
gay am vang, dong chat. Trong ttf the n&m sap, vung giam gay
am vang nay la di dong, “roi xuong” d mat phia trtfdc cua ton
thtfOng.

5.3.3. Nang cua ket mac

Nang nho ra d thanh trong, phia trtfdc cua nhan cau, rat
nhd, khong gay am vang. Nang phat trien gay day lui nhiing
cau true phia trtfdc, cua mong mat, va choan mot phan cua
tien phong.

243
5.3.4. NhOng nang san (Hydatique)

Hinh 50. Nang san

Phai nghi den nang nay neu ngtfdi benh 0 trong vung co
benh ltfu hanh. Nhtfng nang nay chi co doc nhat hay co nhieu
nang, gidi han ro boi mot boc, chat chiia 0 trong la khong gay
am vang hay giam am vang.

5.3.5. Nhung thoat vj mdng nao (Cephalocele)

Do la nhiing ton thtfOng hiem, co chtfa chat long hoac hon

hop, phat hien ro tren CT scanner.

244
5.4. Nhumg u Schwann va nhumg u vo bao than kinh (neurinome)

Cac u nay co the gay ton thiidng cho tat ca cac day than
kinh cua hoc mat trti day than kinh thi giac, vi diidc bao
quanh bdi nhiing bao mang nao. Sieu am cho phep chan doan
dinh khu va hinh thai cua nhiing khoi u giam gay am vang va
gidi han ro nhiing khong tim thay dau hieu am dien hinh
(H. 51). Khi phat trien ldn, u co the xam lan len tran tren hoc
m&t va mat trong so.

Hinh 51. U Schwann hoc mit.

a. Thiet do tham do kinh tuyen 3 gid.

b. Phi/ong thtic A.

Khoi u co hai thuy giam gay am vang, gidi han ro, n^m 0
giiia cO thang ngoai va day than kinh thi giac. PhiiOng thtic B
cung nhii phiiOng thtic A chi ro nhting moi quan he gitia cO
thang ngoai va khoi u.

5.5. Nhumg u xam lan theo kieu “cudi ngua” (“Cheval”)

Nhting u nay co the “ciidi ngiia” tren hoc mat va phan gitia
cua day so, cac xoang cua mat va cua day so, vom hong
(Cavum) mat va so.

245
 Sieu am ft co gia tri trong benh hoc nay bdi vi no khong
the khao sat trtfc tiep nhiing ton thiiOng xiiOng va sii phat
trien ben ngoai hoc mat cua nhiing u nay. Nhiing khoi u mang
nao cua hoc mat - xiiOng biidm. Nhiing u xiiOng ac tmh nguyen
phat hay thii phat nhiing boc dich hay nhiing khdi u ac tmh
cua cac xoang (H6.44).

Hinh 52. U m&ng nao hoc

mat bifdm.

Ton thiiOng ben ngoai hinh chop gidi han kem (*). Sii dong
dac xiiOng thay rat ro (->). Co thang tren va day than kinh thi
giac co trang thai binh thiidng. Chan doan kho chfnh xac.

Hinh 53. Ung thi/ cua nhumg te

bao xoang sang

246
 Khoi u ben ngoai hinh chop (*) vdi stf chen ep vao day than
kinh thi giac lam noi bat mot cho nho len cua gai thi hdp vdi stf
chen ep cua day than kinh thi giac nay (->). Khoi giam gay am
vang khong dong chat khong co mot dac diem am hoc dac trtfng.

6. NHtfNG TON THI/ONG QUANH HOC MAT

Xtfdng ch ic va day ngan can sieu am khong xuyen sau vao

trong vung quanh hoc mat. Ngay ca khi xtfdng rat mong, sieu
am cung khong the vao trong xoang quanh hoc mat bdi vi no bi
tic nghen hoan toan do khi d trong xoang. Vi vay, bat cd am
doi nao thu dtfOc tti vung quanh hoc m&t mot cach xac dinh
deu cho thay mot tinh trang bat thtfdng. Cac benh quanh hoc
mat, bang cach thay the stf lap day khong khi trong xoang bdi
mang niem mac xoang phi dai, hoac dich, hoac to chtic u, va
dac biet la bdi stf pha huy thanh xtfOng hoc mat cho phep cac
xung sieu am xuyen sau vao trong va don cac am doi trd lai tti
vung quanh hoc mat. Trong cac bieu do sieu am A chuan hoa,
cac dinh xung be mat quanh hoc mat dat chieu cao 100% bien
do hien thi khi thanh xtfOng hoc mat bi pha huy. Ngtfcfc lai cac
dinh xung giam thap dang ke khi thanh xtfOng con nguyen
ven. Trong trtfdng hop thanh xtfOng con nguyen ven, sieu am
phat hien ra benh quanh hoc mat nhtfng khong the phan biet
dtfOc chung. Tuy nhien, khi co stf khuyet xtfOng, sieu am co the
phan biet dtfOc cac tinh trang quanh hoc mat. Ngoai ra, stf lan
rong cua mot khoi u co the dtfOc do dac chinh xac qua nhtfng
cho khuyet xtfOng. Hinh 54 minh hoa cac bieu do sieu am dien
hinh cua cac tinh trang quanh hoc mat khac nhau .

247
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Hinh 54. Cac tinh trang quanh hoc m it. (A-D) Cac bieu do sieu am
cua u nhay hoc mat duoc ghi nhan khi hudng chum am di xuyen qua
cho khuyet xuong cua xuong hoc mat (A) va sau do be gap dau do
theo cac hudng khac nhau qua bo khuyet cua xuong (B-D).(C: u
nhay; S: cung mac; Cac mui ten: be mat cua u; B: tran xuong hoc
mat; S: tran xoang; R: la cac tin hieu hoi am.). LUu y lam the nao
xung cua tran xuong hoc mat tang len ve chieu cao (A-D), nhi/ng ma
xung cua tran xoang lai giam khi chum am duoc be gap goc ra khoi
ch6 khuyet xuong va mot luong ldn cua chum am bj chan lai bdi tran
hoc mat (khong di vao trong xoang). (E,F) Cac bieu do sieu am cua
xoang ham cho thay xoang khong chufa day khi. Xung cua thanh
xoang ben doi dien chi cao trung binh trong hinh E, cho thay rang
khong co khuyet xifOng trong khi chum am di/oc hudng thing vao
trong xoang. Tuy nhien, xung thanh xoang toi da trong hinh F dat
100% chieu cao, cho thay rang co khuyet xuong (vi nang li/Ong sieu
am di vao trong xoang nhieu hCn).(M: xoang ham; W: thanh xoang).
(G,H) cac bieu do sieu am cCia ung thi/ bieu mo xoang xam lan vao
trong hoc mat. Li/u y rang, si/ khong dong deu ve cau true ben trong,
do hoi am va be mat; Cac xung be mat trong hai bieu do sieu am
hien thj nhi/ng vi tri khac nhau hoan toan mac dau thuc te la ca hai
bieu do deu duoc ghi nhan v6i cac hudng chum am sat nhau (cac
xung be mat nhap nhay “jumpy”). (Cac mui tenC; be mat cua u)

Cac tinh trang ac ti'nh quanh hoc mat diiOc dac trUng boi
cac cau true ben trong hinh dang va cac bd khong dong deu.
Mac dau nhiing u nay phan hoi am thap, cac phan xiiOng con
lai trong to chtic u tao ra mot so" dinh xung cao, phan tan
khong dong deu la dau hieu de chan doan phan biet nhting u
nay vdi cac u nhay va nhting khoi u co cau true dong deu khac.
Sieu am khong chi ra dUOc loai te bao nen mot so ton thiiOng
gay pha huy xUOng cung duoc xep vao loai nay: Ung thii bieu
mo (carcinoma), ung thii lien ket (sarcoma) u huy cot bao (u te
bao khong lo -osteoclastoma), u mo bao (histiocytoma) va u
mang nao ma khong xuat phat tti than kinh thi giac. Mac du
nhting u mang nao nhii vay va ung thii tao ra cac kieu dang
bieu do sieu am tUOng tii. Chung thiidng co the dtidc phan biet

249
tren cd sd vi tri cua chung va moi lien quan cua kich thtfdc cua
chung doi vdi do loi cua mat, u mang nao dinh vi 0 phi'a tren,
thtfdng ra phi'a ngoai, ngtfdc lai ung thtf thtfdng xuat phat ttf
xoang ham va xoang sang. U mang nao thtfdng tao ra do loi
mat nhieu trong khi u con ttfdng doi nho, ngtfOc lai cac tinh
trang ac ti'nh phat trien den ki'ch thtfdc lan rong trtfdc khi gay
ra loi mat ro ret.

6.1. U nhay hoc mat thtfdng tao ra nhtfng bieu do sieu am dac
trtfng. Cac tieu chuan am hoc cua nhtfng nang ‘’gia u” thtfdng
gap nay la cau true, hinh dang va bd dong deu, do ttfOng phan
thap, kich thtfdc ngoai hoc mat ldn, khuyet xtfOng deu, ldn mat
do chac va co mot thanh nang.

6.2. Loan san xo b vung quanh hoc m it dtfoc dac trtfng bdi
xtfOng bi day len, tao ra nhtfng bieu do sieu am khac h in vdi
nhtfng bieu do sieu am cua nhtfng ton thtfOng hoc m it va
quanh hoc mat khac. Be mat cua xtfOng trong loan san xd
thtfdng nguyen ven va giong nhtf nhtfng u xtfOng binh thtfdng,
no khong cho sieu am di qua, dinh xung hoc m it giong nhtf
dinh xung xtfOng binh thtfdng. Tuy nhien, be mat xtfOng nay
loi sau vao trong hoc mat, lam hep khoang khong canh nhan
cau va tao ra bieu do sieu am hoc m it bi giam be rong. Cac am
doi thtfdng khong ghi nhan dtfOc trong ton thtfOng xtfOng.

7. Dj VAT NHAN CAU

Thong thtfdng nhtfng di vat co hinh dang khong deu n im

trong dich ki'nh, cung mac hoac trong nhan cau, trong hoc m it
deu co the dtfoc phat hien nhanh chong, de dang, dang tin cay
bang phtfOng phap sieu am chuan hoa khong lien quan den
ban chat di vat (vdi do chi'nh xac tren 98%). Vdi dieu kien la
dtfdng ki'nh cua chung ldn hon 0.5mm, chung se tao ra nhtfng
am doi manh dac hieu va tao ra nhtfng bong toi rieng biet. Chi
70% di vat n im 0 nhtfng vi tri kho nhtf the mi, hau phong,

250
thuy tinh the, goc tien phong va nhiing phan sau cua hoc mat
xa nhan cau thi kho phat hien hon. Nhiing di vat hinh cau nhii
bom bi thi tao ra nhiing kieu song sieu am dac biet (hinh 55)
va co the phat hien diidc va nhan biet mot cach chac chan ngay
ca 0 nhiing vi tri kho thay nay, chung thoat khoi sii phat hien
bang sieu am chi khi khu tru gan dinh hoc mat hoac d ben kia
thanh xiidng hoc mat.

Hinh 55. Dj vat nhan cau. (F: Dj vat; I: Xung dau tien bieu hien be
mat nhan cau; S: Cung mac; O: Hoc mat; M: cac tin hieu hoi am doi
lai cua cac xung sieu am khi tiep xuc v6i di vat hinh cau; Mui ten: chi
cai bong liing (shadow) cua di vat). (G) La bieu do sieu am A ghi
nhan diroc d mire nhan cam to chCrc khi dj vat diioc djnh vj 6 trung
tam buong djch ki'nh; (F) La bieu do sieu am khi chum s ieu am di
ngang qua di vat.

251
 iM it n i ■ m n 4 ii ® C/ll/H- ?7^
kna •
tct

Hinh 57. Hinh anh di vat n im d thi than kinh

a. Thiet do c it qua true triidc sau (axial)

b. Thiet do khao sat qua hi/dng mui

252
 Hinh 58. Chan thi/dng thung nhan cau co kem di vat

Tren bieu do sieu am B cho thay vi tri bi xuyen thung.

DtfOng vao cua di vat xuyen qua dich kmh den ctfc sau cua
nhan cau kem theo xuat huyet dich kmh tao thanh mot vach
dai tren bieu do.

Hinh 59. Di vat bang kirn loai nam sat thanh trong cua
nhan cau dmh vao cung mac

253
 Hinh 60. Dj vat dmh vao the mi rat nho, hut am manh.
Nhin thay ro khi liec mat toi da ra phi'a ngoai.

a. Thiet do khao sat kinh tuyen 4 gid.

b. Thiet do khao sat 6 cung kinh tuyen vdi mat liec toi da ra
phi'a ngoai.
c. Thiet do khao sat kinh tuyen thing goc vdi kinh tuyen 4 gid

254
7.1. Their nghiem nam cham

Vdi sieu am chuan hoa, mot thii nghiem nam cham vo hai
co the diidc thiic hien. Trong thii nghiem nay, di vat khong
diiOc di chuyen khoi vi tri cua no nhiing no bi nghieng toi thieu
(< 1°) bdi vi no xep thang hang theo diidng liic hut nam cham
khi ap nam cham vao. Sii nghieng toi thieu nay tao ra sii thay
doi co y nghla tren chieu cao cua dinh xung khi sii dung
phiiOng phap sieu A chuan hoa (hinh 61). Khi lay dong nam
cham thi chieu cao dinh xung cung thay doi tiiOng dng.

Hinh 61. Thir nghiem nam cham vo hai. Mot thoi nam cham diioc di
chuyen cham va lien tuc theo hiidng di vat trong khi ngiidi kham theo
doi xung sieu am cua di vat tren man hinh (cac hinh tren). Sii chap
anh (photomontage) tii mot chuyen dong cho thay phiic hop xung
hoc mat / thanh nhan cau / di vat bdi vi di vat dirge quan sat trong
tiing 1/12 giay. Liiu y rang moi 1/3 giay (mui ten) thi xung dj vat giam
dot ngot chieu cao, chi lay lai chieu cao ban dau ngay sau day.
Nhi/ng sii len xuong nay cua xung sieu am lam ro tac dong cua nam

255
cham len dj vat. Xung dj vat chi thay doi ve chieu cao va khong thay
doi ve chieu ngang, boi vi dj vat khong di chuyen khoi vj tri ban dau
cua no khi lam thir nghiem nam cham.

Ky thuat: Trtfdc het ngtfdi phu gitf 1 thoi nam cham dtfOc
lay dong cl mot khoang cach an toan doi vdi mat cua ngtfdi
benh. Trong khi ngtfdi kham quan sat dinh xung mot cach can
than va dieu khien ban dap cua nam cham thi ngtfdi phu di
chuyen nhe nhang thoi nam cham gan mat hon. Ngay khi phat
hien chuyen dong theo htfdng thang diing dau tren cua dinh
xung thi tat ca hoat dong cua nam cham va stf di chuyen cua
nam cham deu ngifng lai. Ngay tai diem nay, khoang cach
(tinh bang centimet) giiia dinh cua nam cham va di vat cho
thay di vat co tif tinh va di chuyen du de lay ra b^ng nam
cham qua pars plana (hinh 62). Neu khoang cach it hon 5cm,
thi nam cham se khong keo dtfoc di vat ra khoi vi tri cua no
qua pars plama neu khong cat dich kinh. Neu khoang cach ldn
hon 5cm, di vat co the dtfOc lay ra thanh cong. Khoang thdi
gian cho phep tii khi bi thtfOng cho den khi thtt nghiem khong
qua 48 gid. Sau thdi gian nay thi ngay ca mot di vat co tii tmh
manh thi thtfdng cung khong di chuyen du de lay ra khoi mat
bang nam cham qua dtfdng rach don gian 6 pars plama bdi vi
nhtfng thay doi tien trien cua stf bao boc dich kmh quanh di
vat. Tuy nhien thdi bieu nay cung co the thay doi theo stic
manh cua thoi nam cham. Thii nghiem nam cham co the dtfdc
thtfc hien tai benh phong hoac tai phong mo dtfdi nhiing dieu
kien vo khuan hoac ban vo khuan trtfdc hoac trong khi phau
thuat. Dieu chu yeu la cung mot thoi nam cham dtfOc dung de
thtf nghiem va lay di vat. Thtf nghiem nam cham nay co the
dtfoc thtfc hien an toan vdi thiet bi sieu am A chuan hoa.
Nhtfng thiet bi sieu am A va sieu am B khong dtfoc chuan hoa
thi khong du do nhay de hien thi nhtfng thay doi to'i thieu cac
htfdng cua di vat, di vat phai di chuyen vi tri cua no theo
htfdng nam cham de tao ra nhtfng thay doi tren bieu do sieu
am de chiing minh nhtfng dac tinh tu! tinh cua no. Lay di vat

256
 Hinh 62 a, b, c

a. Di vat nam ngay tren

thanh nhan cau. Thiet
do cat ngang qua djch
kinh.

b. Di vat nam phia sau

thanh nhan cau. Thiet
do canh nhan cau.

c. Di vat nam phia sau

thanh nhan cau. Khong
the nhin thay di/pc di
vat qua thiet do canh
nhan cau neu benh
nhan khong liec mat
tdi da.
nhii vay la nguy hiem vi khong the dieu khien diiOc di vat va
gay nen nhiing ton thiiOng them cho nhan c&u. Cung vi nhiing
ly do tiiOng tii, thii nghiem nam cham khong diiOc thtfc hien,
doi vdi nhiing triidng hop co sii hien dien cua nhiing di vat
hinh cau. Dap ting dau tien cua nhting di vat hinh cau doi vdi
nam cham la khong co do nghieng toi thieu vi ban than di vat
hinh cau khong co dinh hiidng trong moi triidng tti tmh nhiing
no co sii thay doi vi tri dang ke.

7.2. Do sinh hoc va tinh cong suat thuy tinh the nhan tao

7.2.1. Do sinh hoc

Vdi ky thuat do don gian thi chieu dai true nhan cau co the
diioc do dat chinh xac den ± 0,1mm. Mot thiidc dien tti do bang
micro giay dtfOc hien thi dong thdi vdi bieu do sieu am vi the
nhting khoang gitia cac tin hieu sieu am tti giac mac, thuy tinh
the, vong mac va cung mac co the do dac dtfoc. Micro giay sau
do dtfOc chuyen doi thanh milimet ve nhting khoang cach cua
nhan cau nhd mot bang chuyen doi.

258
 Ke ca chieu dai true nhan cau va cong suat thuy tinh the
nhan tao cung dUOc doc ngay bang milimet va diopters . Sieu
am A do duoc be day cua giac mac chinh xac den ± 0,03mm, do
sau tien phong, do day TTT, do day cua ldp hac vong mac, be
day cua dia thi dUOc do chinh xac den mtic ± 0,3mm (hau nhan
cau) va ± 0,5mm (hoc mit sau). Do day tdi da cua co ngoai nhan
dUOc do chinh xac den mtic ± 0,5mm. Nhiing ton thUOng hoc mat
va noi nhan cung nhu canh nhan c&u dUOc do chinh xac tU ± 0, 1
0, 3mm phu thuoc vao kich thudc, vi tri va to chUc.

Hinh 64.
a. 6 m it chinh thj, hudng di cua chum am tao vdi true thi giac
mot goc khoang 5°
b. 6 mat can thj, true nhan cau dai hon nen do dac can phai luu
y diem den phai dung vao cue sau nhan cau.

Hinh 65. Tuthe cua dau do can phai dat thing goc chinh xac de
khao sat true nhan cau trong khi do dac.

259
 Hinh 66. Ket qua do dac chieu dai true nhan cau vdi
van toe 1550m/giay

7.2.2. Tmh co n g s u a t TTTNT

* Cong thtic hoi quy. Nam 1980 Retzlaff, Sanders, Kraff da

tao ra cong thtic SRK I, ve sau 1988 Sanders da co cai tien thanh
cong thtic SRK II ma hien nay dang difOc ap dung pho bien.

P = A - 2,5L - 0,9K

Trong do:

P: Cong suat TTTNT tinh bang dioptrie

A: Hang so" (A = 115 khi tmh cong suat cho TTTNT tien
phong

A = 116 hoac 117,5 khi tmh cong suat TTTNT hau phong

L: Chieu sai cua true nhan cau tmh bang mm, do bang
sieu am he thong A hoac B.

K: Ban kmh do cong giac mac do bang Javal ke

Co the tinh cong suat TTTNT vdi cong thtic SRK II tmh
bang tay, bang bang tmh san hoac tren may vi ti'nh.

260
 Ngoai ra co nhiing cong thiic vdi do chinh xac cao nhii
Hoffer “Q”, Holladay, SRK/T da han che cac sai so den mufc
thap nhat. Hoffer de nghi sU dung cong thiic Hoffer ‘ Q cho
nhiing mat co chieu dai true nhan cau < 22mm, cong thiic
Holladay cho nhiing mat co chieu dai true nhan cau > 24mm
va sii dung ca 3 cong thiic cho nhiing m&t co chieu dai true
nhan cau tii 22 - 24,5mm.
* Cong thiic ly thuyet diia tren mo hinh ly thuyet cua nhan
cau (Fyodorov 1967, Colenbrander 1973, Thijssen 1975, Van
der Heijder 1976) nen tiidng doi khong chinh xac khi ngiidi ta
nhan thay do sau tien phong khong co" dinh sau mo.
Theo Barret, cong thiic hoi quy va cong thiic ly thuyet deu
chi'nh xac vdi nhiing mat co chieu dai true nhan cau trung binh
22 - 24mm.

261
 PHAN KET

Y nghla lam sang

Trong suot nhiing nam qua, sieu am chuan hoa da trd nen
mot cong cu chan doan quan trong trong nhan khoa lam sang.
Trong thiic hanh sieu am da diidc hdp nhat, no trd thanh mot
ho trd khong the thieu diicfc trong dieu tri benh nhan bi due
moi triidng trong suot, dat TTTNT, cac u noi nhan (khong lien
quan den moi triidng trong suot co bi due hay khong) cung nhii
toan bo hoc mat, ngay ca cac van de quanh hoc mat trong mot
chiing miic nao do. Sieu am co tam quan trong trong mot vai
chu de chuyen biet diidi day:

Phau thuat vong mac djch kinh

Sieu am chuan hoa luon cung cap cac thong tin hutu ich ve
ph&n sau nhan cau khi thuy tinh the due chin hoac xuat huyet
dich ki'nh. No chi ra sii hien dien cua cau true dich ki'nh dam
dac chang han nhii nhiing dai hoac mang va cac hinh anh cat
ldp de chan doan phan biet bong vong mac vdi mang dich ki'nh
day dam vdi nhiing thong tin chi tiet, cd the la dac biet hiiu
l'ch. Sieu am chuan hoa xac dinh chi dinh phau thuat, thdi
diem phau thuat vdng mac dich kinh, sieu am chuan hoa cung
tra ldi mot cach chi tiet nhiing cau hoi ve hinh thai hoc cua
phan sau nhan cau ma cd the la cot yeu trong viec chuan bi va
tien hanh phau thuat va giup cho viec theo doi dieu tri sau mo
trong nhiing triidng hop van con due mdi triidng trong suot
(chang han, md giac mac hoac dich ki'nh sau mo va xuat huyet
tai phat). Phan loai tren sieu am ve cac tinh trang dich ki'nh co
chi dinh cat dich kinh nhii sau:

262
 1 . Chong chi dinh (tam thdi) : Khi khong co mang hoac chi
co nhiing mang 0 chu bien
2. Chi dinh tiidng doi: phau thuat hoac theo doi khi co sii
hien dien cua cac mang tren true thi giac, khi co sii co keo hoac
bong do co keo nhe ma khong anh hiidng hoac de doa den
hoang diem. Can co phau thuat nhiing khong cap ciiu.
3. Chi dinh tuyet doi: Khi co bong vong mac toan the, tien
trien hoac lan rong.
4. Chong chi dinh (vinh vien): Khi co bong vong mac ma
khong the mo diicfc hoac mat bi teo nhan.

Nhung cau hoi can phai duoc tra ldi b ln g sieu am cho cac
ph iu thuat vien vong mac djch kinh la

1. Vi tri nao la tot nhat de tao diidng rach cung mac?

2. Nhiing dai hoac mang dich kinh dam dac va chac nhii
the nao?
3. Co keo vong mac d dau, theo hiidng nao?
4. Bong vong mac co keo 0 dau va lan rong nhii the nao?
5. Khoang cach giCta mang dich kinh va vong mac nhii
the nao?

6. O vi tri nao mang diiOc xd ly ma khong de doa den vong mac?

7. Co nhiing tui dich mau khong?
Ve so do
So do vong mac diiOc thiic hien triidc khi phau thuat vong
mac, diiOc diia tren thong tin ve sieu am va giup cho phau
thuat vien vong dich kinh dat diiOc bde tranh khong gian ba
chieu cua phan sau nhan c&u.

263
Hinh 1. Cac so do duoc thuc hien djnh vj bang sieu am truoc khi c it
djch ki'nh. (Cac hinh ben trai) So do duoc ve theo chieu ngang (A),
chieu doc (B), va chieu cheo (C,D) cac mat cat thang dtfng doc d
chinh gitfa cung nhir cac mat cat 6 phia trUdc (a), 0 xi'ch dao (e) 0
phi'a sau (p) va mat cat tran xuyen qua nhan cau. (Cac hinh ben
phai) Cac so do diroc thtfc hien trong mot trUdng hop benh ly vong
mac tang sinh do dai dudng vdi cac mang hinh pheu dam dac cim
vao trong dia thj va lam bong vong mac nhieu 6 chu bien do co keo
va bong nho 0 ctfc sau. Do phan bong vong mac phia chu bien
chiem het 1/4 tren phia thai di/ong nen dudng rach qua pars plana
phai duoc thtfc hien d phia duOi de tranh vung bj bong.

264
Do chieu dai true nhan cau

Hau het cac hien thi sieu am A nhan cau cung cap giai
phap do phan giai can thiet de do dat cac khoang cach trong
nhan cau hoac hoc mat mot cach chi'nh xac . Tren thtfc te la cac
bo phan thu dai rong va cac bo phan khuech dai tuyen ti'nh
dtfdc dung trong hau het cac thiet bi sieu am A co do phan giai
tuyet vdi.
Nhtfng de dat dtfdc stf do dac chi'nh xac ve chieu dai true
nhan va tinh toan cong suat cua TTTNT mot cach chi'nh xac
thi yeu cau chum song sieu am phai thang hang vdi true nhan
cau. Dieu nay co the dat dtfdc vdi sieu am A chuan hoa mot
cach khach quan bdi stf hien thi nhtfng dinh xung cao toi da d
do nhay cam he thong thap tii hai mat cua giac mac, hai mat
cua thuy tinh the, va 2 mat cua vong mac vdi cung mac. Stf
hien thi dong thdi cua nhtfng dinh xung nay vdi bien do toi da
cho thay rang chum song sieu am di thang goc vdi tat ca
nhtfng be mat nay, dieu nay chi co the dat dtfdc khi chum am
di thang hang vdi true quang hoc. Cach do dac la tti dinh nay
den dinh kia. Vi vay tranh dtfdc cac anh nhieu (artifact) von co
trong cach do tti day nay den day kia.

Dj vat noi nhan

Hau het cac di vat nhan cau la can quang va co the dtfdc
phat hien d i dang tren X.quang. Stf phat hien bang sieu am
cac di vat nhan cau co the hdn, doi hoi nhieu thdi gian hdn va d
mot sd vi tri nao do co the it chac chan hdn la kham X.Quang.
Vi vay, kham X.Quang la phtfdng phap chon ltfa de phat hien
di vat nhan cau. Tuy nhien, sieu am cung cap stf dinh vi chi'nh
xac hdn ve di vat lien quan den nhtfng cau true co mach mau
nhtf vong mac va cung mac, va co the cung cap thong tin chi
tiet ve ton thtfdng gay ra do di vat. Stf dinh vi bang X.Quang
thtfdng khong hieu qua va co the tao nguy hiem khong can
thiet d mot mat co mot vet thtfdng hd khi dat khung dinh vi.

265
 Vi vay, kham sieu am luon di kem vdi X.quang ve di vat
nhan cau, khong chi vi stf dinh vi chi'nh xac ma con cho phep
lam thu nghiem nam cham an toan va co the danh gia dtfdc
nhtfng bat thtfdng cua cac mo mem d phan sau nhan cau.
Kich thtfdc dau do nho, ky thuat vo hai va kieu dinh ltfdng
duy nhat lam cho sieu am A chuan hoa la phtfdng phap dtfdc
tfa thi'ch trong dinh vi di vat nhan cau.
Chi co sieu am A chuan hoa cung cap do nhay cam ldn can
de dieu chinh thtf nghiem nam cham vo hai ma trong do di vat
khong di chuyen ma chi nghieng toi thieu.
Dtfdi day la nhtfng tfu diem cua thii nghiem nam cham
dtfdi htfdng dan cua sieu am A chuan hoa.
1. An toan: Di vat khong di chuyen, khong lam tang them
ton thtfdng d m&t bi thtfdng ton
2. Do nhay: Di vat chi nghieng toi thieu nhtfng ghi nhan
dtfdc dap Ung tin hieu ro rang
3. Ddn gian: Tac dong tU tinh giao dong ddn gian, phan
Ung cua di vat de nhan biet
4. Nhe nhang: Khong co nguy cd gay ra ton thUdng do dieu
tri gay ra, vet thUdng hd khong gay trd ngai.
5. Ket qua chac chan: Ca thuoc tinh tU tinh va di dong tU
tinh cua di vat dtfdc phat hien va ket qua chinh xac.

U noi nhan

Trong chan doan sieu am cua u noi nhan, u hac to" ac tinh
la mot vi du dien hinh. Khi m&t bi due thuy tinh the chin hoac
xuat huyet dich kinh thi ro rang sieu am la phudng phap chon
ltfa de chan doan u hac to" ac tinh cua the mi va hac mac. Ngay
ca d nhtfng mat co moi trtfdng trong suot cua u hac to" ac ti'nh
that stf hay nghi ngd ve mat soi day mat, thi sieu am chu&n
hoa dong mot vai tro quan trong bang cach dtfa ra bang chtfng

266
doc lap va bang cach tao ra thong tin chac chan khach quan
hdn ve cau true ben trong cua u. Sieu am chuan hoa cung cho
thay cac do dac chi'nh xac ve stf nho len toi da cua khoi u vao
trong nhan cau ttf be mat cung mac phi'a ben trong. Vi vay,
giup xac dinh cac kieu dang bieu do sieu am theo phat trien
cua u. Gan day van de tranh cai trong viec quyet dinh co nen
hay khong dieu tri btfdc dau doi vdi nhtfng ton thtfdng nho,
trong viec chon loc phtfdng phap dieu tri thi'ch hdp (nghia la
khoet bo nhan cau, quang dong, lanh dong, hoac dung Cobalt)
va theo doi dieu tri bao ton. Vdi sieu am chuan hoa, nhtfng chi
tiet quan trong khac cua u hac mac (nhtf: xam lan cung mac
hoac phat trien ra ngoai nhan cau) dtfdc phat hien, khong chi
giup de xac dinh mot chan doan ltfdng ltf ma con cung cap mot
yeu to" bao ve chu yeu trong dieu tri bao ton cho nhtfng u nho .

Nhumg ton thirdng quanh hoc mat va nhan cau

Trong hoc mat, sieu am chuan hoa cung vdi chup CT

Scaner, da lam mot cuoc cach mang trong chan doan va lam
thay doi dang ke phat do dieu tri benh.
Mac du cong dung cua chup CT Scaner da dtfdc pho bien
rong rai, nhanh chong, sieu am chuan hoa da cho thay chan
doan co chieu sau hdn. Danh sach dtfdi day cho thay nhtfng
thuan ldi cua chup CT Scaner va sieu am chuan hoa lien quan
den chan doan cac benh ly hoc mat va quanh hoc mat.

Chup cat ldp dien toan

1. Hinh anh chup cat ldp tot hdn ve cau true hau nhan cau
va thanh xtfdng hoc mat.
2. Danh gia day du ve nhtfng vung quanh va sau nhan cau
3. Ky thuat kham de hdn
4. Danh gia thuan ldi hdn ve nhtfng ket qua.

267
Sieu am chuan hoa

1. Mot thii nghiem vo hai, co the diidc ap dung thtfdng quy

mien la can thiet.
2. Nhay hdn va ch&c ch&n hdn trong viec phat hien va loai
trtf nhtfng ton thtfdng hoc mat.
3. Hieu qua hdn trong viec phan biet nhtfng ton thtfdng
hoc mat.
4. Chi'nh xac hdn trong viec do dac nhtfng cau true nhan cau.
5. Nhtfng hinh anh xti ly b&ng may ti'nh lam thay ro dong
chay cua mau va cac nhip dap.
6. Cac thiet bi di chuyen dtfdc
7. Co the dtfdc thtfc hien bdi bac si nhan khoa hoac cac ky
thuat vien nhan khoa.
8. Yeu cau stf phoi hdp cua benh nhan it.
9. Thiet bi ft dat tien
Bdi vi no la vo hai va hieu qua hdn nhtfng thtf nghiem
chan doan khac nen sieu am chuan hoa la mot phtfdng phap
sang loc ly ttfdng cho hoc mat va can dtfdc ap dung nhtf la btfdc
chan doan dau tien sau kham xet lam sang (hinh 2).
Trong trtfdng hdp anh htfdng den xtfdng ro ret hoac nghi
ngd hoac ton thtfdng lan rong vtfdt qua gidi han hoc m&t, thi
can co kham X.Quang hoac chup CT Scaner hoac ca hai
phtfdng phap de ho trd them cho sieu am chuan hoa. Chup CT
Scaner cung co the giup phan biet giiia cac nang vdi cac ton
thtfdng ciing khong co vo boc, hdi tron, dac biet la cung cap cac
dtf kien cac ldp bo sung.

268
Hinh 2. Vai tro trung tam cua sieu am chuan hoa trong viec chan
doan benh ly hoc mat. Chan doan lam sang va kham sieu am phai
di/oc thtfc hien vdi moi benh nhan co cac dau hieu va trieu chting
cua benh ly hoc mat. Cac ket qua se cho thay sir can thiet cho cac
bi/6c chan doan va dieu trj tiep theo. Sir ket hop giOra sieu am v6i
chan doan lam sang thtfdng co hieu qua trong viec kiem soat cac ton
thirong hoc mat.

Trong nhting trtfdng hdp khac, sieu am se chi ra stf can

thiet cho nhtfngthti nghiem tiep theo dac hieu hdn, chang han
nhtf thtf nghiem tuyen giap khi cd bi day len va nhtfng dau
hieu khac cua benh ly mat Grave dtfdc phat hien d ca hai hoc
mat hoac chup dong mach canh khi co do dong tmh mach dtfdc
phat hien. Sieu am dac biet chinh xac doi vdi cac ton thtfdng d
2/3 trtfdc hoc mat, nhtf cac gia u, hoac u bach huyet anh htfdng
den tuyen le, u mau xoang hang lan rong trong cac to chtic
canh nhan cau. Trong nhting trtfdng hdp nhtf vay sieu am cung
cap tat ca thong tin c in thiet de sinh thiet c&t bo hoac mot
phan hoac xa tri (hinh 3).

269
Hinh 3. So do khoi gia u hoc mat anh hudng den tuyen le, m3 hoc
mat, va mot so co ngoai nhan d hoc mat ben trai trifdc khi phau thuat
hoc mat va cac so do dinh khu cua ung thi/ bieu mo tuyen di can den
hoc mat ben trai trifdc khi dieu tri tia xa. (A) So do cat qua mat
phang tran (phan tren) va cat ngang qua ca hai hoc mat (phan trung
tam) cung nhi/ cat doc (hoac cat cheo) qua phan hoc mat bj ton
thi/ong (phan day). (B) cac so do cho thay cac dau hieu d benh nhan
bi khoi gia u. (C) Khai quat cua ung thir bieu mo diroc xac dinh tren
sieu am, diroc so do hoa tren anh chup polaroid khuon mat cua benh
nhan; cac dau hieu d ben goc cho thay vung chay tia xa da duoc xac
dinh bang sieu am.

Sieu am phu hdp cho viec kham, theo doi qua trinh dieu tri
(hoa tri lieu hoac xa tri lieu) va qua trinh dien tien tu nhien
cua benh (thoai trien hay tai phat)
U nhay thUdng tao cac kieu dang sieu am dac trUng mot
khi no pha vd xUdng hoc mat va cac thanh xoang trUdc.Trong
viec cha!n doan cac u nhay nhu vay, doi khi sieu am chUng to
sU vUdt troi hdn X.Quang. Benh ly xoang nhe hoac khu tru va
co qua trinh pha huy ben trong vom xUdng hoc m£t (thUdng la

270
ung thu bieu mo di can) cung co the dtfdc thu thap dtf kien
bang sieu am tot hdn la X.Quang bdi vi stf ghi am ddn gian ttf
nhtfng cau true ben kia thanh xtfdng hoc mat.

Ba yeu cau cd ban

Stf ap dung, thanh cong va htfu dung trong lam sang cua
sieu am mat, hoc m it va vung quanh hoc m it phu thuoc vao
kinh nghiem va ky nang cua ngtfdi kham va thiet ke cua dung
cu dtfdc sii dung cung nhtf stf chuan hoa cua thiet bi va ky
thuat dtfdc dung.

Si/thanh thao cua ngu&i kham

Sieu am chuan hoa doi hoi nhtfng ky nang ttfdng ttf nhtf
nhtfng ky nang can co trong soi day mat. Ca hai phtfdng phap
deu kho cho nhtfng ngtfdi mdi tap stf ma thtfdng ghi nhan dtfdc
nhtfng ket qua khong ch in ch in nhtfng nhtfng ky thuat nay da
dang hdn nhieu va cho ket qua chinh xac hdn nhieu khi da co
kinh nghiem. Doi vdi ngtfdi chan doan thanh thao thi mot stf
kham xet vdi ca hai phtfdng phap co the de hoac kho tuy thuoc
vao stf phiic tap cua chan doan dtfdc doi hoi va phu thuoc vao
kfch thtfdc, vi tri, va kieu loai ton thtfdng. Khi co stf hien dien
cua u h lc to" ac tinh cua h lc mac, chang han, ca bac si nhan
khoa va ngtfdi kham sieu am se cam thay ddn gian hdn nhieu
khi goi la co mot ton thtfdng "u” hdn la phai chan doan chuyen
biet la *’u h lc to" ac tmh cua hac mac” . Ca stf phat hien va phan
biet u h lc to" se de dang hdn khi khoi u ldn va khu tru ve phfa
sau nhieu hdn cua day mat hdn la khi khoi u dep, nho va khu
tru d vung ctfc chu bien cua day mat. U hac to ma khong bieu
hien tat ca nhtfng dac tmh sieu am hoac soi day m it kinh dien
se yeu cau nhtfng ky nang kheo leo ngay ca v6i ngtfdi chan
doan co kinh nghiem nhat.
Giong nhtf soi day m it, sieu am chuan hoa co the hoc dtfdc
vdi moi ngtfdi co stf dam me quan tam hoc hoi, mac du mot so"

271
ngtfdi se hoc nhanh hdn mot so khac. De thanh cong trong ca
sieu am chuan hoa va soi day mat, mot kien thtic ve giai phau
nhan cau va benh hoc mat la can thiet. Moi phiidng phap doi
hoi mot thdi gian hoc dai, tap trung va sii ap dung can than, ti
mi. Ngiidi ky thuat vien dong vai tro quan trong trong viec
thiic hien sieu am chuan hoa de xac dinh vi tri ndi nao trong
ket qua nay. Sieu am chuan hoa, giong nhii soi day mat, can
mot ky xao va sii thanh thao cua ngiidi kham sieu am luon anh
hiidng den chat liidng chan doan. Tuy nhien, khong co ngtfdi
lam sieu am nao co the dat dtfdc nhtfng ket qua htfu dung va
thanh cong trong viec chan doan to chtic ma khong co stf dung
nhting thiet bi sieu am chuan hoa dtfdc thiet ke thi'ch hdp cho
cac thao tac chuan hoa.

Thiet ke dac biet cua dung cu

De dat dtfdc nhtfng ket qua nhtf y, nhtfng thiet bi cua ca

sieu am A va sieu am B deu phai dtfdc thiet ke thich hdp.
Trong sieu am B stf hien thi ra van de la ttfdng doi ddn gian.
Sieu am B la nhtfng btfc anh chup va chat ltfdng cua chung
dtfdc xac dinh san. Dieu nay tao thuan ldi cho cac no ltfc cua
nha san xuat cung cap cac tin hieu hien thi sieu am B tot hdn
va thuc day stf chon ltfa tfu the cua sieu am B doi vdi cac nha
chan doan. Tinh trang hien thi doi vdi sieu am A thi lai khac.
Sieu am A giong nhtf la mot ngon ngtf viet; stf xuat hien cua
nhtfng chtf giong nhtf chti viet, khong co moi lien he ro ret de
chuyen tai thong tin. Nhting hien thi sieu am A phai dtfdc hieu
mot cach can ke
Doi vdi nhtfng may co cai tien cong nghe, trong thdi gian
qua cac nha san xuat may sieu am A deu tap trung vao viec cai
tien mau dang hien thi, kha nang chuyen tai thong tin cua
sieu am A nhtf: lam trdn lang hinh anh de giip bac si d i dang
phan biet chan doan.

272
 •IO N a lS ECHOGRAMS
J

WSSSSSt
-
IHI— ITM

Hinh 4. Dong thong tin sieu am tCr to chiic den hien thi
Hinh 4 minh hoa cho dong chay cua thong tin am hoc tii to
chtic dtfdc kham xet (am doi) thong qua may sieu am (bo phan
nhan) bo phan dieu bien de hien thi (Bieu do sieu am). Ban
chat cua to chiic (muc tieu cua sieu am) anh htfdng den stf hien
thi sieu am b ln g cach tao ra va phan hoi cac am doi va bang
cach stfa doi cac am doi nay qua stf hut thu. Bo phan dieu bien
cua may cung co mot tac dong quan trong trong stf hien thi
sieu am thong qua cai goi la "dinh dang tin hieu”. Muc dich
cua dinh dang tin hieu la de hien thi thong tin am hoc nhan
.dtfdc tti cac to chtic ro net nhat vdi do ttfdng phan toi da. Vi vay
tren bieu do sieu am, hien thi stf khac nhau ve am hoc d mtic
toi thieu gitia cac to chtic khac nhau va thuan tien cho viec ghi
nhan bang mat ve cac kieu dang sieu am dien hinh cho cac
nha chan doan.
Nhieu thiet ke dtfcfc dtfa ra de dung hoa cac thai ctfc.
Chang han nhtf tan so" sieu am toi tfu dtfdc dung trong sieu am
A la 8MHz, mot stf dung hoa gitia do phan giai ma tot hdn vdi
tin so" tang len vdi stf xuyen thau vao to chtic ma tot hdn vdi tan
so" thap xuong. Mot tin so" 8 MHz cung cap do phan giai thich

273
dang de phat hien nhiing cau true nho mot each an toan va do
dac cac khoang cach mot cach chinh xac. Dong thdi tan so nay
cho phep stf xuyen thau day du cua sieu am vao trong to chiic
sau hdn ma rat quan trong trong viec kham xet cac khoi u co
kich thiidc 16n hoac nhiing ton thiidng d dinh hoc mat.
Tiidng tii nhii vay, do nhay cam he thong la mot sii dung
hoa giiia kha nang phat hien ngay ca doi vdi nhiing nguon am
doi yeu (hoan thanh tot nhat d do nhay cam he thong cao hdn)
vdi do phan giai can thiet de phan biet cac to chiic khac nhau
(ma rat ngheo nan vdi do nhay cam rat cao). O day, ‘’do nhay
cam to chiic” la sii dung hoa toi liu, cho phep ca sii phat hien
day du va phan biet day du cac ton thiidng hoc mat va trong
noi nhan.
De chan doan diidc cac to chiic chinh xac thi cach thiic va
pham vi khuech dai tin hieu la chinh yeu va phai diidc thiet ke
va dieu chinh vdi sii than trong dac biet. Nhin chung, cac am
doi lai tif nhiing to chiic binh thiidng hoac bat thiidng cua mat
va hoc mat la rat yeu va phai diidc khuech dai manh len nhieu
de tao ra nhiing tin hieu tren man hinh. Dong thdi cac am doi
lai tii cac cau true to chiic khac nhau co the bien doi nhieu ve
ctfdng do cua chung. Kha nang cua mot he thong khuech dai de
lam hien thi cac ciidng do tin hieu khac nhau cung mot luc (d
mot do nhay cam he thong ddn le) diidc goi la pham vi dong
cua no. Mot he thong ma khuech dai nhiing tin hieu am doi de
lam bien doi ldn cac ciidng do am doi co the diidc hien thi cung
mot luc goi la co pham vi dong liic rong, ngiidc lai mot he
thong co the hien thi dong thdi chi nhiing tin hieu co sii bien
doi nho ve ciidng do goi la pham vi dong liic hep. Kha nang cua
mot he thong khuech dai nham chi ra sii khac nhau ve cac
ciidng do am doi diidc goi la do nhay cam tiidng doi. M ot bo
phan khuech dai ma tao ra cac chieu cao dinh xung khac nhau
ro ret giiia hai tin hieu am doi ma chi co sii khac nhau ve
ciidng do rat it, thi cung cap do nhay cam tiidng doi cao, ngiidc

274
lai mot bo phan khuech dai ma doi hoi stf khac nhau that
nhieu ve ctfdng do am doi thi mdi hien thi cac chieu cao dinh
xung khac nhau tuic la co do nhay cam ttfdng doi thap.
De chan doan dtfdc cac to chtfc thi can phai hien thi cac
ctfdng do am doi khac nhau ghi nhan dtfdc tut mot mang to
chtfc ldn d mot do nhay cam he thong ddn le, nghia la do nhay
cam to chtfc (mot pham vi dong ltfc ldn) va bieu hien cung mot
luc nhtfng bien doi that nho vdi ctfdng do am doi vdi stf ttfdng
phan ro ret ve cac bien do dinh xung de lam cho chung co the
dtfdc phan biet de dang (do nhay cam ttfdng doi cao). Vi vay, de
chan doan cac to chiic dtfdc chinh xac, mot he thong khuech
dai phai la mot stf dung hoa toi tfu giiia hai yeu cau trai ngtfdc
nhau ve pham vi dong ltfc va do nhay cam ttfdng doi (giiia miic
do di dong vdi do nhay cam ttfdng doi) tutc la mufq do di dong
cang ldn thi do nhay cam ttfdng doi cang nhd va ngtfdc lai.
Cac nha nhan khoa c in tim hieu ro chiic nang cua do nhay
cam ttfdng doi va miic do hoat dong trong chan doan cac to
chdc, bdi vi ca hai la ttfdng ttf nhtf vai tro cua thi ltfc va thi
trtfdng d m it ngtfdi. Ngay nhtf mot thi giac htfu dung la dtfa
tren ca thi ltfc ro rang va thi ltfc day du. Stf phan biet to chtfc
tren sieu am doi hoi ca ve do s ic sao am hoc day du (do nhay
cam ttfdng doi) va ca ve trtfdng am day du (pham vi hoat dong).
O may sieu am A, stf khech dai dang chtf S dac trtfng dtfdc ap
dung (hinh 31) de hoa giai hai yeu cau trai ngtfdc nhau nay
trong mot he thong. Stf phan chia phan giiia dtfdng doc cua
dtfdng cong dang chtf S bieu thi phan nhay cam nhat cua chiic
nang khuech dai ma tao ra do s ic sao am hoc tot du cho mat di
mot phan trtfdng am day du. Stf phan chia d phan giiia cua cac
chiic nang khuech dai dang chtf S nay ttfdng ttf nhtf hoang
diem d m it. Nhtfng diem tan cung cao nhat va thap nhat cua
dtfdng cong tao ra trtfdng am can thiet (33db. pham vi hoat
dong) trong khi thieu do s ic sao cua am. Hai phan chia d phia
chu bien cua chiic nang khuech dai dang chtf S doi vdi phan

275
biet to chiic tren sieu am gan giong nhii chu bien day mat d
mat ngtfdi trong qua trinh hinh thanh thi giac binh thtfdng. Vi
vay bo phan khuech dai cua may do co cac dac ti'nh dang chtf S
cua no, da hdp nhat ca hai chiic nang ve do sac sao cua am va
trtfdng am cho nhtfng ket cau ve mat am hoc de co the quan
sat dtfdc toi tfu.
Nhtfng bo phan khuech dai tuyen tmh (hinh 5) thtfdng
dtfdc sii dung nhat trong cac hien thi sieu am A khong chuan
hoa. Chung tao ra do s ic sao am hoc tuyet vdi nhtfng han che
trtfdng am c ln thiet de phan biet cac to chiic. Cac bo phan
khuech dai tuyen tmh co the co pham vi hoat dong thap
khoang 12db. Mot so" cac hien thi sieu am A khong chuan hoa
tan dung cac bo phan khuech dai dang logarit ma tao ra
trtfdng am tuyet vdi nhtfng lai han che ve do sac sao am hoc
ma cung rat c in de phan biet cac to chiic. Pham vi hoat dong
cua chiing co the cao den 66dB.

Hinh 5. Cac dtfdng cong dSc trtfng cho stf khuyech dai. Liru y rang
chieu cao cua cac tin hieu sieu am dtfpc danh dau bang milimet doc
theo true y theo kieu tuyen ti'nh, tuy nhien stf khuyech dai dtfoc danh
dau doc theo true x theo phep logarit.

276
S i/chuan hoa cua thiet bj va ky thuat kham
Tat ca cac tieu chuan cua thiet bi sieu am va ky thuat
kham phai diidc thiet ke giong het nhau va diidc dieu chinh
bang nhau de ngiidi kham noi cung mot ngon ngii sieu am ve
bien do sieu am va gia tri chan doan cua chung. Sii chu ln
doan la tuyet doi can thiet de ghi nhan cac bieu do sieu am lap
di lap lai, co the so sanh diidc va cho phep nhiing ngiidi chan
doan sieu am khong chi phat trien kinh nghiem vdi nhiing
thiet bi rieng cua ho ma con sii dung diidc nhiing kinh nghiem
tich luy diidc cua ngiidi khac. Kha nang thiic hien viec chan
doan cac to chiic tren sieu am diidc chinh xac diia tren sii xac
dinh r5 rang cac bieu do sieu am dac biet va dac triing diing
hoac nghieng vdi sii chuan hoa. Sii ch u ln hoa la quan trong,
mac dau vdi nhieu phiidng thiic khac nhau va vdi nhieu miic
do khac nhau, doi vdi ca sieu am A va sieu am B. Cac thong tin
diidc rut ra tii bieu do sieu am cang chi tiet, cang dac hieu thi
viec chuan hoa cang bOfc thiet. Vi ly do nay, sii chuan hoa thiet
bi sieu am A la quan trong hdn trong viec chuan doan cac to
chiic. Trong viec chan doan u hac to" ac tinh cua hac mac,
chlng han, thi tieu chuan phan biet co y nghia nhat (nhii: cau
true ben trong to chiic u dong deu, do phan xa thap, bien mat
khi cii dong nhan cau va xuat hien lai nhanh, di dong tii
nhien) la tieu chuan tren sieu am A, ngiidc lai tieu chuan sieu
am B quan trong nhat (nhii dang hinh nam cua u) thi khong
phai luon luon cd mat va thiidng quan sat ro tren soi day mat.
Sii chuan hoa chinh xac cua thiet bi sieu am A la chu yeu
trong viec tao ra cac tieu chuan vang ro ret, chac ch in , ngiidc
lai hinh dang nam cua khoi u cd the diidc nhan biet tren sieu
am B ngay ca khi thiet bi sieu am B khong diidc chuan hoa tot.

Viec thifc hien sieu am chuan hoa cua ky thuat vien

Triidc tien, sieu am chuan hoa diidc ap dung chi bdi bac si
nhan khoa, trong khi cac ky thuat vien sieu am chuan bi benh
nhan de kham, bao tri thiet bi va dau do, va dien ho sd benh
an, liiu giii cac ket qua sieu am. Do ldi ich cua sieu am diidc

277
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 trong viec htfdng dan ky thuat vien
trong cac trUdng hdp co phiic tap va kho khan cung nhtf kiem
tra chan doan cuoi cung .
Sii thay doi vai tro nay gitia bac si va ky thuat vien co hai
ly do chinh: (1) do cac dich vu sieu am ngay 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 ngay ca khi kien thiic cua ho ve nhan
khoa con han che.
Trtfdc tien, ky thuat vien hoc cach do dac chieu dai true
nhan cau. Thu thap dti lieu anh cua cac bieu do 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 nay 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 trong khi
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 do hoa,
cac ky thuat vien co the giup do dac, khu tru ton thtfdng va
ngay ca phan biet to chiic bang thtfdc chia do hoan chinh trong
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 trong
do 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 khi 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 khi lam
han che hdn la thuc day bac si nhan khoa dtfa ra 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
nay 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, ngay ca
sau nhieu nam thtfc hien sieu am.

279
 TAI LIEU THAM KHAO

1. Clinical Ophthalmology (1986) Harper & Row

publisher - Philadenphia USA
2. Myron Yanoff (1999) Ophthalmology - first edition
copyright Mosby International Ltd
3. Olivier Berges et Marc Torrent (1986) Echographie de
loeilet de 1 orbit
4. K. .Ossoining - Sandra Byrne (1979) Ophthalmic
Ultrasonography - Boston ltd
5. Nguyen Dtic Thuan va Cong sii (2003). Cd sd ky thuat
sieu am - Nha xuat ban khoa hoc va ky thuat Ha Noi.
6 . Nguyen Thi Thu Lien (1998). Hiiclng dan thiic hanh sieu
bung tong quat - Benh vien Chd Ray liiu hanh noi bo.
7. Barry B. GoldBerg (1993) Textbook of Abdominal
Ultrasound-William & Wilkins, USD
8 . P.E.S Palmer (1995) Manual of Diagnostic
Ultragnostic Ultrasound - World Health Organization,
Geneve 1995
9. 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. Roger C. Sandors (1984). Clinical Sonography - Little
and Brown company.

280
 MUC LUC

Ldi noi dau 3

Ljch sur sieu am mat 5
. Sieu dm chuan hod 7
. Cac ting dung lam sang va ket qua 10
Gidi thieu ve may sieu am 18
1. Cau tao may sieu dm 18
1 .1 . Dau do 19
1.1.1. Hinh dang 20
1.1.2. Tan so 21
1.1.3. Do ly giai va do xuyen thau 21
1.2. Than may 22
1.2.1. Gain 22
1 .2 .2 . 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 .6 . Thang xam 26
1.2.7. Phan hu 6 ng dan dinh vi di vat nhan cau 26
1.3. Thiet bi xuat 26
2. Mot so van de lien quan 26

281
 2 . 1 .The nao la may sieu am chuan cho kham mat? 26
2 .2 .Van de dinh hiidng tren hinh sieu am 26
2.3.Cac sai lam thtfdng gap khi stf dung may sieu am 27
2.4.Cac dieu can biet trong bao quan may 27
Nhac lai cd sd vat ly, tao hinh sieu am 28
1. Phan loai song dm 28
1 .1 . Theo phtfdng dao dong 28
1.2. Theo tan so" 29
1.3. Do sinh hoc nhan cau 31
2. Stf phan hoi vd stf khuc xa dm 34
3. Stf tan xa 36
3.1. Stf khuech dai - gain 36
3.2. Khuech dai bu trii theo do sau 37
4. Ky thuat cua phtfdng phap tao hinh bang sieu dm 37
4.1. Nguyen ly tao hinh 37
4.2. Chan doan sieu am trong 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

5. Sieu dm Doppler 42
5.1. Ky thuat sieu am Doppler 42
5.1.1. Hieu iing Doppler 42

282
 5.1.2. Cong thiic Doppler 43
5.1.3. Am thanh Doppler 44
5.1.4. Ky thuat Doppler - mau 44
5.1.5. Ky thuat Power Doppler 45
6. Hinh anh tinh vd hinh anh dong 46

6 .1 . 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
7. Mot so nhat cat cd ban trong nhan khoa 48
7.1. Qui lidc chieu hiidng tren man hinh 48
7.1.1. Tii the dau do vdi “dau chi”
hiidng ve phia mi tren 49
7.1.2. Tii the dau do vdi “dau chi”
hiidng ve phia thai diidng 49
7.1.3. Tii the dau do vdi “dau chi”
hiidng ve phia mi tren 49
7.1.4. Tii the dau do vdi “dau chi”
hiidng ve phia th in g len tran nha 49
Sieu am chuan hoa 51
1. Su chuan hod sieu am A 51
2. Su chuan hod sieu dm B 53
3. Sieu dm A so vdi sieu dm B 57

283
 3.1. Sieu am A va sieu am B dtfa ra
thong tin khac nhau 58
3.2. Sieu am A va sieu am B doi hoi nhtfng
thiet bi cau tao khac nhau 59
3.3. Sieu am A cho nhieu thong tin hdn sieu am B 61
3.4. Cac bieu do 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 63
3.4.3. Sieu am Doppler 65
4. Ket luan 66
Cac phtfdng thtic kham sieu am dac biet va cd ban 68
1. Suphat hien cac ton thUdng noi nhan 68

2. Sieu dm dinh khu 70

3. Sieu dm dinh lUOng 71
3.1. Sieu am dinh ltfdng loai I 71

3.2. Sieu am dinh ltfdng loai II 73

4. Sieu dm dong 75

5. Phat hien cac ton thuang hoc mat 75

6. Chan doan phan biet cac ton thUOng hoc mdt 78

6 .1 . Sieu am dinh ltfdng 78

6.2. Sieu am dinh khu 80

284
6.3. Sieu am dong 81
N h lc lai giai phau hoc 83
1. Cung mac 84
2. Hac mac 87
3. Hoang diem 87

4. Thuy tinh the 87

5. Tien phong 88

6. Dich kinh 88

7. Day than kinh thi giac 88

8. Nhiing mach mau hoc mat 89

9. Nhiing tuyen le 89

Cach tham kham 90

1. Thiet do true cat theo chuoi 92

2. thiet do cat ngang dich kmh tham do mat 93
3. Thiet do c&t ngang qua dich kinh tham do mot kinh tuyen 96
4. Thiet do tham do hoang diem 98
5. Thiet do tham do gai thi va thi than kinh 99
6. Nhiing thiet do canh nhan cau 103
Nhtfng dau hieu sieu am nhan cau binh thi/dng 114
Nhumg ton thtfdng d phan trade nhan cau 116
1. Ton thiidng giac mac 116
2. Ton thiidng tien phong 117

285
 3. Ton thiidng thuy tinh the 117
4. Cac tinh trang dich ki'nh 121
NhCirng ton thi/dng d phan sau nhan cau 127
1. Bong vong mac 127
2. Bong hac mac 136
3. Lom gai thi trong benh glaucom 141
4. 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 143
4.1.3. Sii lan tran ra hac mac 147
4.1.4. Sii lan tran den thi than kinh 147
4.1.5. Sii lan tran ra 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
5. 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 168
5.3.2. U hac to" ac ti'nh co kich thiidc trung binh 169

286
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
1. 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
2. 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
3. Nhiing khoi u 6 phan triidc nhan cau
xam lan vao phan tren hoc mat vung mat 217

287
 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
4. 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
5. Nhiing khoi u ben trong 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

288
5.4. Nhiing u Schwann va u vo bao than kinh 245
5.5. Nhiing u xam lan theo kieu “cdi ngiia” 245
6. 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
7. 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 thanh 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 ngay 10/01/2005.
In xong va nop lull chieu quy IV nam 2005.