00 Roman 2/2016 OKrcopt.org/images/uploads/Ophthalmo J 30_2_2016.pdf · Recommendations on screening for chloroquin and hydroxychloroquin retinopathy Phenpan Hirunyachote, M.D. Editorial

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The Thai Journal of Ophthalmology®—°…ÿ‡«™ “√

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President Paisan Ruamviboonsuk, MD

Vice-President Chakrapong Namatra, MD

Secretary Thitiporn Ratanapojnard, MD

Treasurer Puwat Charukamnoetkanok, MD

Scientific Committee Sorot Wutthiphan, MD

Committee Yosanan Yospaiboon, MD

Pornchai Simaroj, MD

Wichai Prasartritha, MD

Thawat Tantisarasart, MD

Pongsak Pachimkul, MD

Saichin Isipradit, MD

Pannet Pangputhipong, MD

Manapon Lekskul, MD

Prin Rojanapongpun, MD

Prut Hanutsaha, MD

Boonsong Wanichwecharungruang, MD

Winai Chaidaroon, MD

Anukul Thaithanan, MD

Naris Kitnarong, MD

Olan Suwan-Apichon, MD

Sakchai Vongkittirux, MD

Manchima Makornwattana, MD

Nattawut Wanumkarng, MD

The Royal College Executive Committee2014 - 2016


IIIIII

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Prof. Harold Furr USA.

Prof. Yozo Miyake Japan

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The Journal of the Royal College of Ophthalmologists and Ophthalmological Society of Thailand


Editor

Pornchai Simaroj Department of Ophthalmology, Ramathibodi Hospital, Faculty of Medicine

Editorial boardPrut Han-utsaha Department of Ophthalmology, Ramathibodi Hospital, Faculty of Medicine

Apatsa Leksakul Department of Ophthalmology, Ramathibodi Hospital, Faculty of Medicine

Anuchit Poonyathalang Department of Ophthalmology, Ramathibodi Hospital, Faculty of Medicine

Pisit Preeechawat Department of Ophthalmology, Ramathibodi Hospital, Faculty of Medicine

Kevalin Lekhanon Department of Ophthalmology, Ramathibodi Hospital, Faculty of Medicine

Apichart Singalavanija Department of Ophthalmology, Siriraj Hospital, Faculty of Medicine

Wanicha Cheunkongkaew Department of Ophthalmology, Siriraj Hospital, Faculty of Medicine

Sumalee Vangveeravong Department of Ophthalmology, Siriraj Hospital, Faculty of Medicine

Yos-anna Yos-paiboon Department of Ophthalmology, Srinagarind Hospital Khon Kaen University.

Somkiat Asawaphurikorn Department of Ophthalmology, Srinagarind Hospital Khon Kaen University.

Nimitr Ittipankul Department of Ophthalmology, Faculty of Medicine, Chiengmai University.

Prin Rojanapongpan Department of Ophthalmology, Faculty of Medicine, Chulalongkorn University.

Mansing Ratanasukon Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University.

Thawat Tantisarasart Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University.

Boonsong Wanitwacharungreung Department of Ophthalmology, Rajvithti Hospital

Pannet Pangputipong Department of Ophthalmology, Metta pracharak, Wat Rai Kling Hospital

Sorot Wuttiphan Department of Ophthalmology, Priest Hospital

Prof. Harold Furr USA.

Prof. Yozo Miyake Japan

Office:The Royal College of Ophthalmologists.

10th Floor, Royal Golden Jubilee Building,

2 Soi Soonvijai, Petchburi Road, Bangkok, 10320

Tel. + 662 718 0715, + 662 718 0716

VV

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VIVI

Contents

Vol. 30 No. 2 July-December 2016

75


Original Articles

Keratometric Effect in Predicting the Refractive Outcome Post Cataract SurgeryAuraya Pruttiphong, M.D. Chaisiri Jumroendararasame, M.D.Wallop Iemsomboon, M.D. Raveewan Choontanom, M.D.

Optimal Corneal Incisions to Correct Pre-existing Astigmatism in Cataract SurgeryPrakairut Thongphiew, M.D. Manassawee Joradoln, M.D.Rosanun Sikarinkul, M.D.

Prevalence and associated factors for pterygium at a tertiary referral center in NorthernThailandWinai Chaidaroon, M.D. Warangkhana Vichakutakul, M.D.

Review Articles

Central retinal artery occlusion after filler injectionThitiyaporn Panawattanawong, M.D.

Intraocular Tuberculosis: The Great MimicKesara Pathanapitoon, M.D.

Special Article

Recommendations on screening for chloroquin and hydroxychloroquin retinopathyPhenpan Hirunyachote, M.D.

Editorial

85

101

109

118

114

95

Thai J Ophthalmol Vol. 30 No. 2 July-December 2016 75

Keratometric Effect in Predicting the Refrac-tive Outcome Post Cataract Surgery

Department of Ophthalmology, Phramongkutklao Hospital

π‘æπ∏åμâπ©∫—∫/Original Article

Auraya Pruttiphong, M.D.Chaisiri Jumroendararasame, M.D.Wallop Iemsomboon, M.D.Raveewan Choontanom, M.D.

Abstract

Objective: To determine the keratometric effect in predicting the refractive outcome post cataract surgery by

comparing the difference between the mean absolute error values of an automated keratometer and IOL

Master.

Methods: A prospective consecutive case series was conducted on 73 patients who underwent uncompli-

cated phacoemulsification with IOL implantation, performed by one experienced surgeon, at Phramongkutklao

Hospital between March 2013 to August 2013. Preoperatively, the patientûs refraction were estimated and

calculated based on keratometric data of both automated keratometer (Pre-K) and IOL Master (Pre-M). The

objective mean absolute error (MAE) was obtained by comparing these predicting values with the actual

post-operative refraction.

Results: 77 consecutive eyes of 73 patients, 31 males (42.47%) and 42 females (57.53%) were enrolled in

the study. The mean age was 68.13 years (range 53-82). The study comprised 35 right eyes (45.45%) and 42

left eyes (54.55%). The Pre-K and Pre-M were -1.21 to +0.34 Diopters (D) (mean, -0.15+0.23) and -0.49 to

+0.18 D (mean, -0.16+0.13), respectively. The actual post operative refraction (spherical equivalent) was -1.13

to +0.50 D (mean, -0.31+0.34). The MAE of automated keratometer and IOL Master were -0.16+0.40 D and

-0.16+0.36 D, respectively. (P-value = 0.89)

Conclusions: The study results showed no statistical difference between an automated keratometer and IOL

Master in predicting the post cataract surgery refraction. Thai J Ophthalmol 2016; July-December 30(2):

75-84.

No Author has a financial or proprietary interest in material or method mentioned

Thai J Ophthalmol Vol. 30 No. 2 July-December 201676

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«—μ∂ÿª√– ß§å: ‡æ◊ËÕ»÷°…“§«“¡‡∫’Ë¬ß‡∫π¢Õß§à“ “¬μ“∑”π“¬°àÕπºà“μ—¥∑’Ë§”π«≥¡“®“°§à“§«“¡‚§âß°√–®°μ“∑’Ë‰¥â®“°°“√«—¥¥â«¬‡§√◊ËÕß¡◊Õ Automated keratometer ·≈– IOL Master ‡∑’¬∫°—∫§à“ “¬μ“®√‘ßÀ≈—ßºà“μ—¥μâÕ°√–®°

√Ÿª·∫∫°“√»÷°…“: ‡ªìπ°“√»÷°…“·∫∫ Prospective consecutive case study

«‘∏’°“√»÷°…“: ∑”°“√‡°Á∫¢âÕ¡Ÿ≈ºŸâªÉ«¬μâÕ°√–®°®”π«π 73 √“¬ (∑—ÈßÀ¡¥ 77 μ“) ∑’Ë‡¢â“√—∫°“√ºà“μ—¥ ≈“¬μâÕ°√–®°¥â«¬«‘∏’Phacoemulsification ·≈–„ à‡≈π å·°â«μ“‡∑’¬¡∑’Ë‚√ßæ¬“∫“≈æ√–¡ß°ÿÆ‡°≈â“√–À«à“ß‡¥◊Õπ¡’π“§¡ 2556 ∂÷ß ‘ßÀ“§¡ 2556‚¥¬®–§”π«≥À“§à“§«“¡·μ°μà“ß¢Õß§à“ “¬μ“∑”π“¬°àÕπºà“μ—¥∑’Ë§”π«≥¡“®“°§à“§«“¡‚§âß°√–®°μ“∑’Ë‰¥â®“°°“√«—¥¥â«¬‡§√◊ËÕß Automated keratometer ·≈– IOL Master ‡∑’¬∫°—∫§à“ “¬μ“®√‘ßÀ≈—ßºà“μ—¥μâÕ°√–®°∑’Ë —ª¥“Àå∑’Ë 4

º≈°“√»÷°…“ : ºŸâªÉ«¬ 73 √“¬ (∑—ÈßÀ¡¥ 77 μ“) ‡ªìπ™“¬ 31 √“¬ (√âÕ¬≈– 42.47) ‡ªìπÀ≠‘ß 42 √“¬ (√âÕ¬≈– 57.53) ∑—ÈßÀ¡¥¡’Õ“¬ÿ√–À«à“ß 53-82 ªï (§à“‡©≈’Ë¬ 68.13+7.38 ªï) ‡¢â“√—∫°“√ºà“μ—¥μ“¢â“ß¢«“ 35 μ“ (√âÕ¬≈– 45.45) ºà“μ—¥μ“¢â“ß´â“¬42 μ“ (√âÕ¬≈– 54.55) ·≈–ºà“μ—¥∑—Èß Õßμ“ 4 √“¬ (√âÕ¬≈– 5.19) §à“ “¬μ“∑”π“¬°àÕπºà“μ—¥‡¡◊ËÕ§”π«≥¥â«¬§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥®“°‡§√◊ËÕß Automated keratometer ‡∑à“°—∫ -1.21 ∂÷ß +0.34 Dioptor(D) (§à“‡©≈’Ë¬ -0.15+0.23 D) §à“ “¬μ“∑”π“¬°àÕπºà“μ—¥‡¡◊ËÕ§”π«≥¥â«¬§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥®“°‡§√◊ËÕß IOL Master ‡∑à“°—∫ -0.49 ∂÷ß +0.18 D(§à“‡©≈’Ë¬ -0.16+0.13 D) §à“ “¬μ“®√‘ßÀ≈—ßºà“μ—¥ (Post-operative spherical equivalent) ¡’§à“‡∑à“°—∫ ›1.13 ∂÷ß + 0.50 D(§à“‡©≈’Ë¬-0.31+0.34 D) §à“‡©≈’Ë¬¢Õß§«“¡‡∫’Ë¬ß‡∫π√–À«à“ß§à“ “¬μ“À≈—ßºà“μ—¥μâÕ°√–®°°—∫§à“ “¬μ“∑”π“¬°àÕπºà“μ—¥(Mean absolute error) ∑’Ë§”π«≥‰¥â®“°§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥®“°‡§√◊ËÕß¡◊Õ Automated keratometer ·≈– IOLMaster ‡∑à“°—∫ -0.16+0.40 D ·≈– -0.16+0.36 D μ“¡≈”¥—∫

√ÿª: ‰¡àæ∫§«“¡·μ°μà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘√–À«à“ß§à“§«“¡‡∫’Ë¬ß‡∫π¢Õß “¬μ“∑”π“¬°àÕπºà“μ—¥∑’Ë‰¥â®“°°“√§”π«≥‚¥¬„™â§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥®“°‡§√◊ËÕß¡◊Õ∑—Èß Õß ‰¥â·°à Automated keratometer ·≈– IOL Master ®“°§à“

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ª√–™“°√∑—Ë«‚≈° ®“°¢âÕ¡Ÿ≈¢ÕßÕß§å°“√Õπ“¡—¬‚≈° ªí®®ÿ∫—π

¡’ºŸâªÉ«¬‚√§μâÕ°√–®° Ÿß∂÷ß 17 ≈â“π§π ·≈–Õ“®‡æ‘Ë¡¡“°¢÷Èπ

∂÷ß 40 ≈â“π§π„πªïæÿ∑∏»—°√“™ 25632 ‡™àπ‡¥’¬«°—∫„π

ª√–‡∑» À√—∞Õ‡¡√‘°“ æ∫«à“ ª√–™“°√∑’ËÕ“¬ÿ¡“°°«à“ 40 ªï

ªÉ«¬‡ªìπ‚√§μâÕ°√–®°¡“°∂÷ß 20.5 ≈â“π§π §‘¥‡ªìπ√âÕ¬≈–

17.21

ªí®®ÿ∫—πÕ“®∂◊Õ‰¥â«à“°“√ºà“μ—¥‡ªìπ«‘∏’°“√√—°…“‡æ’¬ß«‘∏’

‡¥’¬«∑’Ë “¡“√∂∑”„ÀâºŸâªÉ«¬‚√§μâÕ°√–®° ¡’√–¥—∫°“√¡Õß‡ÀÁπ

∑’Ë¥’¢÷Èπ‰¥â2 °“√ºà“μ—¥μâÕ°√–®°π—Èπ “¡“√∂∑”‰¥âÀ≈“¬«‘∏’

·μà«‘∏’°“√ºà“μ—¥∑’Ë‡ªìπ∑’Ëπ‘¬¡·≈–·æ√àÀ≈“¬∑—Ë«‰ª §◊Õ°“√„™â

«‘∏’°“√ºà“μ—¥ ≈“¬μâÕ°√–®°¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß (pha-

coemulsification) ·≈–Ωíß‡≈π å·°â«μ“‡∑’¬¡‡¢â“‰ª·∑π

‡≈π å®√‘ß„π≈Ÿ°μ“ ªí®®—¬∑’Ë¡’º≈μàÕ√–¥—∫°“√¡Õß‡ÀÁπ¢Õß

ºŸâªÉ«¬À≈—ßºà“μ—¥μâÕ°√–®°π—Èπ¡’¡“°¡“¬ πÕ°‡Àπ◊Õ‰ª®“°

°“√ºà“μ—¥∑’Ë¥’·≈–ªí®®—¬„π à«π¢Õß§π‰¢â·≈â« °“√∑”π“¬

§à“ “¬μ“¢ÕßºŸâªÉ«¬À≈—ßºà“μ—¥°Á¡’§«“¡ ”§—≠ ‡æ√“– àßº≈

‚¥¬μ√ßμàÕ√–¥—∫°“√¡Õß‡ÀÁπ¢ÕßºŸâªÉ«¬ ‚¥¬ªí®®—¬∑’Ë¡’º≈

μàÕ°“√∑”π“¬§à“ “¬μ“ ‰¥â·°à §à“§«“¡¬“«≈Ÿ°μ“3-5, §à“

§«“¡‚§âß·≈–°”≈—ß¢¬“¬¢Õß°√–®°μ“, §à“§«“¡≈÷°¢Õß™àÕß

Àπâ“¡à“πμ“, μ”·Àπàß¢Õß‡≈π å·°â«μ“‡∑’¬¡ (expected lens

position)3, §à“ surgeon factor, °“√ª√–‡¡‘π§à“ “¬μ“

À≈—ßºà“μ—¥ (postoperative refraction determination)3

·≈–§à“ “¬μ“∑’Ë«—¥‰¥â°àÕπºà“μ—¥ (preoperative refraction)

®“°°“√∑∫∑«π«√√≥°√√¡æ∫«à“ ¡’°“√»÷°…“«‘®—¬¡“°¡“¬

∑’Ë»÷°…“§«“¡ —¡æ—π∏å¢Õß√–¥—∫°“√¡Õß‡ÀÁπÀ≈—ßºà“μ—¥°—∫

À≈“¬ªí®®—¬¥—ß°≈à“«¢â“ßμâπ ·μàæ∫°“√»÷°…“∑’Ë —¡æ—π∏å°—∫

ªí®®—¬¥â“π§à“§«“¡‚§âß°√–®°μ“§àÕπ¢â“ßπâÕ¬ ÷Ëßªí®®—¬

¥—ß°≈à“«‰¥â√—∫§«“¡ π„®®“°®—°…ÿ·æ∑¬å¡“°¢÷Èπ ‡π◊ËÕß®“°

ªí®®ÿ∫—π‰¥â¡’°“√æ—≤π“‡≈π å·°â«μ“‡∑’¬¡∑’Ë “¡“√∂·°â ‰¢

¿“«– “¬μ“‡Õ’¬ß∑’Ë‡°‘¥®“°°√–®°μ“‰¥â ¥—ßπ—Èπ°“√«—¥§à“§«“¡

‚§âß°√–®°μ“∑’Ë·¡àπ¬”®– àßº≈μàÕ°“√μ—¥ ‘π„®‡≈◊Õ°™π‘¥

‡≈π å∑’Ë‡À¡“– ¡„Àâ·°àºŸâªÉ«¬¡“°¢÷Èπ

°“√ª√–‡¡‘π§«“¡‚§âß°√–®°μ“ “¡“√∂∑”‰¥â‚¥¬„™â

‡§√◊ËÕß¡◊ÕÀ≈“°À≈“¬™π‘¥ ‡™àπ ‡§√◊ËÕß¡◊Õ«—¥§«“¡‚§âß

°√–®°μ“™π‘¥ª°μ‘ (manual keratometer), ™π‘¥Õ—μ‚π¡—μ‘

(Automated keratometer), Pentacam ·≈– IOL Master

‡ªìπμâπ ‚¥¬„πª√–‡∑»‰∑¬¡’°“√„™â‡§√◊ËÕß¡◊Õ Automated

keratometer (AutoK) ·≈– IOL Master ·æ√àÀ≈“¬¡“°

°«à“‡§√◊ËÕß¡◊Õ™π‘¥Õ◊Ëπ ‡π◊ËÕß®“° AutoK ‡ªìπ‡§√◊ËÕß¡◊Õ∑’Ë¡’

ª√–«—μ‘°“√„™âß“π¡“¬“«π“π°«à“ ¡’√“§“∂Ÿ°°«à“®÷ß¡—°„™â‡ªìπ

‡§√◊ËÕß¡◊ÕÀ≈—°„π°“√ª√–‡¡‘π§à“§«“¡‚§âß°√–®°μ“¢ÕßºŸâªÉ«¬

°àÕπºà“μ—¥μâÕ°√–®°„π‚√ßæ¬“∫“≈¢π“¥‡≈Á°„πª√–‡∑»‰∑¬

‰¥â·°à ‚√ßæ¬“∫“≈™ÿ¡™π ·≈–‚√ßæ¬“∫“≈®—ßÀ«—¥ à«π‡§√◊ËÕß

IOL Master ∂÷ß·¡â®–‡ªìπ‡§√◊ËÕß¡◊Õ™π‘¥„À¡à„™âß“πßà“¬·μà

°Á¡’√“§“ Ÿß ®÷ßæ∫«à“¡’°“√„™âß“π‡©æ“–„π‚√ßæ¬“∫“≈¢π“¥

„À≠à ‡™àπ ‚√ßæ¬“∫“≈»Ÿπ¬å ·≈–‚√ß‡√’¬π·æ∑¬å‡∑à“π—Èπ ‡ªìπ

∑’Ë¡“¢Õß§”∂“¡∂÷ß§«“¡®”‡ªìπ„π°“√®—¥À“‡§√◊ËÕß¡◊Õ‡æ‘Ë¡‡μ‘¡

¢Õß‚√ßæ¬“∫“≈¢π“¥‡≈Á° ·≈–§«“¡‡¢â“°—π‰¥â¢Õß¢âÕ¡Ÿ≈

®“°‡§√◊ËÕß¡◊Õ∑—Èß Õß ´÷Ëß®“°°“√∑∫∑«π«√√≥°√√¡æ∫«à“

‡√“Õ“®®–‰¡à “¡“√∂π”§à“§«“¡‚§âß°√–®°μ“®“°‡§√◊ËÕß∑—Èß

Õß¡“‡ª√’¬∫‡∑’¬∫À√◊Õ∑¥·∑π°—π‰¥â‚¥¬μ√ß ‡π◊ËÕß®“°§à“

§«“¡‚§âß°√–®°μ“∑’Ë«—¥‰¥â®“°‡§√◊ËÕß¡◊Õμà“ß™π‘¥°—πÕ“®¡’

§«“¡·μ°μà“ß°—π ¥—ß‡™àπ√“¬ß“π®“°°“√»÷°…“¢Õß Uri Elbaz

·≈–§≥–4 ∑’Ëæ∫§«“¡·μ°μà“ßÕ¬à“ß¡’π—¬ ”§—≠√–À«à“ß§à“

§«“¡‚§âß°√–®°μ“ (Keratometry) ∑’Ë«—¥‰¥â®“°‡§√◊ËÕß IOL

Master, ‡§√◊ËÕß AutoK ·≈–‡§√◊ËÕß Pentacam ´÷Ëß§«“¡

·μ°μà“ß¢Õß§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥‰¥â¥â«¬‡§√◊ËÕß¡◊Õμà“ß

™π‘¥°—π¥—ß°≈à“«π’È Õ“® àßº≈‚¥¬μ√ßμàÕ§«“¡·¡àπ¬”„π°“√

ª√–¡“≥§à“ “¬μ“°àÕπºà“μ—¥‰¥âÕ’°∑—Èß¬—ß‰¡àæ∫ß“π«‘®—¬°àÕπ

Àπâ“∑’Ë»÷°…“º≈¢Õß§à“§«“¡‚§âß°√–®°μ“μàÕ°“√ª√–¡“≥

§à“ “¬μ“À≈—ß°“√ºà“μ—¥μâÕ°√–®°„πª√–‡∑»‰∑¬ ®“°‡Àμÿº≈

¥—ß°≈à“«∑“ß§≥–ºŸâ«‘®—¬®÷ß‰¥â∑”°“√»÷°…“π’È´÷Ëßº≈®“°°“√

78 Õ√¬“ æƒ∑∏‘æß…å ·≈–§≥– Vol. 30 No. 2 July-December 2016

«‘®—¬Õ“® “¡“√∂π”¡“Õπÿ¡“π∂÷ß§«“¡·¡àπ¬”¢Õß‡§√◊ËÕß¡◊Õ

∑—Èß Õß™π‘¥„π°“√ª√–¡“≥§à“§«“¡‚§âß°√–®°μ“ ·≈–Õ“®

π”¡“„™â„π°“√Õâ“ßÕ‘ß æ‘®“√≥“§«“¡§ÿâ¡§à“ ”À√—∫°“√

®—¥À“‡§√◊ËÕß¡◊Õ¢Õß‚√ßæ¬“∫“≈μà“ßÊ „πª√–‡∑»‰∑¬μàÕ‰ª

«‘∏’°“√»÷°…“‡ªìπ°“√»÷°…“·∫∫ Prospective consecutive case

study ‚¥¬∑”°“√»÷°…“„πºŸâªÉ«¬‚√§μâÕ°√–®°®”π«π 73

√“¬ ∑’Ë‡¢â“√—∫°“√μ√«®·≈–ºà“μ—¥∑’Ë°Õß®—°…ÿ°√√¡ √.æ.

æ√–¡ß°ÿÆ‡°≈â“ √–À«à“ß‡¥◊Õπ¡’π“§¡ 2556 ∂÷ß ‘ßÀ“§¡ 2556

‡°≥±å°“√‡≈◊Õ°ª√–™“°√μ—«Õ¬à“ßInclusion criteria

1. ºŸâªÉ«¬μâÕ°√–®°∑’Ë¡’Õ“¬ÿ¡“°°«à“ 50 ªï·≈–¡’¢âÕ

∫àß™’È ”À√—∫°“√ºà“μ—¥ ≈“¬μâÕ°√–®°

2. “¡“√∂«—¥§à“§«“¡¬“«≈Ÿ°μ“¥â«¬«‘∏’ Partial co-

herence interferometry (IOL Master)

3. “¡“√∂‡¢â“√—∫°“√ª√–‡¡‘π°àÕπ·≈–À≈—ßºà“μ—¥

μâÕ°√–®°‰¥âμ“¡√–‡∫’¬∫ß“π«‘®—¬

4. ‰¡à¡’¿“«–·∑√°´âÕπ√–À«à“ß°“√ºà“μ—¥ ≈“¬μâÕ

°√–®°√à«¡°—∫„ à‡≈π å·°â«μ“‡∑’¬¡

5. ¡’¢π“¥§«“¡¬“«≈Ÿ°μ“Õ¬Ÿà„π™à«ßª°μ‘§◊Õ 22.0-24.5

¡‘≈≈‘‡¡μ√

Exclusion criteria

1. ¡’§«“¡º‘¥ª°μ‘¢Õß°√–®°μ“∑’Ë àßº≈μàÕ√–¥—∫°“√

¡Õß‡ÀÁπ‡™àπ¡’·º≈‡ªìπ∑’Ë°√–®°μ“ °√–®°μ“Õ—°‡ ∫ ¡’¿“«–

‚√§°√–®°μ“‚§âßπŸπº‘¥ª°μ‘

2. ¡’¿“«– “¬μ“‡Õ’¬ß™π‘¥∑’Ë¡’ “‡Àμÿ®“°§«“¡‚§âß

°√–®°μ“ (corneal astigmatism) ¡“°°«à“ 1.0 Dioptor

(D) À√◊Õ¡’¿“«– “¬μ“‡Õ’¬ß™π‘¥‰¡àª°μ‘ (irregular astig-

matism)

3. ¡’ª√–«—μ‘°“√ºà“μ—¥°√–®°μ“ À√◊Õ laser refrac-

tive surgery

4. ¡’ª√–«—μ‘‡¢â“√—∫°“√ºà“μ—¥‚√§®Õμ“ À√◊Õ‡§¬‰¥â√—∫

°“√©’¥ intraocular gas

5. ¡’¿“«–·∑√° âÕπ√–À«à“ß‡¢â“√—∫°“√ºà“μ—¥μâÕ

°√–®° À√◊Õ ®”‡ªìπμâÕß‰¥â√—∫°“√‡¬Á∫ªî¥·º≈ºà“μ—¥∑’Ë°√–®°μ“

«‘∏’¥”‡π‘π°“√«‘®—¬ë §”π«≥®”π«π°≈ÿà¡ª√–™“°√»÷°…“∑’ËμâÕß°“√‚¥¬

Õ‘ß¢âÕ¡Ÿ≈®“°°“√»÷°…“¢Õß Giacomo Savini ·≈–§≥–1,6

‚¥¬„™â§à“§«“¡·μ°μà“ß√–À«à“ß§à“‡©≈’Ë¬¢Õß§à“ “¬μ“

∑”π“¬°àÕπºà“μ—¥°—∫§à“ “¬μ“®√‘ßÀ≈—ßºà“μ—¥ ∑’Ë«—¥¥â«¬

‡§√◊ËÕß IOL Master ‡∑à“°—∫ 0.23x0.33 D

§”π«≥°≈ÿà¡ª√–™“°√μ—«Õ¬à“ß¥—ßπ’È

®”π«π°≈ÿà¡ª√–™“°√μ—«Õ¬à“ß∑’ËμâÕß°“√„π°“√»÷°…“

§√—Èßπ’È‡∑à“°—∫ 75 μ“

À¡“¬‡Àμÿ

n = ¢π“¥μ—«Õ¬à“ß∑’ËμâÕß„™â»÷°…“

σ = §à“§“¥§–‡π¢Õß§à“‡∫’Ë¬ß‡∫π¡“μ√∞“π„π°≈ÿà¡

ª√–™“°√‡∑à“°—∫ 0.23

Δ = §à“§«“¡·μ°μà“ß¢Õß§à“ “¬μ“®√‘ßÀ≈—ßºà“μ—¥

μâÕ°√–®°‡∑’¬∫°—∫§à“ “¬μ“∑”π“¬°àÕπºà“μ—¥∑’Ë§”π«≥‰¥â

®“°§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥®“°‡§√◊ËÕß¡◊Õ IOL Master

(effect size) ºŸâ«‘®—¬°”Àπ¥„Àâ‡∑à“°—∫ 20% ¢Õß§à“‡©≈’Ë¬∑’Ë

«—¥‰¥â ‡∑à“°—∫ 0.20x0.33

ë ‚§√ß°“√ºà“π§«“¡‡ÀÁπ™Õ∫®“°§≥–Õπÿ°√√¡°“√

æ‘®“√≥“‚§√ß°“√«‘®—¬°√¡·æ∑¬å∑À“√∫° ÷ËßºŸâ‡¢â“√à«¡«‘®—¬

∑ÿ°√“¬®–‰¥â√—∫°“√™’È·®ß√–‡∫’¬∫«‘∏’«‘®—¬‚¥¬≈–‡Õ’¬¥æ√âÕ¡

‡¢â“√à«¡‚§√ß°“√


ë ºŸâªÉ«¬∑ÿ°§π®–‰¥â√—∫°“√ Õ∫ª√–«—μ‘∑“ßμ“‚¥¬

≈–‡Õ’¬¥·≈–√—∫°“√μ√«®ª√–‡¡‘π “¬μ“°àÕπºà“μ—¥¥—ßπ’Èo «—¥√–¥—∫°“√¡Õß‡ÀÁπ (Visual acuity) ∑—Èß

°àÕπ·≈–À≈—ßºà“μ—¥ ‚¥¬„™â EDTRS charto μ√«®μ“‚¥¬„™â°≈âÕß àÕßμ“ slit lamp ·≈–

μ√«®®Õμ“ (fundus) ‚¥¬®—°…ÿ·æ∑¬åo «—¥§à“§«“¡‚§âß°√–®°μ“‚¥¬‡§√◊ËÕß¡◊Õ Auto-

mated keratometer (Speedy-K, Righton, Japan) ·≈–

IOL Master (√ÿàπ500) (Zeiss, Jena, Germany), «—¥§à“

§«“¡¬“«≈Ÿ°μ“¥â«¬‡§√◊ËÕß IOL Master, §”π«≥§à“‡≈π å

·°â«μ“‡∑’¬¡‚¥¬„™â Ÿμ√ SRK/T ®“°‡§√◊ËÕß IOL Mastero æ‘®“√≥“‡≈◊Õ°§à“‡≈π å·°â«μ“‡∑’¬¡®“°§à“

∑”π“¬∑’Ë§”π«≥‰¥â®“°‡§√◊ËÕß IOL Master ‚¥¬®—°…ÿ·æ∑¬åo ‡¢â“√—∫°“√ºà“μ—¥ ≈“¬μâÕ°√–®°¥â«¬«‘∏’ Pha-

coemulsification ·≈–„ à‡≈π å·°â«μ“‡∑’¬¡™π‘¥ Blue-

blocker IOL ‚¥¬®—°…ÿ·æ∑¬åo √—∫°“√μ√«®ª√–‡¡‘πÀ≈—ßºà“μ—¥∑’Ë 1 «—π, 7 «—π

·≈– 4 —ª¥“Àå‚¥¬∑ÿ°§√—Èß®–‰¥â√—∫°“√ª√–‡¡‘π√–¥—∫°“√

¡Õß‡ÀÁπ §«“¡¥—πμ“ ·≈–‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπo ª√–‡¡‘π§à“ “¬μ“À≈—ßºà“μ—¥∑’Ë —ª¥“Àå∑’Ë 4 ¥â«¬

‡§√◊ËÕß Automated refractometer (Speedy-K, Righton,

Japan) ‚¥¬§à“∑’Ë«—¥‰¥â®–∂Ÿ°§”π«≥‡ªìπ§à“ Spherical equi-

valent ‡æ◊ËÕ„™â‡ª√’¬∫‡∑’¬∫°—∫§à“ “¬μ“∑”π“¬μ“¡√–‡∫’¬∫

«‘®—¬μàÕ‰ªo „™â‚ª√·°√¡ paired t-test ·≈– Wilcoxon

Signed Ranks test „π°“√§”π«≥§à“§«“¡‡∫’Ë¬ß‡∫π (Ab-

solute error) ¢Õß§à“ “¬μ“∑’Ë«—¥‰¥â®√‘ßÀ≈—ßºà“μ—¥‡∑’¬∫°—∫

§à“ “¬μ“∑”π“¬°àÕπºà“μ—¥ ∑’Ë§”π«≥®“° 2 ‡§√◊ËÕß¡◊Õ

§”π‘¬“¡ë Absolute error §◊Õ §à“§«“¡‡∫’Ë¬ß‡∫π¢Õß§à“

“¬μ“∑’Ë«—¥‰¥â®√‘ßÀ≈—ßºà“μ—¥‡∑’¬∫°—∫§à“ “¬μ“∑”π“¬°àÕπ

ºà“μ—¥ §”π«≥‚¥¬„™â§à“ “¬μ“®√‘ß (Spherical equivalent)

À≈—ßºà“μ—¥∑’Ë —ª¥“Àå∑’Ë 4 - §à“ “¬μ“∑”π“¬

ë Mean absolute error (MAE) §◊Õ §à“‡©≈’Ë¬

§«“¡‡∫’Ë¬ß‡∫π¢Õß§à“ “¬μ“∑’Ë«—¥‰¥â®√‘ßÀ≈—ßºà“μ—¥‡∑’¬∫°—∫

§à“ “¬μ“∑”π“¬°àÕπºà“μ—¥

º≈°“√»÷°…“ºŸâªÉ«¬‰¥â√—∫°“√ºà“μ—¥μâÕ°√–®°·≈–„ à‡≈π å·°â«μ“

‡∑’¬¡∑—ÈßÀ¡¥®”π«π 73 √“¬ (77 μ“) ‡ªìπ™“¬ 31 √“¬

§‘¥‡ªìπ√âÕ¬≈– 42.47 ‡ªìπÀ≠‘ß 42 √“¬ §‘¥‡ªìπ√âÕ¬≈– 57.53

¡’Õ“¬ÿ√–À«à“ß 53-82 ªï (‡©≈’Ë¬ 68.13+7.38 ªï) ‰¥â√—∫°“√

ºà“μ—¥μ“¢â“ß¢«“ 35 μ“ §‘¥‡ªìπ√âÕ¬≈– 45.45 ºà“μ—¥μ“

¢â“ß´â“¬ 42 μ“ §‘¥‡ªìπ√âÕ¬≈– 54.55 ‚¥¬¡’ºŸâªÉ«¬®”π«π 4

√“¬ ∑’Ë‰¥â√—∫°“√ºà“μ—¥∑—Èß 2 μ“ §‘¥‡ªìπ√âÕ¬≈– 5.19 §à“

§«“¡¬“«≈Ÿ°μ“¡’§«“¡¬“«μ—Èß·μà 22.02-24.18 ¡¡. (§à“‡©≈’Ë¬

23.10 ¡¡.) §à“°”≈—ß¢¬“¬‡≈π å·°â«μ“‡∑’¬¡∑’Ë‡≈◊Õ°„™â„Àâ

ºŸâªÉ«¬¡’§à“μ—Èß·μà 17.5-26.5 D (§à“‡©≈’Ë¬ 21.97 D) (μ“√“ß

∑’Ë 1) §à“‡©≈’Ë¬§«“¡‚§âß°√–®°μ“∑’Ë«—¥‰¥â®“°‡§√◊ËÕß AutoK

‡∑à“°—∫ 44.38+1.21 D (median, 44.37 D) ·≈–§à“‡©≈’Ë¬

§«“¡‚§âß°√–®°μ“∑’Ë«—¥‰¥â®“°‡§√◊ËÕß IOL Master ‡∑à“°—∫

44.42+1.21 D (median, 44.47 D) (μ“√“ß∑’Ë 2)

Table 1 General characteristics of study population

Baseline characteristicsGender (person)

- Male 31 (42.47%)- Female 42 (57.53%)

Age (years) 53-82 (median 68)Laterality (eyes)

- Right eye 35 (45.45%)- Left eye 42 (54.55%)

Mean Axial length (mm) 23.10 (22.02-24.18)


√–¥—∫°“√¡Õß‡ÀÁπ°àÕπºà“μ—¥ (Pre-operative UCVA)

Õ¬Ÿà„π™à«ß 0.2-3 log unit (§à“‡©≈’Ë¬ 0.68+0.53 log unit)

·≈–À≈—ßºà“μ—¥ (Post-operative UCVA) Õ¬Ÿà„π™à«ß 0-0.7

log unit (§à“‡©≈’Ë¬ 0.19+0.15 log unit) §à“‡©≈’Ë¬ “¬μ“

®√‘ßÀ≈—ßºà“μ—¥ (Post-operative spherical equivalent)

‡∑à“°—∫ -0.31+0.34 D (range, ›1.13 D ∂÷ß +0.50 D) §à“

‡©≈’Ë¬ “¬μ“∑”π“¬‡¡◊ËÕ§”π«≥¥â«¬§à“§«“¡‚§âß°√–®°μ“

∑’Ë«—¥¥â«¬‡§√◊ËÕß AutoK ‡∑à“°—∫ -0.15+0.23 D (range,

-1.21 D ∂÷ß +0.34 D) §à“‡©≈’Ë¬ “¬μ“∑”π“¬‡¡◊ËÕ§”π«≥

¥â«¬§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥¥â«¬‡§√◊ËÕß IOL Master ‡∑à“

°—∫ -0.16+0.13 D (range, -0.49 ∂÷ß +0.18 D) (μ“√“ß∑’Ë 3

·≈– Figure 1)

Parameter AutoK IOL master P-Value

Median K (D) 44.37 44.47 0.397(min-max) (40.21-48.06) (41.09-47.98)

Table 2 A comparison of median value of keratometry from difference instruments

*Wilcoxon Signed Ranks test for Median K

Table 3 A mean predicted refractive value calculated from keratometric values of AutoK and IOL Master comparedwith post-op spherical equivalent.

Parameter

AutoK

IOL master

Mean Predicted RF (D)

-0.15 + 0.23(-1.21 to +0.34)-0.16 + 0.13

(-0.49 to +0.18)

Post-op refraction(Spherical equivalent) (D)

-0.31 + 0.34(-1.13 to +0.5)

P-Value

0.001

<0.001

*P-Value ‡ª√’¬∫‡∑’¬∫§à“ Mean predicted RF √–À«à“ß‡§√◊ËÕß AutoK ·≈– IOL Master °—∫§à“ Post-op Refraction

Table 4 A comparison of mean absolute error (MAE) from AutoK and IOL Master

Parameter AutoK IOL master P-Value MAE (D) -0.16 + 0.40 -0.16 + 0.36 0.894

(-1.34 to +0.86) (-1.02 to +0.89)

*Paired t-test for MAEMean absolute error = (Actual post-op RF) - (Predicted RF)

‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§à“ “¬μ“®√‘ß°—∫§à“ “¬μ“∑”π“¬

®“°‡§√◊ËÕß¡◊Õ∑—Èß Õßæ∫«à“ §à“ “¬μ“∑”π“¬®“°‡§√◊ËÕß¡◊Õ

∑—Èß Õß¡’§«“¡‡∫’Ë¬ß‡∫π‰ª®“°§à“ “¬μ“®√‘ßÕ¬à“ß¡’π—¬

”§—≠∑“ß ∂‘μ‘ §◊Õ ‡§√◊ËÕß Auto K ¡’§à“§«“¡‡™◊ËÕ¡—Ëπ¢Õß

§«“¡μà“ß P = 0.001 ·≈–‡§√◊ËÕß IOL Master ¡’§à“§«“¡

‡™◊ËÕ¡—Ëπ¢Õß§«“¡μà“ß P < 0.001 μ“¡≈”¥—∫ (μ“√“ß∑’Ë 3)

·≈–æ∫°“√°√–®“¬μ—«¢Õß§à“§«“¡‡∫’Ë¬ß‡∫π‰ª„π∑‘»∑“ß≈∫

¡“°¢÷Èπ (Figure 2. ·≈– Figure 3.) ·μà‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫

‡©æ“–§à“‡©≈’Ë¬§«“¡‡∫’Ë¬ß‡∫π (MAE) ¢Õß§à“ “¬μ“∑”π“¬

√–À«à“ß‡§√◊ËÕß¡◊Õ∑—Èß Õß°≈—∫‰¡àæ∫§«“¡·μ°μà“ßÕ¬à“ß¡’

π—¬ ”§—≠∑“ß ∂‘μ‘‚¥¬¡’§à“ MAE ¢Õß‡§√◊ËÕß Auto K ·≈–

IOL master ‡∑à“°—∫ -0.16+0.40 D ·≈– -0.16+0.36 D

μ“¡≈”¥—∫ (μ“√“ß∑’Ë 4.)


Figure 1 Show Predicted refraction from AutoK & IOL Master compared to actual post-op refraction.

Figure 2 Percentage of eyes in range of deviation of refractive outcomes used keratometric values from IOL Master


Figure 3 Percentage of eyes in range of deviation of refractive outcomes used keratometric values from AutoK

®“° Figure 2. æ∫«à“®”π«πμ“¢ÕßºŸâªÉ«¬ à«π„À≠à

®”π«π 60 μ“ ®“° 77 μ“ À√◊Õ§‘¥‡ªìπ√âÕ¬≈– 77.92 ¡’§à“

§«“¡‡∫’Ë¬ß‡∫π¢Õß “¬μ“Õ¬Ÿà„π™à«ß +0.5 D ·≈–∑—ÈßÀ¡¥¡’

§«“¡‡∫’Ë¬ß‡∫πÕ¬Ÿà„π™à«ß +1D ·≈–§à“ “¬μ“ à«π„À≠à®”π«π

48 μ“ ∑’Ë‡∫’Ë¬ß‡∫π‰ª∑“ß§à“≈∫§‘¥‡ªìπ√âÕ¬≈– 62.34 à«π

§à“ “¬μ“∑’Ë‡∫’Ë¬ß‡∫π‰ª∑“ß§à“∫«°®”π«π 29 μ“ §‘¥‡ªìπ

√âÕ¬≈– 37.66

®“° Figure 3. §à“‡∫’Ë¬ß‡∫π®“° AutoK æ∫«à“¡’§à“

Õ¬Ÿà„π™à«ß +0.5 D ‡∑à“°—∫ 57 μ“ §‘¥‡ªìπ√âÕ¬≈– 74.02 ·≈–

‡°◊Õ∫∑—ÈßÀ¡¥¡’§à“Õ¬Ÿà„π™à«ß +1.0 D ‡∑à“°—∫ 76 μ“ À√◊Õ

§‘¥‡ªìπ√âÕ¬≈– 98.7 ·≈–¡’‡æ’¬ß 1 μ“ §‘¥‡ªìπ√âÕ¬≈– 1.3 ∑’Ë

¡’§à“§«“¡‡∫’Ë¬ß‡∫π¢Õß “¬μ“‡°‘π -1.0 D ´÷Ëßæ∫«à“§à“

“¬μ“ à«π„À≠à¡’°“√‡∫’Ë¬ß‡∫π‰ª„π∑‘»∑“ß≈∫®”π«π 50

μ“ §‘¥‡ªìπ√âÕ¬≈– 64.93 ·≈–∑’Ë‡À≈◊Õ¡’§à“‡∫’Ë¬ß‡∫π‰ª„π

∑‘»∑“ß∫«°®”π«π 27 μ“ §‘¥‡ªìπ√âÕ¬≈– 35.07

«‘®“√≥å®“°º≈°“√«‘®—¬ æ∫«à“ºŸâªÉ«¬∑ÿ°√“¬∑’Ë‡¢â“√—∫°“√ºà“μ—¥

μâÕ°√–®°·≈–„ à‡≈π å·°â«μ“‡∑’¬¡ ¡’√–¥—∫°“√¡Õß‡ÀÁπ∑’Ë¥’

¢÷Èπ ‚¥¬¡’§à“‡©≈’Ë¬¢Õß√–¥—∫°“√¡Õß‡ÀÁπ°àÕπ (Pre-op UCVA)

·≈–À≈—ßºà“μ—¥ (Post-op UCVA) ‡∑à“°—∫ 0.68+0.53 log

unit ·≈– 0.19+0.15 log unit μ“¡≈”¥—∫ —ß‡°μ‰¥â«à“

ºŸâªÉ«¬∑ÿ°√“¬®–‰¥â√—∫°“√∑”π“¬§à“ “¬μ“μ—Èß·μà°àÕπºà“μ—¥

¥â«¬‡§√◊ËÕß IOL Master ‚¥¬®—°…ÿ·æ∑¬åºŸâºà“μ—¥‰¥â‡≈◊Õ°

§à“ “¬μ“∑”π“¬‰«â∑’Ë -0.49 ∂÷ß +0.18 DÀ√◊Õ°Á§◊Õª√–¡“≥

emmetropia ‰ª∂÷ß mild myopia ´÷Ëß®—°…ÿ·æ∑¬åºŸâºà“μ—¥

¡’§«“¡‡™◊ËÕ«à“∑’Ë√–¥—∫§à“ “¬μ“¥—ß°≈à“«ºŸâªÉ«¬®–¡’§«“¡

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ºŸâªÉ«¬‰¥â¥’‡™àπ‡¥’¬«°—∫°“√»÷°…“°àÕπÀπâ“ ∑’Ë√“¬ß“π«à“ „π

™à«ß§à“ “¬μ“¥—ß°≈à“«Õ“®™à«¬≈¥‚Õ°“ ‡°‘¥ “¬μ“¬“«À≈—ß

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ºŸâªÉ«¬®– “¡“√∂ª√—∫μ—«μàÕ “¬μ“ —Èπ‰¥â¥’°«à“‡¡◊ËÕ‡∑’¬∫°—∫

“¬μ“¬“«„πª√‘¡“≥∑’Ë‡∑à“°—π Õ’°∑—Èß°“√·°â ‰¢¥â«¬·«àπμ“

‡≈π å‡«â“°Á “¡“√∂≈¥°”≈—ß¢¬“¬¢Õß¿“æ‰¥â ´÷Ëß®–∑”„Àâ

ºŸâªÉ«¬ “¡“√∂ª√—∫μ—«‰¥â¥’¢÷Èπ·≈–≈¥‚Õ°“ ‡°‘¥ Aniseiko-

nia „π°√≥’∑’Ë∑”°“√ºà“μ—¥‡æ’¬ß¢â“ß‡¥’¬«5 Õ¬à“ß‰√°Áμ“¡

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√à«¡¥â«¬ ‡™àπ Õ“¬ÿ¢ÕßºŸâªÉ«¬ ≈—°…≥–ß“π·≈–°‘®«—μ√

ª√–®”«—π¢ÕßºŸâªÉ«¬ ‡ªìπμâπ

‡¡◊ËÕæ‘®“√≥“√–¥—∫§à“ “¬μ“∑”π“¬°àÕπºà“μ—¥®“°

‡§√◊ËÕß IOL Master §◊Õ -0.49 ∂÷ß +0.18 D ‡ª√’¬∫‡∑’¬∫°—∫

§à“ “¬μ“∑”π“¬®“°‡§√◊ËÕß AutoK æ∫«à“¡’§«“¡ —¡æ—π∏å


‰ª„π∑‘»∑“ß‡¥’¬«°—π §◊Õ -1.21 ∂÷ß +0.34 D´÷Ëß· ¥ß∂÷ß

§«“¡ —¡æ—π∏å∑’Ë‡ªìπ‰ª„π∑‘»∑“ß‡¥’¬«°—π¢Õß§à“§«“¡‚§âß

°√–®°μ“∑’Ë«—¥‰¥â®“°‡§√◊ËÕß¡◊Õ∑—Èß Õß¥â«¬ ‚¥¬æ∫«à“§à“‡©≈’Ë¬

¢Õß§à“§«“¡‚§âß°√–®°μ“∑’Ë«—¥‰¥â¡’§«“¡„°≈â‡§’¬ß°—π¡“°

§◊Õ §à“‡©≈’Ë¬§«“¡‚§âß°√–®°μ“∑’Ë«—¥‰¥â®“°‡§√◊ËÕß AutoK

‡∑à“°—∫ 44.38+1.21D (median, 44.37 D) ·≈–§à“‡©≈’Ë¬

§«“¡‚§âß°√–®°μ“∑’Ë«—¥‰¥â®“°‡§√◊ËÕß IOL Master ‡∑à“°—∫

44.42+1.21 D (median, 44.47 D) (μ“√“ß∑’Ë 2.) ‚¥¬§à“

§«“¡‚§âß∑’Ë«—¥‰¥â®“°‡§√◊ËÕß Auto K ®–¡’§à“πâÕ¬°«à“‡≈Á°πâÕ¬

∑”„Àâ§à“ “¬μ“∑”π“¬∑’Ë‰¥â®“°‡§√◊ËÕß AutoK ¡’§à“‰ª∑“ß

“¬μ“ —Èπ¡“°¢÷Èπ‡¡◊ËÕ‡∑’¬∫°—∫§à“ “¬μ“∑”π“¬®“°‡§√◊ËÕß

IOL Master ·μà‰¡à¡’π—¬ ”§—≠∑“ß ∂‘μ‘

®“°μ“√“ß∑’Ë 3. ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫§à“ “¬μ“®√‘ß°—∫§à“

“¬μ“∑”π“¬®“°‡§√◊ËÕß¡◊Õ∑—Èß Õß ∂÷ß·¡â®–æ∫«à“ §à“ “¬μ“

∑”π“¬®“°‡§√◊ËÕß¡◊Õ∑—Èß Õß¡’§«“¡‡∫’Ë¬ß‡∫π‰ª®“°§à“ “¬μ“

®√‘ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ ·μà§à“§«“¡‡∫’Ë¬ß‡∫π¥—ß°≈à“«

Õ“® àßº≈À√◊Õ¡’π—¬ ”§—≠∑“ß§≈‘π‘°‰¡à¡“°π—° ¥—ß¢âÕ¡Ÿ≈®“°

Figure 2. ·≈– Figure 3. ∑’Ë· ¥ß§à“§«“¡‡∫’Ë¬ß‡∫π„π

√–¥—∫μË” °≈à“«§◊Õ √âÕ¬≈– 74.02 ·≈–√âÕ¬≈– 77.92 ¢Õß

§à“§«“¡‡∫’Ë¬ß‡∫π®“°‡§√◊ËÕß AutoK ·≈– IOL Master

μ“¡≈”¥—∫ ¡’§«“¡‡∫’Ë¬ß‡∫πÕ¬Ÿà„π™à«ß +0.5 D ·≈–√âÕ¬≈–

98.7 ∂÷ß√âÕ¬≈– 100 ¡’§«“¡‡∫’Ë¬ß‡∫π‰¡à‡°‘π +1.0 D.

·μà¢âÕæ÷ß√–«—ß∑’ËÕ“®μâÕß„Àâ§«“¡ π„®‰¥â·°à √âÕ¬≈–

62.34 ¢Õß§à“§«“¡‡∫’Ë¬ß‡∫π®“°‡§√◊ËÕß IOL Master·≈–

√âÕ¬≈– 64.93 ¢Õß§à“§«“¡‡∫’Ë¬ß‡∫π®“°‡§√◊ËÕß AutoK ®–

¡’§à“‰ª„π∑‘»∑“ß≈∫¡“°¢÷Èπ ·≈–¡’∂÷ß√âÕ¬≈– 37.66 ¢Õß§à“

§«“¡‡∫’Ë¬ß‡∫π®“°‡§√◊ËÕß IOL Master ·≈–√âÕ¬≈– 35.07

¢Õß§à“§«“¡‡∫’Ë¬ß‡∫π®“°‡§√◊ËÕß AutoK ∑’Ë¡’§«“¡‡∫’Ë¬ß‡∫π

‰ª„π∑‘»∑“ß∫«° π—ËπÀ¡“¬§«“¡«à“ ∂â“‡√“ª√–¡“≥§à“ “¬μ“

„ÀâÕ¬Ÿà∑’Ë emmetropia ‚¥¬„™â§à“§«“¡‚§âß°√–®°μ“®“°‡§√◊ËÕß

IOL Master °Á¡’ ‚Õ°“ ∑’Ë®–∑”„ÀâºŸâªÉ«¬¡’§à“ “¬μ“‡ªìπ

“¬μ“ —Èπ·≈– “¬μ“¬“«À≈—ßºà“μ—¥‰¥â¡“°∂÷ß√âÕ¬≈– 62.34

·≈–√âÕ¬≈– 37.66 μ“¡≈”¥—∫ ‡™àπ‡¥’¬«°—π∂â“‡√“ª√–¡“≥

§à“ “¬μ“‚¥¬„™â§à“§«“¡‚§âß°√–®°μ“®“° AutoK °Á¡’‚Õ°“

∑’Ë®–∑”„Àâ§à“ “¬μ“ºŸâªÉ«¬‡ªìπ “¬μ“ —Èπ·≈– “¬μ“¬“«‰¥â

¡“°¢÷Èπ®“°§à“∑”π“¬∂÷ß√âÕ¬≈– 64.93 ·≈–√âÕ¬≈– 35.07

μ“¡≈”¥—∫ ‚¥¬ “‡Àμÿ¢Õß§«“¡‡∫’Ë¬ß‡∫π¥—ß°≈à“« Õ“®‡ªìπ

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factor), ªí®®—¬¥â“π‡≈π å·°â«μ“‡∑’¬¡ À√◊Õªí®®—¬®“°°“√

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‡æ‘Ë¡‡μ‘¡®÷ß‰¡à¢Õ«‘®“√≥å ≥ ∑’Ëπ’È·μàÕ“®æÕ √ÿª‰¥â«à“°“√

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≈¥§«“¡‡ ’Ë¬ß¥—ß°≈à“«‰¥â

®“° Figure 1. · ¥ß°“√°√–®“¬μ—«¢Õß§à“ “¬μ“

∑”π“¬®“°‡§√◊ËÕß¡◊Õ∑—Èß Õß™π‘¥‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫§à“ “¬μ“

®√‘ßÀ≈—ßºà“ ∑’Ë¡’§à“√–À«à“ß - 1.13 D ∂÷ß + 0.50 D (§à“‡©≈’Ë¬

-0.31+0.34 D) æ∫«à“§à“ “¬μ“∑”π“¬®“° IOL Master ¡’

°“√°√–®“¬μ—«πâÕ¬°«à“§à“ “¬μ“∑”π“¬®“° AutoK ´÷Ëß

“¡“√∂Õ∏‘∫“¬‰¥â®“°√–‡∫’¬∫«‘®—¬∑’Ë ®—°…ÿ·æ∑¬åºŸâºà“μ—¥

‡≈◊Õ°®–‡≈◊Õ°§à“∑”π“¬ “¬μ“‚¥¬„™â¢âÕ¡Ÿ≈®“° IOL Mas-

ter ‡ªìπÀ≈—°π—Ëπ‡Õß

®“°μ“√“ß∑’Ë 4. ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫‡©æ“–§à“‡©≈’Ë¬§«“¡

‡∫’Ë¬ß‡∫π (MAE) √–À«à“ß‡§√◊ËÕß¡◊Õ∑—Èß Õß°≈—∫‰¡àæ∫§«“¡

·μ°μà“ßÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘‚¥¬¡’§à“ MAE ®“°‡§√◊ËÕß

AutoK ·≈–‡§√◊ËÕß IOL Master ‡∑à“°—∫ -0.16+0.40 D

·≈– -0.16+0.36 D μ“¡≈”¥—∫ π—ËπÀ¡“¬§«“¡«à“‡§√◊ËÕß¡◊Õ

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Reference1. The Eye Diseases Prevalence Research Group. Prevalence of

cataract and pseudophakia/aphakia among adults in the UnitedStates. Arch Ophthalmol 2004;122:487-94

2. Thomas JL, Gregory LS, Louis BC.Epidemiology of cataract.Basic and clinical science Course Section 11: Lens and cata-

ract. San Francisco, American Academy of Ophthalmology2010-2011:80-3.

3. SverkerNorrby, Sources of error in intraocular lens powercalculation, J Cataract Refract Surg 2008; 34:368›376 Q 2008ASCRS and ESCRS

4. Uri†Elbaz, MD, Yaniv†Barkana, MD, Yariv†Gerber, PhD,Isaac†Avni, MD, David†Zadok, MD , Comparison of DifferentTechniques of Anterior Chamber Depth and KeratometricMeasurements. American Journal of Ophthalmology, Vol.143,Issue 1, Pages 48-53, January 2007

5. Chaisiri Jumroendararasame, Predicting the refractive out-come after phacoemulsification with intraocular lens implan-tation in Songklanagarind Hospital, Thai J Ophthalmol, Vol.20No.2, July-December 2006;155-62.

6. Giacomo Savini, MD, Piero Barboni, MD, Michele Carbonelli,MD, Kenneth J. Hoffer, MD, Accuracy of Scheimpflug cornealpower measurements for intraocular lens power calculation,J Cataract Refract Surg 2009; 35:1193–1197 Q 2009 ASCRSand ESCRS


°“√‡≈◊Õ°μ”·Àπàß·º≈ºà“μ—¥μâÕ°√–®°∑’Ë‡À¡“– ¡™à«¬·°â‰¢¿“«– “¬μ“‡Õ’¬ß‰¥â

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«‘∏’«‘®—¬: ºŸâªÉ«¬∑’Ë‡¢â“√—∫°“√ºà“μ—¥μâÕ°√–®°∑’Ë»Ÿπ¬å°“√·æ∑¬å°“≠®π“¿‘‡…°μ—Èß·μàªï 2553-2558 ‡≈◊Õ°≈ß·º≈∑’Ë steepestmeridian ·∫àßºŸâªÉ«¬ÕÕ°‡ªìπ 2 °≈ÿà¡ °≈ÿà¡∑’Ë 1 ºŸâªÉ«¬∑’Ë¡’¿“«– “¬μ“‡Õ’¬ß°àÕπºà“μ—¥πâÕ¬°«à“ 1.50D °≈ÿà¡∑’Ë 2 ºŸâªÉ«¬∑’Ë¡’¿“«–μ—Èß·μà 1.50D ¢÷Èπ‰ª §”π«≥¢âÕ¡Ÿ≈¢Õß§à“ “¬μ“‡Õ’¬ß·≈–·°π¢Õß “¬μ“‡Õ’¬ß (vector analysis) (K1/K2) °àÕπºà“μ—¥,√–¬–‡«≈“ 1 ‡¥◊Õπ·≈– 3 ‡¥◊ÕπÀ≈—ßºà“μ—¥·≈â«‡ª√’¬∫‡∑’¬∫°—π

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™π‘¥·°â “¬μ“‡Õ’¬ß (toric IOL) ®—°…ÿ‡«™ “√ 2016; °√°Æ“§¡-∏—π«“§¡ 30(2): 85-94.

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86 Thai J Ophthalmol Vol. 30 No. 2 July-December 2016

Optimal Corneal Incisions to CorrectPre-existing Astigmatism in Cataract Surgery

Prakairut Thongphiew, M.D.

Golden Jubilee Medical Center, Mahidol University.


Manassawee Joradoln, M.D.Rosanun Sikarinkul, M.D.

Abstract

Objective: To explore the effect of clear corneal incisions on reducing astigmatism in different degrees ofpre-existing astigmatism

Materials & Methods: We retrospectively reviewed patients who underwent phacoemulsification at GoldenJubilee Medical Center between 2010 and 2015. A sutureless clear corneal incision was made on thesteepest axis. Patients were divided into 2 groups by degree of preoperative astigmatism (<1.50 and >1.50D). The differences of postoperative astigmatism and vector analysis (K1/K2) at one month and three monthspostoperatively were compared.

Results: Overall in 70 cataract operations, median astigmatism reduced from 1.50 D preoperatively to 1.25D at one month postoperatively (p<0.001), and 1.00 D at three months postoperatively (p<0.001). Thedifference between preoperative (2.00 D) and 1-month and 3-month postoperative astigmatism (1.50 D and1.50 D) was statistically significant only in the severe group (>1.50 D) (p<0.001). No significant difference(0.75 D vs. 0.75 D and 0.75 D) was found in the mild group (<1.50 D), neither at one month (p=0.97) nor threemonths after surgery (p=0.83). Vector analysis showed no significant change in either vertical or horizontalcomponents of astigmatism. The overall surgically induced astigmatism in this study was 0.60 D at onemonth, and 0.71 D at three months postoperatively.

Conclusion: A clear corneal incision on the steepest axis in phacoemulsification cataract surgery can helpreduce pre-existing astigmatism only in severe astigmatism over 1.50 D, and this may be beneficial in

patients with astigmatism over 1.50 D who undergo a cataract surgery. Thai J Ophthalmol 2016; July-

December 30(2): 85-94.

Keywords: Corneal incision, Astigmatism Correction, Cataract

No Author has a financial or proprietary interest in material or method mentioned

‰¡à¡’√Ÿª¡“

87Optimal Corneal Incisions to Correct Pre-existing Astigmatism in Cataract Surgery

IntroductionCataract is one of the most common causes

of blindness and is conventionally treated with sur-

gery. Visual loss occurs because the opacification of

the lens obstructs the light from passing and being

focused on to the retina. This opacification process

is mostly due to biological aging.

Nowadays, phacoemulsification is the most

widely used cataract surgery. This procedure uses

ultrasonic energy to emulsify the cataract lens. Entry

to the eye is done through a small self-sealing inci-

sion, which has a diameter of 2.8 to 3.2 mm and

most likely will not need stitches. Its advantages are

shorter operative time and rapid visual rehabilitation.

Precise intraocular lens (IOL) power calculation is

essential for optimal benefits of implant surgery.

A simple monofocal IOL, designed with a single fo-

cal point to correct cataracts and provide distant

vision, enhances visual quality for patients with simple

myopia or hyperopia. However, spectacles should

be considered to correct residual astigmatism after

cataract surgery. A toric lens, on the other hand, has

a single focal point, and is designed to correct both

cataracts and pre-existing astigmatism. This lens not

only helps with distant vision, but also offers en-

hanced image quality, without the need for glasses

after surgery. A toric lens has two different powers

with curves at different angles. One curve is for astig-

matism and the other is for myopia or hyperopia.

However, toric lenses are expensive and not readily

available in all hospitals in developing countries such

as Thailand. Moreover, improper alignment or rota-

tion of the IOL after surgery may result in more

residual astigmatism than predicted. For every 1

degree the toric IOL axis is away from the true post-

operative axis of astigmatism, there will be a 3.3%

loss of toric correction1. Thus, the toric lens is still

not a popular choice for cataract surgery in mild

astigmatism.

Theoretically, small amounts of astigmatism can

be managed by placing the surgical wound to coin-

cide with the steep axis of astigmatism. Neverthe-

less, it may be difficult to operate along some axes,

particularly if a patient is relatively enophthalmic or

has a large brow or nose bridge. Surgeons frequently

choose a temporal corneal incision because it

provides better exposure to the surgical limbus, even

in deep-set eyes. Several studies recommend

that choosing the location of a corneal incision

based on preexisting astigmatism offers potential

benefit2,3. A clear corneal incision causes flattening

in the incised meridian (increasing the radius of cur-

vature) and steepening in the meridian 90 degrees

away2,4.

The effect of corneal incision to induce post-

operative astigmatic change between patients with

different severity of astigmatism has never been

concluded. In this study, we explored the effect of

corneal astigmatic change after putting corneal inci-

sions at the steep axis of astigmatism in patients

with preexisting astigmatism less than 1.5 diopter

(D) and those with astigmatism of 1.5 D or more.

Materials & MethodsPatients with visually significant cataract who

had cataract surgery at Golden Jubilee Medical Cen-

ter, Mahidol University, Thailand between July 2010

and June 2015 were included in this retrospective

cohort study. The study was approved by Mahidol

University Institutional Review Board. The patients

were given written informed consent of the plan,

consequences and risks of treatment.

88 Prakairut Thongphiew, Manassawee Joradoln, Rosanun Sikarinkul Vol. 30 No. 2 July-December 2016

We included patients who underwent phaco-

emulsification with foldable IOL insertion in capsular

bag and had a sutureless clear corneal incision. Pa-

tients who had a past history of intraocular surgery,

radial keratectomy, excimer laser to reshape cornea

or traumatic corneal laceration repair were excluded.

We also excluded patients with progressive increase

in corneal curvature, for example, keratoconus and

pellucid marginal degeneration, and those whose

curvature of cornea could not be measured. Patients

found to have phacodonesis or unstable capsule with

missing zonules and patients who had other simul-

taneous ocular operation with cataract extraction

procedure, such as pterygium excision, were also

excluded from the study population.

Preoperatively collected data included age,

gender, side, type of cataract, uncorrected visual acuity

(UCVA), best corrected visual acuity (BCVA) by Snellen

chart, corneal astigmatism covariates obtained from

Canon RK-F1 Autorefractor/Keratometer (Canon,

Tokyo, Japan) [refractive power, vertical component

of a vector (K1), horizontal component of a vector

(K2) and their axes], immersion A-scan, IOL power

(calculated by SRK-T formula5, aiming for a post-

operative refraction of -0.50 D), and fundoscopic

examination.

All operations were performed by the same

surgeon who is right-handed. Retrobulbar block and

a two-step, self-sealing clear corneal incision (3.0-

mm blade) were applied in all cases. The location of

corneal incision was based on pre-existing astigma-

tism, at the steepest axis. For an eye without astig-

matism (cylindrical power = 0 D), a corneal incision

was made at temporal site. After introduction of vis-

coelastic material into the anterior chamber, a 5-mm

capsulorhexis was made, followed by hydrodissection.

The phacoemulsifier machine, INFINITI˙ Vision Sys-

tem (Alcon, TX, USA) with the Ozil˙ torsional hand-

piece (Alcon, TX, USA), was applied to divide and

concur or phaco chop and aspirate cortical masses.

Acrysof˙ SN60WF IOL implant (Alcon, TX, USA) was

inserted. The corneal incision was left unsutured.

Postoperatively, patients were given 1% predniso-

lone acetate eye drops every hour, levofloxacin eye

drop qid, maxitrol ointment once a day, and the regi-

men was tapered over one months. Patients were

examined at one day, one week, one month and

three months postoperatively.

Postoperative data were collected at one month

and three months after surgery, including UCVA,

BCVA, corneal astigmatism covariates obtained from

Autorefractor/Keratometer (refractive power, K1/K2

and their axes), date of surgery, location of corneal

incision, and surgically induced astigmatism (SIA).

The corneal SIA was calculated by means of

vector analysis using the Holladay 10-step formula

on the basis of the results of topography. The

Microsoft Excel-based SIA Calculator software has

been obtained from https://sia-calculator.com6. This

program has been designed to calculate the amount

of SIA created during the cataract surgical proce-

dure. Information about date of surgery, age, eye

laterality, location and site of corneal incision, pre-

operative and postoperative K1, K2 and their axes

were input into the calculator program, and SIA mag-

nitude and axis were calculated.

The preoperative and postoperative astigma-

tism, K1, K2 and their axes were described in terms

of their median and inter-quartile range (IQR), and

compared using Wilcoxon sign-rank test. Patients

were then separated into two groups by severity of

preoperative astigmatism with the cut-off point at


the median astigmatism of the study cohort. Pa-

tients with cylindrical power of less than 1.50 D were

assigned into mild astigmatism group (Group 1), while

patients with cylindrical power of 1.50 D or more

were in severe astigmatism group (Group 2). The

difference of variables between both groups was

compared using Mann-Whitney test. The level of sig-

nificance at 0.05 was used. There was no missing

value of any variables included in the analyses. All

statistical analyses were performed using Stata˙ ver-

sion 11 (StataCorp, College Station, TX, USA).

ResultsThere were 70 cataract operations (32 on right

eyes and 38 on left eyes) in 50 patients included in

this study. Patients were divided into two groups:

Group 1 (mild astigmatism group) consisted of 30

eyes with cylindrical power of less than 1.50 D (right

eye, n=12; left eye, n=18); and Group 2 (severe astig-

matism group) contained 40 eyes with cylindrical

power of 1.50 D or more (right eye, n=20; left eye,

n=20). The median and IQR of preoperative astigma-

tism were 1.50 D (0.75 D to 2.25 D). At one month

and three months postoperatively, the median (IQR)

decreased to 1.25 D (0.75 D to 1.50 D) and 1.00 D

(0.75 D to 1.50 D), respectively (Figure 1). There was

a statistically significant difference between pre-

operative and postoperative astigmatism at both

one month (p<0.001) and three months (p<0.001).

Vector analyses of astigmatism showed that

there was no statistically significant difference in

the vertical component of astigmatism at one month

postoperative (p=0.09) and three months postopera-

tive (p=0.74). The median preoperative K1 was 44.87,

and postoperative K1 at one month and three months

were both 44.88 (Figure 2). There was also no sig-

nificant difference between preoperative and post-

operative horizontal component of astigmatism at

one month (p=0.39) and three months (p=0.12). The

median preoperative K2 was 43.75, and postopera-

tive K2 at one month and three months were both

43.94 (Figure 3).

The median and IQR of the magnitude of SIA

at one month and three months postoperatively were

0.60 D (0.38 D to 1.00 D) and 0.71 D (0.42 D to 1.10

D), respectively. The change in the axis of astigma-

tism at one month postoperatively was 99 degrees

(83 to 141), and that at three months postoperatively

was 99 degrees (86 to 138).

When performing subgroup analysis between

those with mild (<1.50 D) and severe astigmatism

(>1.50 D), we found a statistically significant diffe-

rence between preoperative and postoperative astig-

matism at one month (p<0.001) in the severe astig-

matism group. This difference between preoperative

and postoperative astigmatism remained statistically

significant at three months postoperatively (p<0.001).

The median preoperative astigmatism was 2.00 D,

while at one month after surgery, the median astig-

matism reduced to 1.50 D and remained at 1.50 D at

three months postoperatively. The medians of the

magnitude of SIA in this group were 0.67 D at one

month, and 0.78 D at three months after surgery.

On the contrary, in the mild astigmatism group,

there was no statistically significant difference be-

tween preoperative and postoperative astigmatism

at one month (p =0.97), or between preoperative and

postoperative astigmatism at three months (p=0.83).

All of the medians of preoperative and postoperative

astigmatism at both one month and three months

were 0.75 D in this group (Figure 4). The median SIA

magnitude in this group was 0.52 D at one month


Figure 1. Preoperative, 1-month and 3-month postoperative astigmatism (diopter)

Figure 2. Preoperative and postoperative vertical component (K1) of the vector analysis ofastigmatism


Figure 3. Preoperative and postoperative horizontal component (K2) of the vector analysis ofastigmatism

Figure 4. Preoperative and postoperative astigmatism (diopter) categorized by severity ofpreoperative astigmatism


postoperatively, and 0.55 D at three months postop-

eratively.

When comparing between the magnitude of

SIA between the two groups, there was a statisti-

cally significant difference of SIA at 3 month postop-

eratively (0.78 D vs. 0.55 D; p=0.005). However, there

was no significant difference of SIA at 1 month post-

operatively (0.67 D vs. 0.52 D; p=0.13).

There was no significant change in preopera-

tive and postoperative vertical (K1) and horizontal

(K2) components in both groups (all p-value>0.05).

In the mild astigmatism group, median preoperative,

1-month and 3-month postoperative K1 were 44.87,

44.63 and 44.5, respectively, and the corresponding

values for K2 were 43.88, 44.12 and 44.19, respec-

tively. For the severe astigmatism group, median

preoperative, 1-month and 3-month postoperative

K1 were 45.25, 45.31 and 45.38, respectively, and

those of K2 were 43.69, 43.94 and 43.94, respec-

tively.

DiscussionClear corneal incisions have been widely used

in cataract surgery because they can be self-resealed.

However, clear corneal incisions may affect the

curvature of cornea and cause surgically induced

astigmatism. There are many factors responsible for

surgically induced astigmatism such as the location

and type of cataract incision, size, configuration of

wound, suture material used, etc. Smaller size of

incision, self-sealing wound as well as locating the

incision as peripherally as possible to maximize the

distance from the optical centre of the cornea lead

to lesser astigmatism7. A temporal incision is advan-

tageous because it can be made easily in deep soc-

kets, small eyes or patients who have a large brow

or nose bridge. Among these mentioned factors, the

major factor responsible for post-operative astigma-

tism is the site of cataract incision4,8. An incision on

the corneal causes flattening in the incised axis and

steepening in the meridian 90 degrees away. There-

fore, placing an incision on the steep axis of pre-

existing astigmatism can increase the radius of

curvature and reduce pre-existing astigmatism4,9-11.

In this study, we showed that the technique of

putting a clear corneal incision on the steepest axis

decreased the magnitude of pre-existing astigma-

tism, particularly in patients with severe astigmatism

(1.5 D or more). This effect was observed at both

one month and three months postoperatively. In the

mild astigmatism group (less than 1.5 D), there was

almost no change in median of cylindrical power.

There was one eye with no astigmatism. In this par-

ticular patient, temporal corneal incision was done

and the SIA result was 0.13 D at 45 degree.

However, the vector analyses between preop-

erative and postoperative astigmatism did not find

any significant difference in both the vertical (K1),

and the horizontal (K2) components of astigmatism,

neither in the whole study cohort nor in both sub-

groups.

We demonstrated that creating a clear corneal

incision on the meridian of the steepest axis can

improve spherical and astigmatic outcome. Never-

theless, there were some minor difficulties to ope-

rate along some axes, especially in cases of enoph-

thalmos, large brow or nose bridge.

The efficiency in reducing astigmatism by

making incision on the steepest meridian has al-

ready been addressed in many previous studies2,9-12.

However, the astigmatism-reducing effects by inci-

sion on the steepest axis are not consistent, ranging


from 0.20 D to 0.80 D10,13,14. We hypothesized that the

effect would depend on the severity of astigmatism,

in particular, more significant in eyes with higher

degree of astigmatism. Some ophthalmologists pre-

fer incisions on the steepest axis for patients with

astigmatism of more than 1.50 D, and temporal or

superior incisions for patients with minor degree of

astigmatism (<1.50 D)9. In this study, we confirmed

that the implication of surgically induced astigma-

tism on reducing pre-existing astigmatism can be

used more effectively in patients with severe astig-

matism of more than 1.5 D.

We used a 3.0-mm blade for a clear corneal

incision, and this was found to produce higher SIA

than other previous reports that used a keratome

incision of 2.4-2.6 mm. Therefore, for larger amounts

of astigmatism, using a large wound size should

increase the SIA and may be advantageous if toric

lenses are not used.

An opposite clear corneal incision was pro-

posed by Lever and Dahan as making two clear

corneal incisions, one on the steepest axis and the

other on the opposite side (180o from the first inci-

sion)11. Mukherjee and Muhtaseb found that oppo-

site clear corneal incisions could reduce pre-existing

astigmatism more effectively than a single incision

at the steepest axis9. However, all patients in their

study had more than 1.50 D of preoperative astig-

matism.

Strength and limitationsThis is a retrospective study designed to eva-

luate the effect of a clear corneal incision on the

steepest axis on reducing pre-existing astigmatism

in different degrees of astigmatism. All operations

were performed by the same surgeon, thus the tech-

nique of the incision would be consistent.

Nevertheless, this study has some limitations.

We used a Canon RK-1 Autorefractor/ keratometer

to measure K-values and refraction. In some pa-

tients who had dense posterior subcapsular cataract

with severe visual impairment, the autorefractor/

keratometer might not measure K-values and refrac-

tion accurately because these patients could not focus

on a target in the measurement procedure. Only a

small area of the paracentral cornea (two points at

the 3-4 mm zone) could be measured, and it would

assume that the shape of the cornea is a symmetric

spherocylinder with a major and minor axis sepa-

rated by 90 degrees. The manual keratometry and

the rotating Scheimpflug photography system (Pen-

tacam) can provide accurate readings for most

patients even with severe visual impairment15,16.

Pentacam has also been the standard method for

determining astigmatism for IOL calculation17-20. The

use of the manual keratometry or Pentacam may

provide more accurate measurement in further study.

ConclusionIn conclusion, we showed that an incision on

the steepest axis of an eye with pre-existing astig-

matism can reduce astigmatism significantly in

severe astigmatism over 1.50 D. A clear corneal inci-

sion at the steepest axis is beneficial in patients with

severe astigmatism over 1.5 diopters who undergo a

cataract surgery and can be an alternative option if

toric lenses are not available.

AcknowledgementsThe authors would like to thank Dr. Chutwichai

Tovikkai for his kind help in statistical analysis and

proof reading the manuscript.


References1. Sanders DR, Grabow HB, Shepherd J. The toric IOL. In: Gills

JPE, Martin RGE, Sanders DRE, editors. Sutureless cataractsurgery: an evolution toward minimally invasive technique.Thorofare NJ; Slack; 1992. p. 183.

2. Tejedor J, Murube J. Choosing the location of corneal inci-sion based on preexisting astigmatism in phacoemulsification.Am J Ophthalmol 2005; 139: 767-76.

3. Nielsen PJ. Prospective evaluation of surgically induced astig-matism and astigmatic keratotomy effects of various self-sealing small incisions. J Cataract Refract Surg 1995; 21:43-8.

4. Vinay KV, Sudheendra AN, Vishal K, Beena DN. A study onsurgically induced astigmatism following small incision cata-ract surgery. Indian Journal of Fundamental and Applied LifeSciences. 2012; 2: 147-52.

5. Retzlaff JA, Sanders DR, Kraff MC. Development of the SRK/T intraocular lens implant power calculation formula. J Cata-ract Refract Surg 1990; 16: 333-40.

6. Surgically Induced Astigmatism (SIA) Calculator. Availableat: http://www.doctor-hill.com/iol-main/toric_sia_calculator.htm. Accessed 26 January 2014.

7. Archana S, Khurana AK, Chawla U. A comparative study ofsclero-corneal and clear corneal tunnel incision in manualsmall-incision cataract surgery. Nepal J Ophthalmol 2011; 3:19-22.

8. Altan-Yaycioglu R, Akova YA, Akca S, Gur S, Oktem C. Effecton astigmatism of the location of clear corneal incision inphacoemulsification of cataract. J Refract Surg 2007; 23:515-8.

9. Mukherjee A, Muhtaseb M. Opposite clear corneal incisionsfor astigmatism. Cataract and refractive surgery today Europe2008.

10. Gills JP. Treating astigmatism at the time of cataract surgery.Curr Opin Ophthalmol 2002; 13: 2-6.

11. Lever J, Dahan E. Opposite clear corneal incisions to correctpre-existing astigmatism in cataract surgery. J CataractRefract Surg 2000; 26: 803-5.

12. Tejedor J, Perez-Rodriguez JA. Astigmatic change induced

by 2.8-mm corneal incisions for cataract surgery. InvestOphthalmol Vis Sci 2009; 50: 989-94.

13. Susic N, Brajkovic J, Kalauz-Surac I. Analysis of postopera-tive corneal astigmatism after phacoemulsification through aclear corneal incision. Acta Clin Croat 2007; 46: 37-40.

14. Ben Simon GJ, Desatnik H. Correction of pre-existing astig-matism during cataract surgery: comparison between theeffects of opposite clear corneal incisions and a single clearcorneal incision. Graefes Arch Clin Exp Ophthalmol 2005;243: 321-6.

15. Mehran Taban, Ashley Behrens. Acute Endophthalmitis Fol-lowing Cataract Surgery: A Systematic Review of the Litera-ture. Arch Ophthalmol. 2005; 123: 613-20.

16. Chang M, Kang SY, Kim HM. Which keratometer is mostreliable for correcting astigmatism with toric intraocular lenses?Korean J Ophthalmol 2012; 26: 10-4.

17. Tejedor J, Guirao A. Diagnosis and Imaging of Corneal Astig-matism. In: Goggin M, editor. Astigmatism - Optics, Physio-logy and Management: Intech; 2012.

18. Yong Park C, Do JR, Chuck RS. Predicting postoperativeastigmatism using Scheimpflug keratometry (Pentacam) andautomated keratometry (IOLMaster). Curr Eye Res 2012; 37:1091-8.

19. Norrby S. Pentacam keratometry and IOL power calculation.J Cataract Refract Surg 2008; 34: 3; author reply 4.

20. Xu K, Hao Y, Qi H. Intraocular lens power calculations usinga Scheimpflug camera to measure corneal power. BiotechHistochem 2014; 89: 348-54.

21. Viteri E. Using the Pentacam for IOL Power Calculation. High-lights of Ophthalmology 2008; 36: 13.

22. Febbraro JL1, Koch DD. Detection of static cyclotorsion andcompensation for dynamic cyclotorsion in laser in situkeratomileusis. J Cataract Refract Surg. 2010; 36: 1718-23.

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95Thai J Ophthalmol Vol. 30 No. 2 July-December 2016

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Prevalence and associated factors for pterygiumat a tertiary referral center in Northern Thailand

Winai Chaidaroon, M.D.

Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai


Warangkhana Vichakutakul, M.D.

Abstract

Objective: This study aimed to evaluate the prevalence of pterygium and its associated factors in a univer-

sity-based referral center.

Methods: A cross-sectional descriptive study was conducted at the out-patient eye clinic at Chiang Mai

University hospital between May 2015 and May 2016. Subjects were patients of 30 years or older who were

diagnosed with pterygium by an ophthalmologist. Socio-demographic parameters including age, gender,

number of hours of sunlight exposure per day, and smoking status were included for analysis.

Results: This study comprised 391 eyes (0.97% of 40309 eyes presented at the clinic) diagnosed with

pterygium. Most patients with pterygium (35.04%) were between 50-59 years of age. Pterygium was asso-

ciated with female gender (207 eyes), right eye (223 eyes), nasal site (330 eyes), history of smoking (240

eyes), and duration of sunlight exposure for 6 hours or more per day (231 eyes).

Conclusion: Prevalence of pterygium in this study was 0.97%. Pterygium was related with increasing age,

female gender, right eye, nasal region, history of smoking, and long duration of sunlight exposure. Thai J

Ophthalmol 2016; July-December 30(2): 95-100.

Disclosure statement: None of the authors has any conflicts of interest concerning this research

97Prevalence and associated factors for pterygium at a tertiary referral center in Northern Thailand

IntroductionPterygium refers to the degeneration of the

conjunctiva and is mostly found among people in

tropical regions, especially those living closer to the

equator. Although the exact causes and mechanisms

of pterygium still remain unknown1,2, it is believed

that factors including age1,3,4, sunlight5,6, ultraviolet

radiation6, smoking7, and chronic irritation or dryness

of eyes usually cause this condition. Pterygium is a

triangular fibrovascular tissue that develops from the

bulbar conjunctiva and encroaches toward the cor-

nea. The blood vessels are raised and visible. Signs

and symptoms of pterygium depend on its severity.

An inflamed pterygium can cause swelling, irritation,

tearing, and redness. In advanced cases where the

tissue has invaded the pupil resulting in blurred

vision, surgical treatment may be required.

The aim of this study is to explore the preva-

lence and risk factors of pterygium in a university-

based referral center. The information may raise

awareness to prevent the risks of pterygium deve-

lopment.

MethodsA cross-sectional descriptive study was con-

ducted between May 2015 and May 2016. The study

population was out-patients aged 30 years or older

treated in Chiang Mai University hospital. Socio-

demographic variables including age, gender, num-

ber of hours of sunlight exposure, and smoking sta-

tus were considered for analysis. Patients diagnosed

with pterygium by ophthalmology residents or full-

time ophthalmologists underwent anterior segment

photography and complete eye examination. Patients

who could not undergo anterior segment photogra-

phy, patients below 30 years of age and patients

diagnosed with pinguecula were excluded from the

study. Patients were divided into five age groups

(30-39, 40-49, 50-59, 60-69, 70 years or older).

Laterality and location of pterygium were recorded.

ResultsThe numbers of eyes presented at the out-

patient eye clinic during May 2015 to May 2016 were

40309. Three hundred and ninety-one eyes (0.97%)

were diagnosed with pterygium. The number of pa-

tients divided by age groups of 30-39, 40-49, 50-59,

60-69, 70 years or older were 18, 52, 137, 123, 61,

respectively (Figure 1). Females had a higher preva-

lence than males (female 207 eyes, male 184 eyes).

Pterygium was presented in the right eye more than

the left eye (right eye 223 eyes, left eye 168 eyes).

The site of pterygium was nasal (Figure 2) in 330

eyes and temporal in 32 eyes. Twenty-nine eyes had

both nasal and temporal pterygium. One hundred

and fifty one subjects had no history of smoking and

240 subjects had a history of smoking. Patients who

had exposure to sunlight less than 6 hours per day

and 6 hours or more per day were 160 eyes and 231

eyes, respectively (Figure 3).

DiscussionThe prevalence of pterygium which presented

in a university-based referral center was 0.97%. Many

studies reported a wide range of the prevalence of

pterygium between 0.7% and 48%8-11. These varia-

tions may be caused by the cut-off age for ptery-

gium diagnosis and also the type of study such as

population or hospital-based data collection. The

results of our study indicate that pterygium is more

prevalent in elderly people than in younger people.

Also, it more often affects the right eye than the left

98 Winai Chaidaroon, Warangkhana Vichakutakul Vol. 30 No. 2 July-December 2016

Figure 2. Nasal pterygium in left eye

Figure 1. Prevalence of pterygium classified by age

99Prevalence and associated factors for pterygium at a tertiary referral center in Northern Thailand

eye. Interestingly, we have not found bilateral ptery-

gium. Although the exact reason is unknown and no

other studies have investigated this, nasal pterygium

is the most common location found among the sub-

jects of the study. It has also been observed that

smoking subjects are more likely to develop ptery-

gium than non-smoking subjects. This result was

different from study of Rong et al 7. However, it may

depend on the definition of smoking which varies

from study to study. Patients who were exposed to

sunlight more than 6 hours per day had a greater

risk of pterygium than those who had less than 6

hours of sunlight exposure. This result is consistent

with other studies as it is a known fact that ultravio-

let is a major factor in causing pterygium6. Since

most patients presented at our out-patient eye clinic

had worked in agricultural sectors, they are inevita-

bly exposed to direct sunlight.

This study has some limitations. Firstly, the re-

search was set up as a university-based study which

may be potentially biased compared to a popula-

tion-based study. Secondly, because this is a cross

sectional study, it did not allow identification of a

long-term association between pterygium and age

and other parameters.

ConclusionPrevalence of pterygium in this study was

0.97%. Pterygium was related to increasing age,

female gender, right eye, nasal region, history of smok-

ing, and sunlight exposure. This information may raise

awareness to avoid the preventable risks of ptery-

gium development and progression.

AcknowledgementsThe authors gratefully acknowledge Dr. Atcha-

reeya Wiwatwongwana, MD. for reviewing the Eng-

lish manuscript and Miss Kittika Kanjanaratanakon,

MSc. (Statistics) for assisting in the statistical analy-

sis.

Figure 3. Associated factors related to pterygium

100 Winai Chaidaroon, Warangkhana Vichakutakul Vol. 30 No. 2 July-December 2016

References1. Turgut FG, Helvacioglu F. Incidence of pterygium in patients

admitted to a university hospital. J Clin Exp Invest 2013;4:436-42.

2. Zhao L, You QS, Xu L, Ma K,Wang YX, Yang H, et al. 10-yearincidence and associations of pterygium in adult Chinese:the Beijing Eye Study. Invest Ophthalmol Vis Sci 2013; 54:1509-14.

3. Alqahtani JM. The prevalence of pterygium in Alkhobar:A hospital-based study. J Family Community Med 2013; 20:159-61.

4. Zhong H, Cha X, Wei T, Lin X, Li X, Li J, et al. Prevalence ofand risk factors for pterygium in rural adult Chinese popula-tions of the Bai nationality in Dali: the Yunnan Minority EyeStudy. Invest Ophthalmol Vis Sci 2012; 53:6617-21.

5. Tano T, Ono K, Hiratsuka Y, Otani K, Sekiguchi M, Konno S,et al. Prevalence of pterygium in a population in NorthernJapan: the Locomotive Syndrome and Health Outcome inAizu Cohort Study. Acta Ophthalmol 2013; 91:232-6.

6. Nangia V, Jonas JB, Nair D, Saini N, Nangia P, Panda-JonasS. Prevalence and associated factors for pterygium in ruralagrarian central India. The central India eye and medicalstudy. PLoS One 2013; 8:e82439.

7. Rong SS, Peng Y, Liang YB, Cao D, Jhanji V. Does cigarettesmoking alter the risk of pterygium? A systematic review andmeta-analysis. Invest Ophthalmol Vis Sci 2014; 55:6235-43.

8. Norn MS. Prevalence of pinguecula in Greenland and inCopenhagen, and its relation to pterygium and spheroiddegeneration. Acta Ophthalmol (Copenh) 1979; 57:96-105.

9. Liang QF, Xu L, Jin XY, You QS, Yang XH, Cui TT. Epidemiol-ogy of pterygium in aged rural population of Beijing, China.Chin Med J (Engl) 2010; 123:1699-701.

10. Panchapakesan J, Hourihan F, Mitchell P. Prevalence of ptery-gium and pinguecula: the Blue Mountains Eye Study. Aust NZ J Ophthalmol 1998; 26:S2-5.

11. Viso E. Gude F, Rodriguez-Ares MT. Prevalence of pingueculaand pterygium in a general population in Spain. Eye (Lond)2011; 25;350-7.


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·∑√°´âÕπ ¥—ßπ—Èπ «‘∏’°“√©’¥ ·≈–Õÿª°√≥å°“√©’¥®÷ß¡—°‰¡à‰¥â

¡’°“√®¥∫—π∑÷°‰«â

™π‘¥¢Õß “√‡μ‘¡‡μÁ¡ “√‡μ‘¡‡μÁ¡ (filler) §◊Õ “√∑’Ë„™â©’¥‡æ◊ËÕ‡μ‘¡À√◊Õ‡ √‘¡

„π™—Èπº‘«Àπ—ßÀ√◊Õ„μâ®“°º‘«Àπ—ß ‡æ◊ËÕ™à«¬≈¥ ·°â ‰¢ À√◊Õ

≈∫‡≈◊Õπªí≠À“∫“ßª√–°“√¢Õßº‘«Àπ—ß‡™àπ √Õ¬¬àπ®“°«—¬

√Õ¬¬àπ∑’Ë‡°‘¥®“°· ß·¥¥ ·º≈‡ªìπ™π‘¥À≈ÿ¡ À√◊Õ‡ √‘¡„π

∫√‘‡«≥∑’Ë¢“¥‡™àπ √àÕß·°â¡ √‘¡Ωïª“° §“ß ·≈–®¡Ÿ° ‡ªìπμâπ

102 ∞‘μ‘≠“¿√≥å æπ“«—≤π«ß»å Vol. 30 No. 2 July-December 2016

“√‡μ‘¡‡μÁ¡ “¡“√∂·∫àß‰¥âÀ≈“¬·∫∫

·∫∫·√° ·∫àßμ“¡·À≈àß∑’Ë¡“¢Õß “√ ÕÕ°‡ªìπ 3 °≈ÿà¡

§◊Õ “√®“°¡πÿ…¬å ‡™àπ autologous fat, “√®“° —μ«å ·≈–

“√ —ß‡§√“–Àå

·∫∫∑’Ë Õß “√‡μ‘¡‡μÁ¡·∫àßμ“¡√–¬–‡«≈“°“√ ≈“¬

¢Õß “√„π√à“ß°“¬ ·∫àß¬àÕ¬ÕÕ°‡ªìπ 3 °≈ÿà¡‰¥â·°à

°≈ÿà¡∑’Ë 1 “√ —ß‡§√“–Àå·∫∫™—Ë«§√“« (temporary

filler) ¢âÕ¥’§◊Õ‡ªìπ “√ —ß‡§√“–Àå∑’Ë‡≈’¬π·∫∫ “√„π√à“ß°“¬

μ—« “√ ≈“¬À¡¥‰¡à‡À≈◊Õ‡ªìπ ‘Ëß·ª≈°ª≈Õ¡μ°§“ß Õ¬Ÿà‰¥â

π“πª√–¡“≥ 6 ‡¥◊Õπ ¢âÕ®”°—¥§◊Õ‰¡à‰¥âº≈∂“«√ ‡™àπ

- §Õ≈≈“‡®π (collagen) ‡ªìπ “√∏√√¡™“μ‘∑’Ë °—¥

®“°§Õ≈≈“‡®π¢Õß«—« ¡’‚Õ°“ ·æâª√–¡“≥‹√âÕ¬≈– 3-5

- Hyaluronic acid À√◊Õ hyalluran ‡ªìπ “√

∏√√¡™“μ‘∑’Ë ‰¥â®“°°“√À¡—°¢Õß‡™◊ÈÕ‚√§ Streptococcus

°—¥®π‰¥â “√∑’Ë‡À¡◊Õπ “√„π√à“ß°“¬¡πÿ…¬å

°≈ÿà¡∑’Ë 2 “√ —ß‡§√“–Àå°÷Ëß∂“«√ (semi permanent

filler) μ“¡À≈—°°“√∂◊Õ«à“μ—« “√®– ≈“¬‰¥âÀ¡¥·μàÕ¬Ÿà„π

√à“ß°“¬‰¥âπ“π°«à“°≈ÿà¡·√° ‚¥¬Õ¬Ÿà‰¥â∂÷ßª√–¡“≥ 1 ªï

°≈ÿà¡∑’Ë 3 “√ —ß‡§√“–Àå‰¡à ≈“¬ (permanent filler)

‡™àπ ´‘≈‘‚§π À√◊Õæ“√“øîπ ∂◊Õ‡ªìπ “√·ª≈°ª≈Õ¡ ‡¡◊ËÕ©’¥

‡¢â“√à“ß°“¬·≈â« ¡’Õ“¬ÿ°“√„™âß“πª√–¡“≥ 2 ªï ‡¡◊ËÕ‡«≈“ºà“π

‰ª “√°≈ÿà¡π’È®–‰À≈‰ª∑’Ëμà“ßÊ μ“¡·√ß‚πâ¡∂à«ß¢Õß‚≈°

´÷Ëß¬“°μàÕ°“√·°â ‰¢ “√„π°≈ÿà¡π’È¬—ß‰¡à‰¥â√—∫°“√√—∫√Õß®“°

”π—°§≥–°√√¡°“√Õ“À“√·≈–¬“ª√–‡∑»‰∑¬ μ“¡À≈—°

°“√∂◊Õ‡ªìπ¢âÕÀâ“¡„π°“√©’¥‡¢â“„π√à“ß°“¬¡πÿ…¬å4

„πª√–‡∑»‰∑¬‰¥â®—¥ª√–‡¿∑¢Õß “√‡μ‘¡‡μÁ¡‰«â‡ªìπ

¬“ °“√π”‡¢â“μâÕßºà“π°“√¢÷Èπ∑–‡∫’¬π°—∫ ”π—°¬“ ”π—°

§≥–°√√¡°“√Õ“À“√·≈–¬“ (Õ¬.)

°“√‡μ‘¡‡μÁ¡º‘«¥â«¬‰¢¡—πμ—«‡Õß (autologous fat)

´÷Ëß‰¥â®“°°“√¥Ÿ¥‰¢¡—π∫√‘‡«≥Àπâ“∑âÕßÀ√◊Õμâπ¢“ ‡ªìπ∑“ß

‡≈◊Õ°∑’Ë‰¥â√—∫§«“¡π‘¬¡Õ¬à“ß¡“°„π°“√≈¥√‘È«√Õ¬„Àâ¥Ÿμ◊Èπ¢÷Èπ

∫π„∫Àπâ“À√◊Õ∫√‘‡«≥Õ◊ËπÊ ‡æ√“–Õ¬Ÿà‰¥âπ“π∂÷ßª√–¡“≥ 3

ªï ∑—Èß¬—ßª≈Õ¥¿—¬‡æ√“–‡ªìπ “√∏√√¡™“μ‘·≈–‰¡à°àÕ„Àâ‡°‘¥

Õ“°“√·æâ‡´≈≈å‰¢¡—π®“°√à“ß°“¬μ—«‡Õß∑’Ëπ”¡“©’¥ ÷Ëß‡ªìπ

«‘∏’∑’Ë„™â∫àÕ¬∑’Ë ÿ¥„π°“√‡μ‘¡‡μÁ¡√àÕß√‘È«√Õ¬∫π„∫Àπâ“ ·≈–

√Õ¬®“°°“√¢¡«¥§‘È«

“√∑’Ë‡ªìπ∑’Ëπ‘¬¡√Õß≈ß¡“ ·≈–‰¥â√—∫§«“¡π‘¬¡‡æ‘Ë¡

¢÷Èπμ“¡‡«≈“§◊Õ hyaluronic acid ´÷Ëß‡ªìπ “√ —ß‡§√“–Àå

¡’∑—Èß∑’Ëª√–°Õ∫¥â«¬ à«πª√–°Õ∫®“°§π‡∑à“π—Èπ À√◊Õ¡’

“√ª√–°Õ∫®“° —μ«åº ¡ ¡’¢π“¥‚¡‡≈°ÿ≈‡≈Á° 400-750

‰¡§√Õπ ‡¡◊ËÕ‡∑’¬∫°—∫ autologous fat ÷Ëß¡’¢π“¥‚¡‡≈°ÿ≈

„À≠à°«à“∂÷ß 0.1-0.3 mL4

≈—°…≥–∑“ß°“¬«‘¿“§¢ÕßÀ≈Õ¥‡≈◊Õ¥∫π„∫Àπâ“·≈–‡∫â“μ“

‡≈◊Õ¥∑’Ë¡“‡≈’È¬ßº‘«Àπ—ß„∫Àπâ“ à«π„À≠à‰¥â¡“°®“°

À≈Õ¥‡≈◊Õ¥·¥ß external carotid ¬°‡«âπ ∫√‘‡«≥‡ª≈◊Õ°μ“

¥—Èß®¡Ÿ° ·≈–Àπâ“º“°‰¥â√—∫‡≈◊Õ¥®“°À≈Õ¥‡≈◊Õ¥·¥ß oph-

thalmic ´÷Ëß‡ªìπ·¢πß®“°À≈Õ¥‡≈◊Õ¥·¥ß internal carotid

·≈–·μ°·¢πßÕÕ°¡“‡≈’È¬ß™—Èπº‘«Àπ—ß·≈–‡π◊ÈÕ‡¬◊ËÕ√Õ∫‡∫â“μ“

¥â«¬À≈Õ¥‡≈◊Õ¥·¥ß supraorbital, supratrochlear, dor-

sal nasal ·≈– lacrimal (√Ÿª∑’Ë 1)

À≈Õ¥‡≈◊Õ¥·¥ß facial ÷Ëß‡ªìπ·¢πß®“°À≈Õ¥‡≈◊Õ¥

·¥ß external carotid ‡≈’È¬ßº‘«Àπ—ß„∫Àπâ“ μ—Èß·μà∫√‘‡«≥

§“ß¢÷Èπ¡“ ®π∂÷ß∫√‘‡«≥®¡Ÿ° ‚¥¬·μ° “¢“‡ªìπÀ≈Õ¥‡≈◊Õ¥

·¥ß inferior ·≈– superior labial, lateral nasal ·≈–

°≈“¬‡ªìπÀ≈Õ¥‡≈◊Õ¥·¥ß angular ∑’Ë∫√‘‡«≥√àÕß·°â¡„°≈â

ªï°®¡Ÿ°

√–∫∫‡≈◊Õ¥®“° internal carotid ·≈– external

carotid ¡’§«“¡À≈“°À≈“¬„π√Ÿª·∫∫°“√‡™◊ËÕ¡°—π (anas-

tamosis) Õ¬à“ß¡“° ∫π„∫Àπâ“√Õ∫‡∫â“μ“ Àπâ“º“° ·≈–

®¡Ÿ°

°≈‰°°“√‡°‘¥°“√Õÿ¥μ—π¢ÕßÀ≈Õ¥‡≈◊Õ¥®“°°“√©’¥ “√‡μ‘¡‡μÁ¡

°“√©’¥ “√‡μ‘¡‡μÁ¡‡¢â“À≈Õ¥‡≈◊Õ¥ (intravascular

injection) ·≈–‰À≈¬âÕπ‰ª Ÿà‡ âπ∑’Ë‡≈’È¬ßÕ«—¬«– à«π∑’Ë≈÷° (re-

trograde embolization of the filler)5

·¡â«à“À≈Õ¥‡≈◊Õ¥ à«πª≈“¬∫√‘‡«≥∑’Ë©’¥¬“®–¡’¢π“¥

‡≈Á°≈ß‡√◊ËÕ¬Ê ‡¡◊ËÕ¡“‡≈’È¬ß∫√‘‡«≥º‘«Àπ—ß ·≈–¿“¬„πÀ≈Õ¥

‡≈◊Õ¥·¥ßπ—Èπ¡’§«“¡¥—π‡≈◊Õ¥∑’Ë Ÿß°Áμ“¡ ·μà°Á¬—ßæ∫«à“ª≈“¬

‡¢Á¡ ∑—Èß·∫∫§¡À√◊Õ∑◊ËÕ Õ“®¡’°“√·∑ß‡¢â“‰ª·¢πßÀ≈Õ¥‡≈◊Õ¥

103¿“«–·∑√° âÕπÀ≈Õ¥‡≈◊Õ¥·¥ß¢Õß®Õμ“Õÿ¥μ—πÀ≈—ß°“√©’¥ “√‡μ‘¡‡μÁ¡

‚¥¬∫—ß‡Õ‘≠ ·≈–‡¡◊ËÕ‰¥â√—∫°“√©’¥¥â«¬§«“¡·√ß·≈–ª√‘¡“≥

¡“°„π§√“«‡¥’¬«°—π Õ“®∑”„Àâ “√‡μ‘¡‡μÁ¡∫“ß à«πÀ≈ÿ¥‡¢â“

‰ª„π·¢πßÀ≈Õ¥‡≈◊Õ¥ ·≈–‰À≈¬âÕπ°≈—∫‰ª¬—ßÀ≈Õ¥‡≈◊Õ¥

à«πμâπ‰¥â ‡¡◊ËÕÀ¬ÿ¥©’¥ “√‡μ‘¡‡μÁ¡´÷ËßÀ≈ÿ¥‡¢â“‰ª„πÀ≈Õ¥‡≈◊Õ¥

à«πμâπ·≈â« ·√ß¥—π¿“¬„πÀ≈Õ¥‡≈◊Õ¥·¥ß®–æ“ “√‡μ‘¡‡μÁ¡

¬âÕπÕÕ°¡“ ÷Ëßπ”‰ª Ÿà°“√Õÿ¥μ—π¢ÕßÀ≈Õ¥‡≈◊Õ¥·¥ß à«π

ª≈“¬‰¥âÕ’°À≈“¬ “¢“ √“¬ß“π à«π„À≠à√“¬ß“π°“√‡°‘¥

¿“«–·∑√° âÕπ®“° “√‡μ‘¡‡μÁ¡·¡â©’¥„πª√‘¡“≥‡æ’¬ß‡≈Á°

πâÕ¬ (0.5 ´’´’ À√◊ÕπâÕ¬°«à“)5 Yong-Kyu Kim ‰¥â√“¬ß“π

∑’Ë “√‡μ‘¡‡μÁ¡∑’ËÀ≈ÿ¥‡¢â“‰ª„π‡ âπ‡≈◊Õ¥ ·≈–∑”„Àâ‡°‘¥°“√

Õÿ¥μ—π∂÷ßÀ≈Õ¥‡≈◊Õ¥·¥ß internal carotic ®“°π—Èπ “√

‡μ‘¡‡μÁ¡≈Õ¬‡¢â“ Ÿà ¡Õß·≈–Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥ ¡Õß‡ªìπº≈

„Àâ‡°‘¥Õ—¡æ“μμ“¡¡“6,10 À≈Õ¥‡≈◊Õ¥·¥ß ophthalmic ¡’

·¢πßÕÕ°¡“‡≈’È¬ß‡π◊ÈÕ‡¬◊ËÕ·≈–º‘«Àπ—ß√Õ∫¥«ßμ“ √«¡∂÷ß

‡ª≈◊Õ°μ“ „°≈â°—∫∫√‘‡«≥Àπâ“º“°·≈–®¡Ÿ° ‰¥â·°à À≈Õ¥‡≈◊Õ¥

·¥ß supraorbital, supratrochlear ·≈– dorsal nasal

√«¡∂÷ß·¢πßΩÕ¬∑’Ë¡’°“√‡™◊ËÕ¡°—π°—∫·¢πßÀ≈Õ¥‡≈◊Õ¥¢Õß

„∫Àπâ“ ·≈– à«π≈÷°„Àâ·¢πß‡ªìπÀ≈Õ¥‡≈◊Õ¥·¥ß posterior

ciliary ·≈–À≈Õ¥‡≈◊Õ¥·¥ß central retinal ÷ËßÀ“°‡°‘¥°“√

Õÿ¥μ—π ®–°àÕ„Àâ‡°‘¥¿“«–·∑√°´âÕπμàÕ°“√¡Õß‡ÀÁπ ∂÷ß¢—Èπ

μ“∫Õ¥‰¥â7

®“°√Ÿª∑’Ë 2 · ¥ß “√‡μ‘¡‡μÁ¡ ( “√ ’‡À≈◊Õß„πÀ≈Õ¥

‡≈◊Õ¥·¥ß) ´÷Ëß —ππ‘…∞“π«à“‰À≈¬âÕπ‡¢â“ ŸàÀ≈Õ¥‡≈◊Õ¥·¥ß

ophthalmic ºà“π∑“ßÀ≈Õ¥‡≈◊Õ¥·¥ß suprotrochlear,

supraorbital À√◊Õ dorsal nasal. °“√Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥·¥ß

ophthalmic (ophthalmic artery occlusiosn; OAO) πà“

®–‡°‘¥®“°°“√Õÿ¥μ—π¥â«¬ “√‡μ‘¡‡μÁ¡ª√‘¡“≥¡“°¥â«¬·√ß©’¥

Ÿß πÕ°®“°π’È‡»…¢Õß “√‡μ‘¡‡μÁ¡Õ“®®–‰À≈¬âÕπ‡¢â“ Ÿà

À≈Õ¥‡≈◊Õ¥·¥ß posterior ciliary ·≈–∑”„Àâ‡°‘¥°“√Õÿ¥μ—π

¢Õß·¢πßÀ≈Õ¥‡≈◊Õ¥·¥ß posterior ciliary ∑—ÈßÀ¡¥∑ÿ°·¢πß

(generalized posterior ciliary artery occlusion; GPCAO)

À√◊Õ∫“ß·¢πß (localized posterior ciliary artery occlu-

sion; LPCAO) πÕ°®“°π’È ¬—ßÕÿ¥μ—π„πÀ≈Õ¥‡≈◊Õ¥·¥ß∑’Ë‡≈’È¬ß

®Õμ“ (central retinal artery occlusion; CRAO) À√◊Õ

√Ÿª∑’Ë 1 ≈—°…≥–∑“ß°“¬¿“æ¢ÕßÀ≈Õ¥‡≈◊Õ¥∫π„∫Àπâ“ (®“° Carruthers JD Blindness caused by cosmetic filler injection:a review of cause and therapy. Plast Reconst Surg 2014;134:1197-201) (√Ÿª ’∑â“¬‡≈à¡)


·¢πß¢ÕßÀ≈Õ¥‡≈◊Õ¥·¥ß∑’Ë‡≈’È¬ß®Õμ“‰¥â (branch retinal

artery occlusion; BRAO) „π à«π°≈‰°°“√‡°‘¥¿“«–¢“¥

‡≈◊Õ¥¢Õß¢—È«ª√– “∑μ“∑“ß à«πÀ≈—ß (posterior ischemic

optic neuropathy; PION) π—Èπ¬—ß‰¡à¡’§”Õ∏‘∫“¬‰¥â™—¥‡®π

‚¥¬ —ππ‘…∞“π«à“ °≈ÿà¡·¢πßÀ≈Õ¥‡≈◊Õ¥·¥ß pia (pial

plexus) ÷Ëß à«π„À≠à‰¥â√—∫‡≈◊Õ¥¡“®“°À≈Õ¥‡≈◊Õ¥·¥ß oph-

thalmic ‡¡◊ËÕ‡°‘¥°“√Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥·¥ß ophthalmic ®–

‡ªìπ “‡Àμÿ„Àâ‡≈◊Õ¥‰ª‡≈’È¬ß°≈ÿà¡·¢πßÀ≈Õ¥‡≈◊Õ¥·¥ß pia

‰¡à‡æ’¬ßæÕ ‡¡◊ËÕ “√‡μ‘¡‡μÁ¡‰À≈¬âÕπ‡¢â“‰ª∂÷ßÀ≈Õ¥‡≈◊Õ¥·¥ß

internal carotid Õ“®¡’∫“ß à«π‰À≈¢÷Èπ‰ªÕÿ¥μ—π∑’ËÀ≈Õ¥‡≈◊Õ¥

¡Õß®π‡°‘¥¿“«– ¡Õß¢“¥‡≈◊Õ¥‰¥â (brain infarction)

°“√‡°‘¥°“√Õÿ¥μ—π¢ÕßÀ≈Õ¥‡≈◊Õ¥®“°°“√©’¥ “√‡μ‘¡‡μÁ¡„πμ”·Àπàßμà“ßÊ

°“√©’¥ “√‡μ‘¡‡μÁ¡∫√‘‡«≥Àπâ“º“°·≈–À«à“ß§‘È« ‡°‘¥

¿“«–·∑√°´âÕπ‰¥â®“°À≈Õ¥‡≈◊Õ¥·¥ß supratrochlear ·≈–

supraorbital ÷ËßÀ“° “√‡¢â“À≈Õ¥‡≈◊Õ¥‡À≈à“π’È®–‰À≈¬âÕπ

‡¢â“‰ª ŸàÀ≈Õ¥‡≈◊Õ¥·¥ß ophthalmic ‰¥â À≈Õ¥‡≈◊Õ¥·¥ß

supratrochlear μ”·Àπàßª√–¡“≥ 5 ¡¡.®“° medial ¡’

∑“ß‡¥‘π¢ÕßÀ≈Õ¥‡≈◊Õ¥¢÷Èπ ŸàÀπâ“º“° À≈Õ¥‡≈◊Õ¥·¥ß supra-

orbital μ”·Àπàßμ√ß°—∫ medial limbus ¢Õß cornea ‚¥¬

¡’∑“ß‡¥‘π¢÷Èπ ŸßÀπâ“º“° ·≈–À≈Õ¥‡≈◊Õ¥∑—Èß Õß®–Õ¬Ÿàμ◊Èπ

„πμ”·Àπàßª√–¡“≥‹ 15-25 ´¡. ‡Àπ◊Õ supraorbital rim

√Ÿª∑’Ë 2 · ¥ßÀ≈Õ¥‡≈◊Õ¥·¥ß ophthalmic ·≈– “¢“ √«¡∂÷ßμ”·Àπàß∑’Ë‡°‘¥°“√Õÿ¥μ—π‰¥â (®“° Kyu Hyung P. Iatrogenic Occlu-sion of the Ophthalmic Artery After Cosmetic Facial Filler Injections A National Survey by the KoreanRetina Society. JAMA Ophthalmol. 2014;132(6):714-723) (√Ÿª ’∑â“¬‡≈à¡)


°“√©’¥ “√‡μ‘¡‡μÁ¡∫√‘‡«≥®¡Ÿ° ‡°‘¥¿“«–·∑√° âÕπ

‰¥â®“°À≈Õ¥‡≈◊Õ¥·¥ß lateral nasal ∑’Ë∫√‘‡«≥ª≈“¬®¡Ÿ°,

À≈Õ¥‡≈◊Õ¥·¥ß dorsal nasal ∑’Ë∫√‘‡«≥¥—Èß 5 ¡¡.‡Àπ◊Õ

medial canthal horizontal line ·≈–√Ÿª·∫∫°“√‡™◊ËÕ¡°—π

(anastomos) √Õ∫Ê ´÷Ëß¡’Õ¬ŸàÕ¬à“ßÀπ“·πàπ

°“√©’¥ “√‡μ‘¡‡μÁ¡∫√‘‡«≥√àÕß·°â¡·≈–√Õ∫¥«ßμ“

‡°‘¥¿“«–·∑√°´âÕπ‰¥â®“°À≈Õ¥‡≈◊Õ¥·¥ß angular ´÷Ëß¡’

§«“¡À≈“°À≈“¬¡“° („π∫“ß√“¬ß“πæ∫«à“‡ªìπ·¢πß®“°

À≈Õ¥‡≈◊Õ¥·¥ß ophthalmic, lacrimal ·≈– infraorbital)

°“√©’¥ “√‡μ‘¡‡μÁ¡∫√‘‡«≥¢¡—∫ ‡°‘¥¿“«–·∑√°´âÕπ

‰¥â®“°À≈Õ¥‡≈◊Õ¥·¥ß superficial temporal ÷Ëß¡’§«“¡

À≈“°À≈“¬¡“°·≈–¡’√Ÿª·∫∫°“√‡™◊ËÕ¡°—π °—∫À≈Õ¥‡≈◊Õ¥

·¥ß supraorbital, supratrochlear ∫√‘‡«≥ Àπ—ß»’√…–

πÕ°®“°π’È¬—ßæ∫«à“°“√©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥” middle tem-

poral ∑”„Àâ “√‡μ‘¡‡μÁ¡À≈ÿ¥‡¢â“‰ª‡°‘¥°“√Õÿ¥μ—π„π caver-

nous sinus ºà“π∑“ßÀ≈Õ¥‡≈◊Õ¥¥” periorbital ‰¥â

°“√©’¥ “√‡μ‘¡‡μÁ¡∫√‘‡«≥‡ª≈◊Õ°μ“ ‡°‘¥¿“«–·∑√°

´âÕπ‰¥â®“°À≈Õ¥‡≈◊Õ¥·¥ß medial, lateral palpebral ´÷Ëß

‡ªìπ·¢πß®“°À≈“¬À≈Õ¥‡≈◊Õ¥‰¥â·°à ophthalmic, facial,

superficial temporal, ·≈– infraorbital ‚¥¬¡’√Ÿª·∫∫

°“√‡™◊ËÕ¡°—πÕ¬à“ßÀπ“·πàπ‚¥¬√Õ∫

Õ“°“√· ¥ß‡¡◊ËÕ‡°‘¥¿“«–·∑√°´âÕπ∑“ßμ“‡¡◊ËÕ¡’¿“«–∑’Ë “√‡μ‘¡‡μÁ¡‡¢â“ ŸàÀ≈Õ¥‡≈◊Õ¥·≈–‡°‘¥°“√

Õÿ¥μ—π ºŸâ ‰¥â√—∫°“√©’¥ “√¡—°¡’Õ“°“√ μ“¡—« ª«¥μ“ ª«¥»’√…–

∑—π∑’À≈—ß‰¥â√—∫°“√©’¥ “√ Õ“°“√μ“¡—« ¡’√“¬ß“π‰«âμ—Èß·μà

√–¥—∫°“√¡Õß‡ÀÁπ 20/20 ‰ª®π∂÷ß no light perception

Õ“°“√· ¥ßÕ◊Ëπ‰¥â·°à §≈◊Ëπ‰ âÕ“‡®’¬π §«“¡¥—π≈Ÿ°μ“ Ÿß¢÷Èπ

√Ÿª∑’Ë 3 μ”·Àπàßμà“ßÊ ¢Õß°“√©’¥ “√ filler ∫π„∫Àπâ“ ‰¥â·°à μ”·Àπàß®ÿ¥ ’ â¡ ·°â√‘È«√Õ¬∑’ËÀπâ“º“°,μ”·Àπàß®ÿ¥ ’·¥ß ·°â√‘È«√Õ¬∑’ËÀ—«§‘È«, μ”·Àπàß®ÿ¥ ’‡À≈◊Õß ·°â√‘È«√Õ¬∑’Ë‡ª≈◊Õ°μ“, μ”·Àπàß®ÿ¥ ’™¡æŸ ·°â√‘È«√Õ¬μ’π°“, μ”·Àπàß®ÿ¥ ’‡¢’¬«ÕàÕπ ·°â√‘È«√Õ¬∑’Ë‡ª≈◊Õ°μ“≈à“ß, μ”·Àπàß®ÿ¥ ’‡¢’¬«‡¢â¡ ·°â ‰¢·°â¡À¬àÕπ§≈âÕ¬, μ”·Àπàß®ÿ¥ ’πÈ”‡ß‘π ‡ √‘¡®¡Ÿ°, μ”·Àπàß®ÿ¥ ’øÑ“‡μ‘¡√àÕß·°â¡, μ”·Àπàß®ÿ¥ ’πÈ”‡ß‘π‡¢â¡ ‡μ‘¡ª“°„ÀâÕ«∫Õ‘Ë¡, μ”·Àπàß®ÿ¥ ’‡∑“ ·°â ‰¢√Õ¬¬àπ ∑’Ë§“ß ·≈–μ”·Àπàß®ÿ¥ ’¥”ª√—∫√ŸªÀπâ“„ÀâÕ«∫Õ‘Ë¡ (From ; Avoiding and Treating Blindness from filler: A review of the world literature. KatieB. Dermatol surg 2015;41L1097-1117) (√Ÿª ’∑â“¬‡≈à¡)


μ“‡À≈à °≈Õ°μ“‰¡à ÿ¥„πÀ≈“¬∑‘»∑“ß‰ª®π∂÷ß°≈Õ°μ“‰¡à‰¥â

‡ª≈◊Õ°μ“μ° Õ“®¡’°“√‡ª≈’Ë¬π ’¢Õßº‘«Àπ—ß‡ªìπ reticular

pattern ‰ª®π∂÷ßº‘«Àπ—ßμ“¬∫√‘‡«≥∑’Ë‡≈’È¬ß¥â«¬À≈Õ¥‡≈◊Õ¥

∑’Ë∂Ÿ°Õÿ¥μ—π2

™π‘¥¢Õß “√‡μ‘¡‡μÁ¡∑’Ëæ∫¿“«–·∑√° âÕπ∑“ßμ“

∫àÕ¬∑’Ë ÿ¥§◊Õ autologous fat ‡π◊ËÕß¡“®“°°“√©’¥μâÕß„™â

ª√‘¡“≥¡“° μ—Èß·μà 2-20 mL ‚¥¬„™â‡¢Á¡„À≠à‡∫Õ√å 23 ∂÷ß

12 guage „™â syringe „À≠à ¢π“¥‚¡‡≈°ÿ≈À≈“°À≈“¬ ·≈–

¬—ß‰¡à¡’¢âÕμ°≈ß∂÷ß‡∑§π‘§°“√©’¥ “√∑’Ëª≈Õ¥¿—¬ æ∫√“¬ß“π

°“√‡°‘¥¿“«–μ“∫Õ¥·∑√° âÕπ®“°°“√©’¥ autologous

fat ‹√âÕ¬≈– 80.9 ‡∑’¬∫°—∫√“¬ß“π°“√‡°‘¥®“° Hyaluronic

acid ‹√âÕ¬≈– 39.1 ¢Õß√“¬ß“π¿“«–·∑√° âÕπ®“° “√π—ÈπÊ

∑—ÈßÀ¡¥ πÕ°®“°π’È autologous fat ∑”„Àâ‡°‘¥Õÿ∫—μ‘°“√¢Õß

°“√Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥ ¡Õß‰¥â Ÿß∂÷ß‹√âÕ¬≈– 82.6 ‡∑’¬∫°—∫‹

√âÕ¬≈– 8.7 ®“°°“√©’¥ hyaluronic acid3

°“√ªÑÕß°—π°“√‡°‘¥¿“«–·∑√° âÕπ∑“ßμ“®“°°“√©’¥ “√‡μ‘¡‡μÁ¡

®“°ß“π«‘®—¬∑’Ë√«∫√«¡√“¬ß“π¿“«–·∑√° âÕπ®“°°“√

©’¥ “√‡μ‘¡‡μÁ¡3 ‰¥â«“ß·π«∑“ß°“√ªÑÕß°—π°“√‡°‘¥¿“«–

·∑√°´âÕπ®“°°“√©’¥ “√‡μ‘¡‡μÁ¡‰«â«à“

1. ºŸâ©’¥§«√¡’§«“¡√Ÿâ§«“¡‡¢â“„®∂÷ß≈—°…≥–∑“ß°“¬

«‘¿“§ §«“¡μ◊Èπ≈÷°¢Õß∑“ß‡¥‘πÀ≈Õ¥‡≈◊Õ¥∫π„∫Àπâ“ ‡æ◊ËÕ

∑’Ë®–‰¥â©’¥ “√‡μ‘¡‡μÁ¡‰ª¬—ß√–¥—∫§«“¡≈÷°∑’Ë‡À¡“– ¡ À≈’°

‡≈’Ë¬ß°“√©’¥‡¢â“À≈Õ¥‡≈◊Õ¥‚¥¬μ√ß

2. ·π–π”„Àâ©’¥™â“ ·≈–„™â·√ß¥—πμË”

3. ©’¥∑’≈–πâÕ¬ ‡æ◊ËÕ«à“À“°¡’ “√‡μ‘¡‡μÁ¡‡¢â“À≈Õ¥

‡≈◊Õ¥ °“√©’¥πâÕ¬·≈–™â“®–™à«¬„Àâ “√ filler ª√‘¡“≥πâÕ¬

π—Èπ∂Ÿ°¥—π‰ª à«πª≈“¬‰¥â¡“° ‡°‘¥¿“«–¢“¥‡≈◊Õ¥¢ÕßÕ«—¬«–

πâÕ¬°«à“

4. ¢¬—∫ª≈“¬‡¢Á¡‡ª≈’Ë¬π∑’Ë©’¥ ‡æ◊ËÕ‰¡à „Àâ©’¥¬“‡¢â“

μ”·Àπàß‡¥‘¡„πª√‘¡“≥¡“°

5. ·π–π”„Àâ≈Õß¥Ÿ¥°àÕπ©’¥ ‡æ◊ËÕª√–‡¡‘π«à“ª≈“¬‡¢Á¡

‡¢â“À≈Õ¥‡≈◊Õ¥À√◊Õ‰¡à ·μà°“√∑”‡™àππ’È°Á¡’¢âÕ‰¡à·¡àπ¬” ‡æ√“–

°“√„™â·√ß¥Ÿ¥ºà“πÀ≈Õ¥·≈–‡¢Á¡©’¥¬“ª≈“¬‡≈Á°∑’Ë¡’ “√‡μ‘¡

‡μÁ¡≈—°…≥–‡®≈Àπ◊¥ Õ“®®–‰¡à “¡“√∂·¬°‰¥â«à“ª≈“¬‡¢Á¡

‡¢â“À≈Õ¥‡≈◊Õ¥À√◊Õ‰¡à

6. „™â¢π“¥‡¢Á¡‡∫Õ√å‡≈Á° ·≈–À≈Õ¥©’¥¬“¢π“¥‡≈Á°

0.5-1 mL ‡æ◊ËÕ∑’Ë®–‰¥â “√ª√‘¡“≥·≈–·√ß©’¥‰¡à¡“°

7. ·π–π”„™âª≈“¬‡¢Á¡∑Ÿà‹ ‚¥¬‡©æ“– ∫√‘‡«≥·°â¡

√àÕß·°â¡ ·≈–√àÕßπÈ”μ“

8. Õ“®æ‘®“√≥“º ¡‡μ‘¡‡μÁ¡¥â«¬ epinephrine

‡æ◊ËÕ„Àâ‡°‘¥°“√À¥μ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥·≈–≈¥§«“¡‡ ’Ë¬ß„π

°“√·∑ß‡¢Á¡‡¢â“À≈Õ¥‡≈◊Õ¥

9. √–«—ß„π°“√©’¥„Àâ·°àºŸâ∑’Ë‡§¬‰¥â√—∫°“√ºà“μ—¥∫√‘‡«≥

„∫Àπâ“ ‡æ√“–≈—°…≥–∑“ß°“¬¿“æ¢Õßº‘«Àπ—ß·≈–À≈Õ¥

‡≈◊Õ¥¡’°“√‡ª≈’Ë¬π·ª≈ß‰ª®“°ª°μ‘

·π«∑“ß°“√ªØ‘∫—μ‘‡¡◊ËÕ‡°‘¥¿“«–·∑√° âÕπ∑“ßμ“®“°°“√©’¥ “√ filler

‡¡◊ËÕ‡°‘¥¿“«–·∑√°´âÕπ∑“ßμ“ ”§—≠∑’Ë ÿ¥§◊Õ°“√

∑”„Àâ‡≈◊Õ¥°≈—∫‰ª‡≈’È¬ß®Õμ“„Àâ ‰¥â‡√Á«∑’Ë ÿ¥ DD Varma. ‰¥â

∑”°“√∑¥≈Õß„π≈‘ßæ∫«à“ ®Õμ“¢“¥‡≈◊Õ¥‡°‘π°«à“ 90 π“∑’

®–‡√‘Ë¡¡’°“√ Ÿ≠‡ ’¬°“√∑”ß“π¢Õß‡´≈≈åÕ¬à“ß∂“«√ ·≈–

æ∫«à“¡’§«“¡º‘¥ª°μ‘¢Õß°“√∑¥ Õ∫°“√ àßºà“π§≈◊Ëπ¢Õß

‡´≈≈å®Õμ“ (electroretinography, ERG) ·≈–°“√ àßºà“π

§≈◊Ëπ¢Õß‡ âπª√– “∑μ“·≈–‡π◊ÈÕ ¡Õß (vision evoked

potential, VEP) À“°°“√¢“¥‡≈◊Õ¥π—Èπ‡°‘π°«à“ 240 π“∑’

®–æ∫«à“¡’°“√ΩÉÕ¢Õß‡ âπª√– “∑μ“‡°◊Õ∫∑—ÈßÀ¡¥ (optic

atrophy)7 ¥—ßπ—Èπ‡«≈“°“√„Àâ°“√√—°…“®÷ß ”§—≠ ºŸâ„Àâ°“√©’¥

“√‡μ‘¡‡μÁ¡§«√¡’·π«∑“ß°“√ àßμàÕºŸâªÉ«¬‰ª¬—ß®—°…ÿ·æ∑¬å

Õ¬à“ß©ÿ°‡©‘π ¡’§”·π–π”„Àâ©’¥ “√ hyaluronidase ´÷Ëß‡ªìπ

‡Õπ‰´¡å∑’Ë¬àÕ¬ “√ hyaluronic acid ‚¥¬©’¥‰ª„πμ”·Àπàß

º‘«Àπ—ß∑’Ë‰¥â√—∫°“√©’¥ hyaluronic acid ·≈–π«¥‡æ◊ËÕ„Àâ

≈“¬ hyaluronic acid ‰¥â‡√Á«¢÷Èπ´÷Ëß∑”‚¥¬·æ∑¬å∑’Ë∑”

°“√©’¥ “√‡μ‘¡‡μÁ¡À√◊Õ°“√©’¥‡¢â“‡∫â“μ“ (retrobulbar or

peribulbar injection) ‚¥¬®—°…ÿ·æ∑¬å ‡π◊ËÕß®“°¡’√“¬ß“π

«‘®—¬„πÀâÕß∑¥≈Õß8 æ∫«à“ “√ hyaluronidase “¡“√∂´÷¡

ºà“π‡π◊ÈÕ‡¬◊ËÕ ·≈–ºπ—ßÀ≈Õ¥‡≈◊Õ¥‰¥âÕ¬à“ß√«¥‡√Á« ÷Ëß‡∑§π‘§

°“√©’¥¬“™“‡¢â“‡∫â“μ“ „™âª√‘¡“≥ hyaluronidase 3-8 mL

Õ¬à“ßπâÕ¬ 500 ¬Ÿπ‘μ ∑’Ë∫√‘‡«≥ retrobulbar À√◊Õ peribulbar

‚¥¬μ”·Àπàß‡¥’¬«°—∫°“√©’¥¬“™“„π°“√∑”ºà“μ—¥∑“ßμ“


·μà¡’¢âÕ§«√√–«—ß„π°“√‡≈◊Õ°„™â “√ hyaluronidase ÷Ëß¡’

2 ™π‘¥§◊Õ™π‘¥∑’Ë¡’ à«πº ¡®“° —μ«å (animal-source) ·≈–

™π‘¥ recombinant human hyaluronidase ‚¥¬æ∫«à“

∫“ß§πÕ“®¡’·æâ “√„π°≈ÿà¡™π‘¥∑’Ë¡’ à«πº ¡®“° —μ«å‰¥â

μ—Èß·μà·æâ‡æ’¬ß‡≈Á°πâÕ¬‰ª®π∂÷ß√ÿπ·√ß‡ªìπ anaphylaxis

‰¥â9 πÕ°®“°π’È¬—ß¡’°“√°≈à“«∂÷ß°“√„™â “√ hyaluronidase

©’¥‡¢â“À≈Õ¥‡≈◊Õ¥·¥ß ophthalmic ‚¥¬μ√ß‚¥¬ neuro-

radiologist À√◊Õ°“√„Àâ “√ hyaluronidase ∑“ßÀ≈Õ¥‡≈◊Õ¥

¥”§≈â“¬°“√√—°…“¿“«–‡ âπ‡≈◊Õ¥À—«„®μ’∫μ—π ´÷Ëß‚¥¬∑ƒ…Æ’

¡’§«“¡‡ªìπ‰ª‰¥â∑’Ë®– ≈“¬ hyaluronic acid ‰¥â‚¥¬μ√ß ·μà

¬—ß‰¡à¡’√“¬ß“π°“√π”‰ª„™â√—°…“®√‘ß„πºŸâ∑’Ë‡°‘¥º≈·∑√° âÕπ

®“°°“√©’¥ “√‡μ‘¡‡μÁ¡

À≈—ß®“°æ‘®“√≥“©’¥ “√ hyaluronidase ‡¢â“∫√‘‡«≥

º‘«Àπ—ß√Õ∫∫√‘‡«≥∑’Ë©’¥ “√‡μ‘¡‡μÁ¡À√◊Õ©’¥‡¢â“‡∫â“μ“·≈â«

·π–π”„Àâ°“√√—°…“‡æ◊ËÕ≈¥§«“¡¥—πμ“„π·π«∑“ß°“√√—°…“

¢ÕßÀ≈Õ¥‡≈◊Õ¥®Õμ“Õÿ¥μ—π (retinal artery occlusion)3 μ“¡

European Assessment Group for Lysis in the Eye

study (EAGLE study)11 ‰¥â·°à isovolumic hemodilu-

tion, °“√π«¥μ“ (ocular massage), °“√„Àâ¬“ acetazo-

lamide °‘π À√◊Õ°“√„Àâ¬“ manitol ∑“ßÀ≈Õ¥‡≈◊Õ¥¥” „Àâ

¬“À¬Õ¥≈¥§«“¡¥—πμ“ „π°“√»÷°…“¢Õß°≈ÿà¡ EAGLE study

æ∫«à“ mean best corrected visual acuity (BCVA) ¢Õß

central retinal artery occlusion (CRAO) ∑’Ë„Àâ°“√√—°…“

∑—Èß 4 Õ¬à“ß¢â“ßμâπ ¥’¢÷Èπ∂÷ß‹√âÕ¬≈– 60 ‡¡◊ËÕ‡∑’¬∫°—∫°àÕπ

„Àâ°“√√—°…“Õ¬à“ß¡’π—¬ ”§—≠ (0.3 logMAR) πÕ°®“°π’È

Atebara NH ·≈–§≥–∑”°“√»÷°…“ °“√‡®“–√–∫“¬πÈ”„π

™àÕßÀπâ“≈Ÿ°μ“ (anterior chamber paracentesis) ·≈–

°“√„Àâ°“√√—°…“¥â«¬°“√¥¡°ä“´§“√å∫Õπ‰¥ÕÕ°‰´¥åº ¡°—∫

ÕÕ°´‘‡®π (carbogen inhalation) „π√“¬∑’Ë¡’À≈Õ¥‡≈◊Õ¥

·¥ß∑’Ë®Õμ“Õÿ¥μ—π (retinal artery occlusion) ‰¡àæ∫«à“¡’

°“√¥’¢÷Èπ¢Õß√–¥—∫°“√¡Õß‡ÀÁπÕ¬à“ß¡’π—¬ ”§—≠‡∑’¬∫°—∫

°àÕπ„Àâ°“√√—°…“12, °“√√—°…“¥â«¬ hyperbaric oxygen ·≈–

°“√„Àâ¬“ ‡μ’¬√Õ¬¥å°‘πÀ√◊Õ©’¥ Õ“®®–™à«¬„Àâ°“√‰À≈‡«’¬π

¢Õß‡≈◊Õ¥‡¢â“‰ª„π®Õμ“¡“°¢÷Èπ13

‡π◊ËÕß®“°√“¬ß“π°“√√—°…“º≈·∑√°´âÕπ∑“ßμ“®“°

°“√©’¥ “√‡μ‘¡‡μÁ¡¬—ß‰¡à¡“°æÕ °“√√—°…“∑’ËÀ≈“°À≈“¬

·≈–¢âÕ¡Ÿ≈‰¡à§√∫∂â«π∂÷ß√“¬≈–‡Õ’¬¥°“√„Àâ°“√√—°…“ ®÷ß‰¡à

“¡“√∂√–∫ÿ‰¥â«à“°“√√—°…“·∫∫„¥‰¥âº≈¥’∑’Ë ÿ¥3

º≈°“√√—°…“Katie B. ·≈–§≥–‰¥â¡’°“√√«∫√«¡√“¬ß“π¿“«–

·∑√° âÕπ∑“ßμ“¢Õß°“√©’¥ “√‡μ‘¡‡μÁ¡‚¥¬√«∫√«¡®“°

°“√§âπÀ“ºà“π National Library of Medicine, Ovid

MEDLINE, ·≈– Cochrane Library3 æ∫√“¬ß“π∑—ÈßÀ¡¥

98 √“¬ à«π„À≠à §◊Õ®”π«π 58 √“¬ ‡ªìπ√“¬ß“π®“°

»Ÿπ¬å√—°…“®Õμ“ª√–‡∑»‡°“À≈’„μâ √Õß≈ß¡“§◊Õ√“¬ß“π®“°

Õ‡¡√‘°“ 8 √“¬ ·≈–®“°ª√–‡∑»Õ◊ËπÊ ‰¥â·°à ®’π ≠’ËªÿÉπ ‡ªπ

∫√“´‘≈ ‡ªìπμâπ ®“°√“¬ß“π∑—ÈßÀ¡¥æ∫«à“‹√âÕ¬≈– 47.9 (47

√“¬) ‰¥â√—∫°“√©’¥ “√‡μ‘¡‡μÁ¡‚¥¬„™â augologous fat

√Õß≈ß¡“§◊Õ hyaluronic acid ‹√âÕ¬≈– 23.5 μ”·Àπàß©’¥

∑’Ë√“¬ß“π°“√‡°‘¥¿“«–·∑√°´âÕπ¡“°∑’Ë ÿ¥§◊Õ À«à“ß§‘È«

(‹√âÕ¬≈– 38.8) μ“¡¥â«¬ ®¡Ÿ° (‹√âÕ¬≈– 25.5), √àÕß·°â¡

(‹√âÕ¬≈– 13.3), ·≈–Àπâ“º“° (‹√âÕ¬≈– 12.2)

°“√√—°…“∑’Ë√“¬ß“π¡’À≈“°À≈“¬μ—Èß·μà°“√‡ΩÑ“μ‘¥μ“¡

Õ“°“√Õ¬à“ß‡¥’¬« °“√π«¥μ“ (ocular massage), anterior

chamber paracentesis, intraocular pressure lowering

drug, IV corticosteroids, antiplatelet therapy ·≈– Intra-

arterial thrombolysis

®“°√“¬ß“πæ∫ºŸâ∑’Ë¡’Õ“°“√μ“∫Õ¥‰¡à‡ÀÁπ· ß (no light

perception) ∑—ÈßÀ¡¥ 65 √“¬ ´÷Ëß„π®”π«ππ’È 38 √“¬ ‡ªìπ

ºŸâ∑’Ë‰¥â√—∫°“√©’¥ “√ autologous fat (§‘¥‡ªìπ‹√âÕ¬≈– 80.9

¢Õß√“¬ß“π∑’Ë‰¥â√—∫°“√©’¥ “√ autologous fat ∑—ÈßÀ¡¥∑’Ë

‡°‘¥¿“«–·∑√°´âÕπ) 5 √“¬ “¡“√∂¡Õß‡ÀÁπ‰¥â ‚¥¬√–¥—∫

°“√¡Õß‡ÀÁπμ—Èß·μà light perception ‰ª®π∂÷ß√–¥—∫ 20/40

·≈–Õ’° 4 √“¬‰¡à√“¬ß“π√–¥—∫°“√¡Õß‡ÀÁπ‡¡◊ËÕ ‘Èπ ÿ¥°“√

√—°…“ πÕ°®“°π’È„π√“¬ß“πæ∫ 2 √“¬∑’Ë°“√¡Õß‡ÀÁπ°≈—∫§◊π

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„°≈â‡§’¬ßª°μ‘§◊Õ 20/30 ·≈–‡¡◊ËÕ„Àâ°“√√—°…“¥â«¬¬“≈¥

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æ∫ 23 √“¬ (‹√âÕ¬≈– 23.5)

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¢Õß “√‡μ‘¡‡μÁ¡∑’Ë©’¥‡¢â“‰ª μ”·Àπàß°“√Õÿ¥μ—πÀ≈Õ¥‡≈◊Õ¥

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‡≈◊Õ¥·¥ß®Õμ“Õÿ¥μ—π °“√‡°Á∫√«∫√«¡¢âÕ¡Ÿ≈·≈– àßμàÕ¢âÕ¡Ÿ≈

√–À«à“ß·æ∑¬åºŸâ©’¥·≈–®—°…ÿ·æ∑¬å∑’Ë„Àâ°“√√—°…“ ”§—≠¡“°

®–π”¡“ ÷Ëßª√–‚¬™πå„π·ßà°“√«‘‡§√“–ÀåÀ“·π«∑“ßæ—≤π“

°“√√—°…“„Àâª√– ∫º≈ ”‡√Á®¡“°¢÷ÈπμàÕ‰ª

‡Õ° “√Õâ“ßÕ‘ß1. Von Bahr G. Multiple embolisms in the fundus of the eye

after an injection in the scalp. Acta Opthalmol (Copenh.)1963;41:85-91.

2. Aliso V. Global Aesthetic Market Study XII. CA: Medical In-sight Inc; 2014;274.

3. Katie B. Avoiding and Treating Blindness from filler: A reviewof the world literature. Dermatol surg 2015;41L1097-1117.

4. Maya Vedamurthy. Dermal fillers: Tips to achieve successfuloutcomes. JCAS 2008:64-7.

5. Jean D. Blindness Caused by Cosmetic Filler Injection: AReview of Cause and Therapy Plast. Reconstr. Surg. 134:1197, 2014

6. Yong-Kyu K. Cerebral Angiographic Findings of CosmeticFacial Filler-related Ophthalmic and Retinal Artery Occlusion.J Korean Med Sci 2015;30:1847-55

7. Varma DD. A review of central retinal artery occlusion: clini-cal presentation and management. Eye 2013;27:688-97.

8. DeLorenzi C. Complications of injectable fillers, part I. AesthetSurg J 2013;33:561-78.

9. Delaere L et al. Allergic reaction to hyaluronidase afterretrobulbar anaesthesia: a case series and review. IntOphthalmol 2009;29:521-8.

10. Yoon SS. Acute fatal stroke immediately following auto-logous fat injection in to the face. Neurology 2003;51:1151-2.

11. Martin S. Central Retinal Artery Occlusion: Local Intra-arterialFibrinolysis versus Conservative Treatment, a MulticenterRandomized Trial. Ophthalmology 2010; 1367-75.e1

12. Atebara NH. Efficacy of anterior chamber paracentesis andCarbogen in treating acute nonarteritic central retinal arteryocclusion. Ophthalmology 1995 Dec;102(12):2029-34

13. Hausmann N. Effect of high dose steroid bolus on occlusionof ocular central artery: angiographic study. BMJ 1991;303:1445-6.


Intraocular Tuberculosis:The Great Mimic

Ocular tuberculosis (TB) À¡“¬∂÷ß°“√μ‘¥‡™◊ÈÕ«—≥‚√§

(Mycobacteria tuberculosis) ¿“¬„π≈Ÿ°μ“ (intraocular)

∫√‘‡«≥√Õ∫¥«ßμ“ (lids, orbit ·≈– lacrimal gland) À√◊Õ

∫πæ◊Èπº‘«¢Õß¥«ßμ“ (conjunctiva, sclera ·≈– cornea)

‚¥¬¡’≈—°…≥–∑“ß§≈‘π‘°¢Õß°“√μ‘¥‡™◊ÈÕ«—≥‚√§∑’Ë·μ°μà“ß°—π

‰ª (μ“√“ß∑’Ë 1)1 „π∑’Ëπ’È®–‡πâπ‰ª∑’Ë°“√μ‘¥‡™◊ÈÕ«—≥‚√§¿“¬„π

≈Ÿ°μ“ (intraocular TB)

„πª√–‡∑»‰∑¬®“°°“√»÷°…“ºŸâªÉ«¬ uveitis „À¡à®”π«π

200 √“¬ æ∫«—≥‚√§‡ªìπ “‡Àμÿ¢Õß uveitis √âÕ¬≈– 2.22

·≈–®“°°“√»÷°…“ºŸâªÉ«¬ uveitis „À¡à®”π«π 108 √“¬‡æ◊ËÕ

À“°“√μ‘¥‡™◊ÈÕ«—≥‚√§√–¬–·Ωß∑’Ë¬—ß‰¡à· ¥ßÕ“°“√ (latent

tuberculosis) ‚¥¬°“√„™â QuantiFERON˙-TB Gold test

(QFT-G test; Cellestis, Australia) æ∫§«“¡™ÿ°¢Õß°“√

μ‘¥‡™◊ÈÕ«—≥‚√§√–¬–·Ωß∑’Ë¬—ß‰¡à· ¥ßÕ“°“√„πºŸâªÉ«¬ uveitis

‡ªìπ√âÕ¬≈– 36 ®“°°“√∑’ËºŸâªÉ«¬¡’º≈ QFT-G test ‡ªìπ∫«°

„π¢≥–∑’Ëº≈ tuberculin skin test (TST) ‡ªìπ∫«°¡’‡æ’¬ß

√âÕ¬≈– 15 ‚¥¬‰¡à¡’ºŸâªÉ«¬ uveitis √“¬„¥∑’Ë¡’Õ“°“√À√◊ÕÕ“°“√

· ¥ß¢Õß°“√μ‘¥‡™◊ÈÕ«—≥‚√§√–¬– active ∑’ËªÕ¥À√◊Õ∑’ËÕ◊Ëπ

√à«¡¥â«¬ ≈—°…≥–∑“ß§≈‘π‘°¢ÕßºŸâªÉ«¬ uveitis ∑’Ë ‰¡à∑√“∫

“‡Àμÿ·≈–¡’º≈ QFT-G test ‡ªìπ∫«°¡—°®–¡’≈—°…≥–

‡°…√“ æ—≤πæ‘±Ÿ√¬å, æ.∫.

¿“§«‘™“®—°…ÿ«‘∑¬“ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à

Review Article/∫∑øóôπøŸ«‘™“°“√

‡ªìπÀ≈Õ¥‡≈◊Õ¥®Õμ“Õ—°‡ ∫ (√âÕ¬≈– 37) ·≈–«ÿâπμ“Õ—°‡ ∫

(√âÕ¬≈– 26)3

°“√«‘π‘®©—¬ ocular TB π—Èπ∑”‰¥â¬“°‡π◊ËÕß®“°‚√§¡’

≈—°…≥–∑“ß§≈‘π‘°∑’ËÀ≈“°À≈“¬ “¡“√∂‡≈’¬π·∫∫ uveitis

∑’Ë‡°‘¥®“° “‡ÀμÿÕ◊ËπÊ ‰¥â¡“°¡“¬ (the great mimic) ·≈–

¡—°‰¡àæ∫°“√μ‘¥‡™◊ÈÕ∑’ËªÕ¥√à«¡¥â«¬4 ¿“«– intraocular TB

‡°‘¥¢÷Èπ‰¥â∑—Èß®“°°“√μ‘¥‡™◊ÈÕ«—≥‚√§‚¥¬μ√ß·≈–®“°°“√μÕ∫

πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕ‚¥¬‰¡àæ∫°“√μ‘¥‡™◊ÈÕ∑“ß°“¬∑’Ë

™—¥‡®π (immune mediated) (μ“√“ß∑’Ë 2)5

≈—°…≥–∑“ß§≈‘π‘°¢Õß intraocular TB ∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥§◊Õ posterior uveitis √Õß¡“§◊Õ anterior uveitis,panuveitis ·≈– intermediate uveitis4

1. Anterior uveitis ®–¡’°“√Õ—°‡ ∫Õ¬à“ß™â“Ê ·≈–

‡√◊ÈÕ√—ß·∫∫ granulomatous Õ“®æ∫ iris nodules À√◊Õ

granuloma μ≈Õ¥®π posterior synchiae ·≈–μâÕ°√–®°

√à«¡¥â«¬6

2. Intermediate uveitis ¡—°‡ªìπ„πμ“∑—Èß Õß¢â“ß

≈—°…≥–§≈â“¬ pars planitis °“√Õ—°‡ ∫®–‰¡à√ÿπ·√ß·≈–

‡√◊ÈÕ√—ß æ∫«ÿâπμ“Õ—°‡ ∫ À≈Õ¥‡≈◊Õ¥®Õμ“√Õ∫πÕ°Õ—°‡ ∫

110 ‡°…√“ æ—≤πæ‘±Ÿ√¬å Vol. 30 No. 2 July-December 2016

√à«¡°—∫ snow ball opacities, snow banking, cystoid

macular edema Õ“®æ∫ peripheral retinochoroidal

granuloma

3. Posterior ·≈– panuveitis ‡ªìπÕ“°“√· ¥ß∑’Ë

æ∫‰¥â∫àÕ¬ ÿ¥ ‰¥â·°à choroidal tubercles, choroidal

tuberculoma (√Ÿª∑’Ë 1), subretinal abscess ·≈– serpi-

ginous-like choroiditis (√Ÿª∑’Ë 2)

4. Retinal vasculitis À≈Õ¥‡≈◊Õ¥®Õμ“Õ—°‡ ∫ à«π

„À≠à‡ªìπÀ≈Õ¥‡≈◊Õ¥¥” (periphlebitis) (√Ÿª∑’Ë 3)7 √à«¡°—∫

«ÿâπμ“Õ—°‡ ∫ Õ“®æ∫‡≈◊Õ¥ÕÕ°®Õμ“ ‡ âπ‡≈◊Õ¥ßÕ°„À¡à ·≈–

neuroretinitis

Eyelids Localized massConjunctivae Conjunctival granulomaSclera Focal necrotizing scleritis, nodular scleritis, sclerokeratitisCornea Interstitial keratitis, phlyctenulosisCiliary body Cyclitis caseating granulomaUvea Anterior granulomatous, uveitisVitreous VitritisChoroid Multifocal choroditis, chorioretinitis, peripapillary choroiditis, tuberclesRetina Retinitis retinochoroiditis, retinal vasculitisOptic nerve Papillitis, optic neuritis, retrobulbar neuritisOrbit Granuloma, localized massLacrimal gland Granuloma, localized mass

¥—¥·ª≈ß®“° Tabbara KF. Tuberculosis. Curr Opin Ophthalmol. 2007;18:493-501.

μ“√“ß∑’Ë 1 ≈—°…≥–∑“ß§≈‘π‘°¢Õß°“√μ‘¥‡™◊ÈÕ«—≥‚√§∑’Ë¥«ßμ“·≈–∫√‘‡«≥√Õ∫¥«ßμ“

Õ“°“√· ¥ß æ¬“∏‘°”‡π‘¥∑’Ë‡ªìπ‰ª‰¥â¢Õß«—≥‚√§∑’Ëμ“

Iris À√◊Õ angle granulomas °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßCiliary body tubercle °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßRetinal vasculitis °“√μÕ∫ πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕChoroiditis °“√μÕ∫ πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕChoroidal tubercle °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßSubretinal abscess °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßEndophthalmitis °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ßPanophthalmitis °“√μ‘¥‡™◊ÈÕ‚¥¬μ√ß

¥—¥·ª≈ß®“° Abu El-Asrar AM, Abouammoh M, Al-Mezaine HS. Tuberculous uveitis. Int Ophthalmol Clin. 2010;50:19-39.

μ“√“ß∑’Ë 2 æ¬“∏‘°”‡π‘¥∑’Ë‡ªìπ‰ª‰¥â¢Õß intraocular tuberculosis

5. Neuroretinitis ·≈– optic neuropathy Õ“®æ∫

optic nerve tubercle, papillitis, papilledema, optic

neuritis, retrobulbar neuritis, neuroretinitis À√◊Õ optico-

chiasmatic arachnoiditis ‡ªìπμâπ

6. Endophthalmitis ·≈– panophthalmitis ¡—°

‡ªìπ·∫∫‡©’¬∫æ≈—π·≈–¥”‡π‘π‰ªÕ¬à“ß√«¥‡√Á« °“√Õ—°‡ ∫

Õ“®√ÿπ·√ß¡“°®π∑”„Àâ‡°‘¥ hypopyon §Õ√Õ¬¥å∑’Ë¡’°“√

Õ—°‡ ∫√ÿπ·√ßÕ“®°≈“¬‡ªìπ subretinal abscess ¢π“¥„À≠à

∑–≈ÿ Bruchs membrane ‡¢â“ Ÿà®Õμ“·≈–«ÿâπμ“°≈“¬

‡ªìπ endophthalmitis ·≈–À“°‡ª≈◊Õ°≈Ÿ°μ“∑–≈ÿ∑”„Àâ

‡°‘¥ panophthalmitis

111Intraocular Tuberculosis: The Great Mimic

√Ÿª∑’Ë 1 ¿“æ∂à“¬®Õμ“¢â“ß¢«“· ¥ß choroidal granuloma „πºŸâªÉ«¬‡Õ¥ å∑’Ë¡’°“√μ‘¥‡™◊ÈÕ«—≥‚√§∑’ËªÕ¥ (√Ÿª ’∑â“¬‡≈à¡)

√Ÿª∑’Ë 2 ¿“æ∂à“¬®Õμ“¢â“ß¢«“· ¥ß serpiginous-like choroiditis °àÕπ·≈–À≈—ß°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§ (√Ÿª ’∑â“¬‡≈à¡)°. · ¥ß multifocal choroiditis ¡’≈—°…≥–‡ªìπ serpiginous-like choroiditis √à«¡°—∫«ÿâπμ“Õ—°‡ ∫ „πºŸâªÉ«¬™“¬Õ“¬ÿ

50 ªï∑’Ë¡’º≈∑¥ Õ∫ QuantiFERON˙-TB Gold ‡ªìπ∫«°∑’Ë√–¥—∫ 2.62 IU/mL ·≈– tuberculin skin test æ∫∫√‘‡«≥°√–¥â“ß (induration) ‡ âπºà“»Ÿπ¬å°≈“ß¢π“¥ 25 ¡‘≈≈‘‡¡μ√ ‚¥¬∑’Ë X-ray ªÕ¥‡ªìπª°μ‘

¢. · ¥ß multifocal choroidal atrophy ·≈– scar ¿“¬À≈—ß°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§

°. ¢.

112 ‡°…√“ æ—≤πæ‘±Ÿ√¬å Vol. 30 No. 2 July-December 2016

°“√«‘π‘®©—¬°“√«‘π‘®©—¬ ocular TB ∑”‰¥â¬“°‡π◊ËÕß®“°ºŸâªÉ«¬¡—°

‰¡à¡’ª√–«—μ‘°“√μ‘¥‡™◊ÈÕ∑’ËªÕ¥À√◊Õ∑’ËÕ◊Ëπ√à«¡¥â«¬ °“√‡æ“–‡™◊ÈÕ

·≈–°“√μ√«®À“‡™◊ÈÕ‚¥¬‡∑§π‘§ polymerase chain re-

action ®“° intraocular fluid ¡—°‰¥âº≈≈∫ à«π°“√∑”

uveal biopsy ‡æ◊ËÕ‡æ“–‡™◊ÈÕπ—Èπ∑”‰¥â¬“° ¥—ßπ—Èπ°“√«‘π‘®©—¬

à«π„À≠à®÷ß‡ªìπ°“√Õπÿ¡“π ‚¥¬Õ“»—¬‡°≥±å°“√«‘π‘®©—¬‚√§

¥—ßπ’È

1. ºŸâªÉ«¬¡“®“°/Õ“»—¬„π∂‘Ëπ√–∫“¥À√◊Õ¡’ª√–«—μ‘ —¡º—

°—∫ºŸâªÉ«¬«—≥‚√§¡“°àÕπ

2. º≈°“√μ√«®∑“ßÕâÕ¡∑’Ë∫àß™’È«à“¡’°“√μ‘¥‡™◊ÈÕ«—≥‚√§

‰¥â·°à º≈ TST ‡ªìπ∫«° ‚¥¬æ∫∫√‘‡«≥°√–¥â“ß (indura-

tion) ‡ âπºà“»Ÿπ¬å°≈“ß¡“°°«à“ 10-15 ¡‘≈≈‘‡¡μ√¿“¬À≈—ß

°“√©’¥ 5 tuberculin units ¢Õß purified protein deriva-

tive ‡¢â“„μâº‘«Àπ—ß ¿“¬À≈—ß 48-72 ™—Ë«‚¡ß À√◊Õº≈∑¥ Õ∫

interferon-gamma release assays (IGRAs) ‡ªìπ∫«°

‰¥â·°à QuantiFERON-TB Gold In-Tube (QFT; Cellestis

Inc., Carnegie, VIC, Australia) ·≈– ELISpotPLUS (T-

SPOT.TB, Oxford Immunotec, Oxford, UK)3

3. ‰¡àæ∫ “‡ÀμÿÕ◊Ëπ∑’Ë∑”„Àâ‡°‘¥ uveitis ‡™àπ syphilis

À√◊Õ toxoplasmosis ‡ªìπμâπ

4. ¡’°“√μÕ∫ πÕßμàÕ°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§

‚¥¬„Àâ¬“ 4 ™π‘¥ ‰¥â·°à isoniazid, rifampicin, ethambu-

tol ·≈– pyrazinamide ‡ªìπ‡«≈“ 4-6 —ª¥“Àå (therapeu-

tic test)

°“√√—°…“‡π◊ËÕß®“°°“√«‘π‘®©—¬‚√§ à«π„À≠à‡ªìπ°“√Õπÿ¡“π

·≈–≈—°…≥–∑“ß§≈‘π‘°∑’Ëæ∫π—Èπ‡°‘¥¢÷Èπ‰¥â∑—Èß®“°°“√μ‘¥‡™◊ÈÕ

«—≥‚√§‚¥¬μ√ß·≈–®“°°“√μÕ∫ πÕß∑“ß¿Ÿ¡‘§ÿâ¡°—πμàÕ‡™◊ÈÕ

∑”„Àâ¬—ß‰¡à‡ªìπ∑’Ë·πà™—¥«à“§«√„Àâ¬“μâ“π«—≥‚√§À√◊Õ‰¡à·≈–

®–„Àâ‡ªìπ√–¬–‡«≈“π“π‡∑à“‰√ ¥—ßπ—Èπ®÷ß§«√æ‘®“√≥“ªí®®—¬

‡ ’Ë¬ß·≈–ª√–‚¬™πå∑’Ë®–‰¥â√—∫®“°°“√„Àâ¬“μâ“π«—≥‚√§8

¬“μâ“π«—≥‚√§∑’Ë„™â„π°“√√—°…“ºŸâªÉ«¬ ocular TB §◊Õ

isoniazid 5 ¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—π rifampicin 450

¡‘≈≈‘°√—¡μàÕ«—π (∂â“πÈ”Àπ—°πâÕ¬°«à“ 50 °‘‚≈°√—¡) ·≈– 600

¡‘≈≈‘°√—¡ (∂â“πÈ”Àπ—°¡“°°«à“ 50 °‘‚≈°√—¡), ethambutol

15 ¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—π ·≈– pyrazinamide 25-30

¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—π ‡ªìπ‡«≈“ 2 ‡¥◊Õπ μ“¡¥â«¬ rifam-

picin ·≈– isoniazid Õ’°Õ¬à“ßπâÕ¬ 4-7 ‡¥◊Õπ (√«¡‡ªìπ

√–¬–‡«≈“ 6-9 ‡¥◊Õπ) °“√„Àâ¬“μâ“π«—≥‚√§πÕ°®“°®–™à«¬

√—°…“·≈â«¬—ßªÑÕß°—π°“√°≈—∫‡ªìπ´È”‰¥â

√Ÿª∑’Ë 3 ¿“æ∂à“¬®Õμ“¢â“ß¢«“· ¥ß retinal periphlebitis „πºŸâªÉ«¬™“¬Õ“¬ÿ 34 ªï∑’Ë¡’º≈∑¥ Õ∫ QuantiFERON˙-TB Gold‡ªìπ∫«°∑’Ë√–¥—∫ 3.5 IU/mL ‚¥¬∑’Ë tuberculin skin test ·≈– X-ray ªÕ¥‡ªìπª°μ‘

113Intraocular Tuberculosis: The Great Mimic

„π∫“ß√“¬Õ“®®”‡ªìπμâÕß„Àâ prednisone √—∫ª√–∑“π

¢π“¥ 0.5-1 ¡‘≈≈‘°√—¡μàÕ°‘‚≈°√—¡μàÕ«—π ·≈–À√◊Õ ¬“°¥¿Ÿ¡‘

μâ“π∑“π (immunosuppressive agents) √à«¡¥â«¬®π¡’

°“√μÕ∫ πÕß®“°π—Èπ§àÕ¬Ê ≈¥¢π“¥¬“≈ß °“√„Àâ·μà¬“

°≈ÿà¡π’È ‚¥¬‰¡à„Àâ¬“μâ“π«—≥‚√§®–∑”„Àâ‚√§·¬à≈ß·≈–°≈—∫

‡ªìπ´È”‰¥â

‡Õ° “√Õâ“ßÕ‘ß1. Tabbara KF. Tuberculosis. Curr Opin Ophthalmol. 2007;18:493-

501.

2. Pathanapitoon K, Kunavisarut P, Ausayakhun S, Sirirungsi W,Rothova A. Uveitis in a tertiary ophthalmology centre in Thai-land. Br J Ophthalmol. 2008;92:474-8.

3. Pathanapitoon K, Kunavisarut P, Sirirungsi W, Rothova A.Looking for ocular tuberculosis: Prevalence and clinical mani-festations of patients with uveitis and positive QuantiFERON(˙)-TB Gold test. Ocul Immunol Inflamm. 2016;16:1-8.

4. Gupta V, Gupta A, Rao NA. Intraocular tuberculosis-an up-date. Surv Ophthalmol. 2007;52:561-87.

5. Abu El-Asrar AM, Abouammoh M, Al-Mezaine HS. Tubercu-lous uveitis. Int Ophthalmol Clin. 2010;50:19-39.

6. Gupta A, Bansal R, Gupta V, Sharma A, Bambery P. Ocularsigns predictive of tubercular uveitis. Am J Ophthalmol. 2010;149:562›70.

7. Apinyawasisuk S, Rothova A, Kunavisarut P, PathanapitoonK. Clinical features and etiology of retinal vasculitis in NorthernThailand. Indian J Ophthalmol. 2013;61:739-42.

8. Ang M, Chee SP. Controversies in ocular tuberculosis. Br JOphthalmol. 2017;101:6-9.


§”·π–π”°“√§—¥°√Õß∑“ß®—°…ÿºŸâªÉ«¬∑’Ë„™â¬“ Chloroquine(CQ) ·≈– Hydroxychloroquine (HCQ)

‡ªìπ∑’Ë∑√“∫°—π¥’«à“ chloroquine ·≈– hydroxy-

chloroquine ‡ªìπ¬“∑’Ë¡’ª√–‚¬™πå„™â„π°“√√—°…“‚√§∑“ß

Õ“¬ÿ√°√√¡¡“°¡“¬‡™àπ SLE, ‚√§¢âÕ√Ÿ¡“μ‘ —Ë¡ (rheumatoid

arthritis) ‡ªìπμâπ ·≈–‡ªìπ¬“∑’Ë¡’¿“«–·∑√° âÕπμàÕ√à“ß°“¬

πâÕ¬ ·μà¬“°≈ÿà¡π’È¡’æ‘…μàÕ®Õª√– “∑μ“ ‚¥¬®–∑”≈“¬‡´≈≈å

√—∫· ß°àÕπ μàÕ¡“∑”≈“¬‡¡Á¥ ’ ®π∑”„Àâ®Õª√– “∑μ“∫“ß

¡’º≈μàÕ°“√¡Õß‡ÀÁπ∑—Èß„π‡«≈“°≈“ß«—π ·≈–°≈“ß§◊π „πºŸâªÉ«¬

∫“ß°≈ÿà¡Õ“®‡°‘¥°“√∫«¡¢Õß∫√‘‡«≥®ÿ¥√—∫¿“æ (cystoid

macular edema) πÕ°®“°π’È¬“°≈ÿà¡π’È‚¥¬‡©æ“– chloro-

quine °Á¬—ß¡’º≈μàÕ°√–®°μ“ ∑”„Àâ‡°‘¥°“√§«“¡º‘¥ª°μ‘¢Õß

º‘«™—ÈππÕ°¢Õß°√–®°μ“ (verticillata ) ‰¥âÕ’°¥â«¬ „πªí®®ÿ∫—π

¬—ß‰¡à “¡“√∂À“«‘∏’ √—°…“¿“«–º‘¥ª°μ‘∑’Ë®Õª√– “∑μ“π’È„Àâ

°≈—∫¡“‡ªìπª°μ‘‰¥â ·¡â·μà°“√À¬ÿ¥¬“°Á¬—ß‰¡à “¡“√∂À¬ÿ¥

ªí≠À“¢Õß¬“°≈ÿà¡π’È ‰¥â∑—π∑’ ¥—ßπ—Èπ°“√§—¥°√ÕßÀ“°≈ÿà¡ºŸâªÉ«¬

∑’Ë‡°‘¥æ‘…®“°¬“°≈ÿà¡ chloroquine ·≈– hydroxychloro-

quine μ—Èß·μà√–¬–·√° ®÷ß¡’§«“¡ ”§—≠ ‡æ◊ËÕ™à«¬ªÑÕß°—π

¿“«–°“√‡ ’¬°“√¡Õß‡ÀÁπ∑’Ë√ÿπ·√ß„πºŸâªÉ«¬∑’Ë„™â¬“°≈ÿà¡π’È

§«“¡™ÿ°¢ÕßºŸâªÉ«¬∑’Ë‡°‘¥ªí≠À“∑’Ë®Õª√– “∑μ“®“°

¬“ hydroxychloroquine ‚¥¬¥Ÿ®“°°“√‡ª≈’Ë¬π·ª≈ß¢Õß

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‚√ßæ¬“∫“≈ μ“ ÀŸ §Õ ®¡Ÿ°

Special Article/∫∑§«“¡æ‘‡»…

≈“π “¬μ“™π‘¥ 10-2 ·≈– spectral domain OCT æ∫«à“

¡’∂÷ß√âÕ¬≈– 7.5 „π‡«≈“ 5 ªï ‚¥¬¡’ªí®®—¬‡ ’Ë¬ß„π°“√‡°‘¥

®Õª√– “∑μ“‡ªìπæ‘… ¥—ßπ’È (μ“√“ß∑’Ë 1)

1. ¢π“¥¢Õß¬“‡∑’¬∫°—∫πÈ”Àπ—°®√‘ß¢ÕßºŸâªÉ«¬

2. √–¬–‡«≈“„π°“√„™â¬“

‚¥¬æ∫«à“ ºŸâªÉ«¬∑’Ë„™â¬“ HCQ < 5 mg/kg ¡’

§«“¡‡ ’Ë¬ß„π°“√‡°‘¥ªí≠À“∑’Ë®Õ¿“æπâÕ¬°«à“√âÕ¬≈– 1 „π

5 ªï·√° ·≈–‡æ‘Ë¡‡ªìππâÕ¬°«à“√âÕ¬≈– 2 ‡¡◊ËÕ„™â¬“¡“ 10 ªï

´÷Ëß§«“¡‡ ’Ë¬ß®–‡æ‘Ë¡¢’Èπ‡ªìπ√âÕ¬≈– 20 À“°„™â¬“¡“π“π∂÷ß

20 ªï ¥—ßπ—Èπ¢π“¥¬“∑’Ë·π–π”«à“ª≈Õ¥¿—¬ ”À√—∫®Õª√– “∑

μ“§◊Õ HCQ < 5 mg/kg μàÕ«—π ·≈– CQ < 2.3 mg/kg

´÷Ëß¬“∑’Ë¡’„™â„π∑âÕßμ≈“¥¢Õß HCQ §◊Õ 200 mg μàÕ ‡¡Á¥

à«π CQ §◊Õ 250 mgμàÕ‡¡Á¥ ¥—ßπ—Èπ∂â“ºŸâªÉ«¬„™â¬“ CQ

1 ‡¡Á¥«—π≈–§√—Èß°Á¬—ß¡“°°«à“¢π“¥∑’Ëª≈Õ¥¿—¬¢Õß¬“μ—«π’È ®÷ß

¡’§«“¡®”‡ªìπμâÕß àßμ√«®μ“ ·≈–§«√π—¥μ“¡¥ŸÕ“°“√Õ¬à“ß

„°≈â™‘¥

3. ºŸâªÉ«¬∑’Ë¡’‚√§‰μ ‡π◊ËÕß®“°¬“°≈ÿà¡π’È¢—∫ÕÕ°∑“ß‰μ

∑”„Àâ„πºŸâªÉ«¬‚√§‰μª√‘¡“≥¢Õß¬“„π°√–· ‡≈◊Õ¥‡æ‘Ë¡¢÷Èπ

‡ªìπ°“√‡æ‘Ë¡§«“¡‡ ’Ë¬ß„π°“√‡°‘¥ªí≠À“μàÕ®Õª√– “∑μ“‰¥â

115§”·π–π”°“√§—¥°√Õß∑“ß®—°…ÿºŸâªÉ«¬∑’Ë„™â¬“ Chloroquine (CQ) ·≈– Hydroxychloroquine (HCQ)

´÷Ëßªí≠À“‚√§‰μ°Á‡ªìπªí≠À“∑’Ëæ∫‰¥â„π°≈ÿà¡ºŸâªÉ«¬∑’Ë„™â¬“™π‘¥

π’È ¥—ßπ—Èπ®÷ß¡’§«“¡®”‡ªìπμâÕß Õ∫∂“¡ ¿“«–‚√§‰μ„πºŸâªÉ«¬

‡æ◊ËÕª√–‡¡‘π§«“¡‡ ’Ë¬ß¢Õß¬“°≈ÿà¡π’ÈμàÕºŸâªÉ«¬

4. °“√„™â¬“ Tamoxifen (¬“√—°…“¡–‡√Áß‡μâ“π¡) √à«¡

°—∫ HCQ À√◊Õ CQ ®–‡æ‘Ë¡§«“¡‡ ’Ë¬ß„π°“√‡°‘¥ªí≠À“μàÕ

®Õª√– “∑μ“¢Õß¬“°≈ÿà¡π’È∂÷ß 5 ‡∑à“ ‚¥¬¬—ß‰¡àæ∫°≈‰°∑’Ë

“¡“√∂Õ∏‘∫“¬§«“¡‡™◊ËÕ¡‚¬ß¢Õß¬“ Õß°≈ÿà¡π’È ‰¥âÕ¬à“ß

™—¥‡®π

5. ºŸâªÉ«¬∑’Ë¡’ªí≠À“∑’Ë®Õª√– “∑μ“·≈–®ÿ¥√—∫¿“æ

Õ¬Ÿà·≈â« °“√„™â¬“Õ“®‡ªìπ°“√‡æ‘Ë¡ªí≠À“„Àâ°—∫ºŸâªÉ«¬ πÕ°

®“°π’È°“√∑’ËºŸâªÉ«¬¡’ªí≠À“∑’Ëμ“Õ¬Ÿà·≈â« ®–∑”„Àâ°“√·ª≈º≈

°“√μ√«®§—¥°√Õß∑”‰¥â¬“°¢÷Èπ

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°“√æ‘ Ÿ®πå∑’Ë™—¥‡®π

®“°°“√»÷°…“∑’Ë‡æ‘Ë¡¢÷Èπ¡“°¡“¬„πªí®®ÿ∫—π ·¡â«à“‡√“®–

¬—ß‰¡à∑√“∫°≈‰°°“√‡ªìπæ‘…¢Õß¬“°≈ÿà¡π’ÈμàÕ®Õª√– “∑μ“

·μà‡√“‰¥â‡√’¬π√Ÿâ«‘∏’∑’Ë®–§—¥°√ÕßºŸâªÉ«¬„π√–¬–‡√‘Ë¡μâπ‰¥â¥’¢÷Èπ

Daily dosageHCQ > 5.0 mg/ kg real weightCQ > 2.3 mg/ kg real weight

Duration of use > 5 yrs, assuming no other risk factorsRenal disease Subnormal glomerular filtration rateConcomitant drug TamoxifenMacular disease May affect screening and susceptibility to HCQ/CQ

CQ = chloroquin; HCQ = hydroxychloroquin.

μ“√“ß∑’Ë 1 ªí®®—¬‡ ’Ë¬ß∑’Ë∑”„Àâ‡°‘¥ toxic retinopathy

Baseline ScreeningFundus examination within first year of useAdd visual field and SD OCT if maculopathy is present

Annual screeningBegin 5 yrs after useSooner in the present of major risk factors

SD OCT = spectral-domain optical coherence tomography

μ“√“ß∑’Ë 2 §«“¡∂’Ë„π°“√μ√«®§—¥°√Õß

°“√«‘π‘®©—¬„πÕ¥’μ ∑’Ë√Õ¥Ÿ≈—°…≥– bullûs-eye maculopathy

ªí®®ÿ∫—π∂◊Õ‡ªìπ°“√μ√«®æ∫∑’Ë™â“‡°‘π‰ª ®÷ß‰¥â¡’§”·π–π”„π

°“√§—¥°√Õß¥—ßπ’È

1. §«“¡∂’Ë„π°“√§—¥°√Õß (¥—ßμ“√“ß∑’Ë 2)

1.1 §«√μ√«®§—¥°√Õß§√—Èß·√°¿“¬„πªï·√°¢Õß

°“√‡√‘Ë¡√—°…“ ‡æ◊ËÕ„™â‡ªìπæ◊Èπ∞“π„π°“√¥Ÿ§«“¡‡ª≈’Ë¬π·ª≈ß

„π§√—ÈßμàÕÊ ‰ª ‚¥¬ ‘Ëß ”§—≠∑’Ë ÿ¥§◊Õ°“√μ√«®®Õª√– “∑μ“

∂â“æ∫§«“¡º‘¥ª°μ‘®÷ß àßμ√«® ≈“π “¬μ“ ·≈– Spectral

domain OCT À“°ºŸâªÉ«¬¡’§«“¡º‘¥ª°μ‘¢Õß®Õª√– “∑μ“

Õ¬Ÿà·≈â« §«√À≈’°‡≈’Ë¬ß°“√„™â¬“°≈ÿà¡π’È

1.2 „π°√≥’∑’Ë„™â¢π“¥∑’Ëª≈Õ¥¿—¬ “¡“√∂√Õ®π

ºŸâªÉ«¬„™â¬“μàÕ‡π◊ËÕß§√∫ 5 ªï®÷ß‡√‘Ë¡μ√«®μ“∑ÿ°ªï‰¥â ·μà„π°√≥’

„π„™â¬“¢π“¥¡“°°«à“∑’Ë·π–π” À√◊Õ¡’ªí®®—¬‡ ’Ë¬ßÕ◊ËπÊ ¥—ß„π

μ“√“ß∑’Ë 1 §«√ ¡’°“√μ√«®§—¥°√Õßªï≈–§√—Èßμ—Èß·μà‡√‘Ë¡¡’°“√

„™â¬“ ‚¥¬°“√§—¥°√Õß∑ÿ°§√—Èß§«√®–¡’°“√∫—π∑÷°¢π“¥¬“

‡∑’¬∫°—∫πÈ”Àπ—° μ—«¢ÕßºŸâªÉ«¬, ªí≠À“‚√§‰μ ·≈–°“√„™â¬“

tamoxifen ‡ ¡Õ ·≈–μ√«®§—¥°√Õß‡√Á«¢÷Èπ‡¡◊ËÕæ∫«à“¡’ªí®®—¬

‡ ’Ë¬ß μ“¡μ“√“ß∑’Ë 1

116 ‡æÁ≠æ√√≥ À‘√—≠‚™μ‘ Vol. 30 No. 2 July-December 2016

√Ÿª∑’Ë 1 · ¥ß§«“¡º‘¥ª°μ‘¢Õß®Õª√– “∑μ“„π§π®’π Õ“¬ÿ 42 ªï∑’Ë‰¥â√—∫ HCQ 8 mg/kg 8 ªï ·≈–μàÕ¡“≈¥≈ß‡À≈◊Õ 4 mg/kg≈“π “¬μ“æ∫°“√‡ ’¬°“√¡Õß‡ÀÁπ∑“ß¥â“π∫π∫√‘‡«≥„°≈â®ÿ¥√—∫¿“æ parafoveal, mfERG æ∫ —≠≠“≥≈¥≈ß ∫√‘‡«≥¥â“π≈à“ß¥â“ππÕ° (inferotemporal) à«π¿“æ¥â“π´â“¬≈à“ß‡ªìπ°“√· ¥ß„Àâ‡ÀÁπ Autofluorescence ∫√‘‡«≥„°≈â¢Õß‡ âπ‡≈◊Õ¥·≈–°“√≈¥§«“¡‡√◊Õß· ß∫√‘‡«≥¢Õ∫πÕ° à«π spectral domain OCT · ¥ß„Àâ‡ÀÁπ™—Èπ‡´≈≈å√—∫· ß∫“ß≈ß

2. ‡∑§π‘§„π°“√μ√«®

2.1 °“√μ√«®≈“π “¬μ“ „π§π‡Õ‡™’¬·π–π”„Àâ

∑”≈“π “¬μ“ HVF 24-2 À√◊Õ 30-2 · ß∑¥ Õ∫ ’¢“«

‡π◊ËÕß®“°æ∫«à“ §π‡Õ‡™’¬¡—°®–‡°‘¥ªí≠À“∫√‘‡«≥∑’Ë‰°≈‰ª

®“°®ÿ¥√—∫¿“æ (parafoveal À√◊Õ vessel arcade) ¥—ß√Ÿª∑’Ë

1 à«π„π§π‡™◊ÈÕ™“μ‘Õ◊ËπÊ ¬—ß·π–π”„Àâ„™â≈“π “¬μ“ HVF

10-2 · ß∑¥ Õ∫ ’¢“« à«π· ß∑¥ Õ∫ ’·¥ßπ—Èπ‰¡à‡ªìπ

∑’Ëπ‘¬¡‡æ√“–«à“∑”¬“° º≈‰¡à§àÕ¬πà“‡™◊ËÕ∂◊Õ ·≈–∑’Ë ”§—≠

¢“¥·ºπ¿Ÿ¡‘°“√‡ª√’¬∫‡∑’¬∫∑’Ë ”§—≠„π°“√·ª≈º≈ (patern

deviation plots) °“√·ª≈º≈®–∂◊Õ§«“¡º‘¥ª°μ‘∫√‘‡«≥

„°≈â®ÿ¥√—∫¿“æ·≈–∫√‘‡«≥∑’ËÀà“ßÕÕ°‰ª‡ªìπ ”§—≠ ‚¥¬∫√‘‡«≥

∑’Ëæ∫§«“¡º‘¥ª°μ‘‰¥â∫àÕ¬¡—°®–‡ªìπ¥â“π®¡Ÿ°∫π¢Õß≈“π

“¬μ“ (superonasal field defect)

2.2 æ∫«à“¡’°“√∫“ß≈ß¢Õß™—Èπ¢Õß‡´≈≈å√—∫· ß

(photoreceptor cell) „°≈âÊ ®ÿ¥√—∫¿“æ™—¥ (parafovea) „π

°≈ÿà¡§π non-Asia ·≈–æ∫„°≈â∫√‘‡«≥À≈Õ¥‡≈◊Õ¥ (arcade)

„π°≈ÿà¡§π‡Õ‡™’¬

¥—ßπ—Èπ°≈ÿà¡§π‡Õ‡™’¬∑’Ë‰¥â√—∫¬“®÷ß§«√μ√«® OCT

„π¡ÿ¡∑’Ë°«â“ß

2.3 °“√μ√«®Õ◊ËπÊ ∑’ËÕ“®¡’ª√–‚¬™πå ‡™àπ mfERG

(®–æ∫§«“¡º‘¥ª°μ‘∫√‘‡«≥„°≈â®ÿ¥√—∫¿“æÀ√◊Õ‰°≈ÕÕ°‰ª

‡≈Á°πâÕ¬ (parafoveal or extramacular), fundus auto-

fluorescence ®–æ∫· ß «à“ß¡“°°«à“ª°μ‘„π®ÿ¥∑’Ë¡’°“√

‡ ’¬‡´≈≈å√—∫· ß

2.4 °“√μ√«®„À¡àÊ ∑’ËÕ“®‡ªìπª√–‚¬™πå·μà¬—ßÕ¬Ÿà

„π°“√∑¥≈Õß ‡™àπ microperimetry, °“√∂à“¬¿“æ adap-

tive optics ¢Õß®Õª√– “∑μ“

3. ‡∑§π‘§°“√μ√«®∑’Ë‰¡à‡ªìπ∑’Ë·π–π”Õ’°μàÕ‰ª ‡π◊ËÕß

®“°¡—°®–æ∫§«“¡º‘¥ª°μ‘™â“‡°‘π‰ª‰¥â·°à

3.1 Fundus examination and photography

3.2 Fluorescein Angiography

3.3 Full-filed Electroretinogram

117§”·π–π”°“√§—¥°√Õß∑“ß®—°…ÿºŸâªÉ«¬∑’Ë„™â¬“ Chloroquine (CQ) ·≈– Hydroxychloroquine (HCQ)

3.4 Amsler-grid

3.5 Time-Domain OCT ¡’§«“¡≈–‡Õ’¬¥‰¡à‡æ’¬ßæÕ

3.6 Color vision

3.7 Electro-oculogram ‰¡à‰¥â√—∫°“√¬Õ¡√—∫„π°“√

μ√«®§—¥°√Õß

°≈à“«‚¥¬ √ÿª „πªí®®ÿ∫—π¡’°“√‡ª≈’Ë¬π·ª≈ß§”·π–π”

„π°“√§—¥°√ÕßºŸâªÉ«¬∑’Ë„™â¬“ chloroquine ·≈– hydroxy-

chloroquine ‚¥¬®ÿ¥ª√– ß§åÀ≈—°„π°“√§—¥°√Õß§◊Õ °“√

§âπÀ“ºŸâªÉ«¬∑’Ë¡’ªí≠À“®“°¬“°≈ÿà¡π’È„π√–¬–·√° μ≈Õ¥®π

„Àâ§«“¡¡—Ëπ„®·°à·æ∑¬å·≈–ºŸâªÉ«¬„π°“√„™â¬“°≈ÿà¡π’ÈμàÕ„π

°√≥’∑’Ë¬—ß‰¡à¡’ªí≠À“ °“√μ√«®§—¥°√Õß®–ª√–‡¡‘π®“°¢π“¥

¬“ √–¬–‡«≈“∑’ËºŸâªÉ«¬„™â ‚√§ª√–®”μ—«∑’Ë¡’ μ≈Õ¥®π¬“∑’Ë

ºŸâªÉ«¬„™â ‚¥¬„πºŸâªÉ«¬∑’Ë¡’ªí≠À“®Õª√– “∑μ“Õ¬Ÿà·≈â« §«√

À≈’°‡≈’Ë¬ß°“√„™â¬“°≈ÿà¡π’È ·≈–«‘∏’„π°“√§—¥°√Õßªí®®ÿ∫—π®–

‡πâπ∑’Ë°“√μ√«®≈“π “¬μ“ ·≈– spectral domain OCT

‡Õ° “√Õâ“ßÕ‘ß1. Marmor MF, Kellner U, Lai TYY, Melles RB and Mieler WF. for

American Academy of Ophthalology . Recommendations onScreening for Chloroquine and Hydroxychloroquine Retin-opathy (2016 Revision). Ophthalmology 2016:123(6);1386-94.


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‚¥¬ √ÿª®“° Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016

Revision) ¢Õß American academy of Ophthalmology ‚¥¬ æ≠. ‡æÁ≠æ√√≥ À‘√—≠‚™μ‘ ™à«¬°√ÿ≥“ √ÿª‡ªìπ¿“…“‰∑¬

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‚¥¬°“√μ‘¥μàÕ®“° Professor Datuk Dr Muthusamy Palanisamy, JP.Founder: Muthusamy Virtual University of Post Graduate Ophthalmology,†Adjunct Professor, Medical School,University Malaysia Sabah. Malaysia - 88300·®âß„Àâ ¡“™‘°∑’Ë π„®∑√“∫«à“

The Royal College of Surgeons of Edinburgh has decided to reciprocate the IOC BasicSciences and Optic & Refraction Examination with the Part A Ophthalmology Exam.

Those who have passed the exam within 7 years are eligible to appear for their Part BOphthalmology Exam.

A free internet courses for Royal Colleges examinations are available from the MuthusamyVirtual University of Postgraduate Ophthalmology.

The courses are conducted free of charge as a service to international ophthalmology.

To know about the university, please visit: www.mvupgo.com

To enrol for The Royal College of Surgeons of Part B Ophthalmology Exam, send yourmails to: [email protected]

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μ—«Õ¬à“ß°“√‡¢’¬π‡Õ° “√Õâ“ßÕ‘ß5.1 ∫∑§«“¡∏√√¡¥“ „ à™◊ËÕºŸâπ‘æπ∏å∑ÿ°§π∂â“¡’®”π«π 6 §π À√◊ÕπâÕ¬°«à“ (∂â“¡“°°«à“ 6 §π·√° μ“¡¥â«¬ et al) ‚¥¬

„ à™◊ËÕ °ÿ≈°àÕπ·≈–„™â‡§√◊ËÕßÀ¡“¬«√√§μÕπ¥—ßμ—«Õ¬à“ß Dogru M, Katakami C, Miyashita M, Hida E, UenishiM, Tetsumoto K, et al. Ocular surface changes after excimer laser phototherapeutic keratectomy.Ophthalmology 2000;107:1144-52. À√◊Õ‡ªìπ«“√ “√∑’Ëæ‘¡æå‡æ‘Ë¡‡ªìπ°√≥’æ‘‡»… (supplement) ‡™àπ Simaroj P,


Kosalprapai K, Chuckpaiwong V. Effect of laser in situ keratomeilusis on the corneal endothelium. J RefractSurg 2003;19(suppl):237-40.

5.2 ºŸâπ‘æπ∏å‡ªìπ°≈ÿà¡„πÀπà«¬ß“π The Health Care Financing Administration. HCFA Mandates preapproval forcataract surgery. Arch Ophthalmol 1988;106:1358.

Àπ—ß ◊ÕÕâ“ßÕ‘ß5.3 ºŸâπ‘æπ∏å§π‡¥’¬«

Shields MB. Textbook of glaucoma 2nd ed. Baltimore: Williams & Wilkins,1987.5.4 ºŸâπ‘æπ∏å‡ªìπ°≈ÿà¡„πÀπà«¬ß“π

American Medical Association Department of Drugs. AMA drug evaluations 3rd ed. Littleton: PublishingSciences Group,1977.

5.5 ºŸâπ‘æπ∏åÀ≈“¬§π ·μà¡’∫√√≥“∏‘°“√À√◊ÕÀ—«Àπâ“„π°“√π—ÈπPeyman GA, Sanders DR, Goldberg MF. Comps. Principle and practice of ophthalmology vol II. Philadelphia:WBSaunders,1980.

5.6 Õâ“ß‡©æ“–∫∑„¥∫∑Àπ÷ËßAsdourian GK, Lewis RA. The phakomatoses. In : Peyman GA, Sanders DR, Goldberg MF, eds. Principlesand practice of ophthalmology vol II. Philadelphia:WB Saunders,1980:1186-204.

5.7 √“¬ß“π¢ÕßÀπà«¬ß“πNational Center for Health Statistics. Acute conditions:incidence and associated disability, United StatesJuly 1986 - June 1969. Rockville, Md.:National Center for Health Statistics, 1972. (Vital and Health Statistics.Series 10 : Data from the National Health Survey, No. 69) [DHEW publication no (HSM) 72-1036].

‡Õ° “√Õ◊ËπÊ5.8 ∫∑§«“¡®“°Àπ—ß ◊Õ√“¬«—π

Shaffer RA. Advances in chemistry are starting to unlock mysteries of the brain : discoveries could helpcure alcoholism and insomnia, explain mental illness. How the messengers work. Wall street Journal1977Aug12:1(col1),10 (coll).

5.9 ∫∑§«“¡®“°«“√ “√√“¬ªí°…å À√◊Õ«“√ “√√“¬‡¥◊ÕπRouche B. Annals of medicine : the Santa Claus culture. The New York.1971Sep4:66-81.

‡Õ° “√Õ‘‡≈Á°∑√Õπ‘°5.10®“° website

Daiger SP, Rossiter BJF, Greenberg J, Christoffels A, Hide W.Data servicwe and software for indentifyinggenes and mutations causing retinal degeneration. Invest Ophthalmol Vis Sci 1998;39:295 (availablefrom:URL:http://www.sph.uth.tmc.edu/retnet)

5.11®“° CD-ROMDuaneûs Clinical Ophthalmology (CD-ROM). William Tasman, Edwars A Jaeger. Lippincott Williams & Wilkins.2004

°“√ àßμâπ©∫—∫®—¥æ‘¡æå„π Microsoft word „™âμ—«Õ—°…√‡ªìπ cordia new ¢π“¥ 16 ‚¥¬‰¡àμâÕß®—¥∑â“¬¢Õß ∫√√∑—¥ μ—«∫∑§«“¡·≈–√Ÿª

„Àâ·¬°‰ø≈åμà“ßÀ“° ‚ª√¥·®âß™◊ËÕ ∂“π∑’Ë∑”ß“π·≈–À¡“¬‡≈¢‚∑√»—æ∑å¢ÕßºŸâπ‘æπ∏å √«¡∂÷ß¿“æ∂à“¬¢ÕßºŸâπ‘æπ∏å™◊ËÕ·√° àß¡“∑’Ë[email protected] ‰¥â À“° àß e-mail ·≈â«‰¡à¡’°“√μÕ∫°≈—∫¿“¬„π 5 «—π°√ÿ≥“ àß¡“„À¡à


The Thai Journal of Ophthalmology invites submission of an article on clinical, experimental, surgical technique inophthalmology or related field. The submitted articles can be categorized as: original article, case report or caseseries, surgical technique, review article, special article, letter to editor and miscellaneous.

The author(S) can submit an article by sending a printed copy of the article and file(S) of CD to the editor at theDepartment of Ophthalmology, Faculty of Medicine Ramathibodi Hospital, Rama 6 road, Rajthewee, Bangkok,Thailand10400, or sending files via email at [email protected]. The editor will send back the notification of receivingthe manuscript within 1 week. If the author does not receive the notification, please resend the manuscript or contactthe editor. All articles will be sent to reviewers. It is the authorûs corresponding to check the status of yourmanuscript. The editor will send reviewersû comment to the author if there is. The accepted publication will benotified to the author after satisfying the reviewers and editorial board.

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The editorial board adheres to the Uniform Requirements set by the International Committee ofMedical Journal Editors (http://www.icmje.org/) for authorship. Each author must meet criteria forauthorship. To qualify for authorship, authors must make substantial contributions to the intellectualcontent of the paper in three categories.Category 1: conception and design, data acquisition or data analysis and interpretation.Category 2: drafting the manuscript and or critical revision of the manuscript.Category 3: statistical analysis, obtaining funding, administrative, technical or material support, orsupervision.An author must take responsibility for at least one component of the work, should be able to identifywho is responsible for each other component, and should ideally be confident in their co-authorsûability and integrity. All authors must declare about financial interests in any products mentioned

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2. The article should compose of several sections as necessary. The sections are: introduction, materials andmethods, results, discussion and acknowledge.

3. Tables. Tables should be separated from the article text.4. Figures. Figures and legends should be separated from the article text. The figures should be saved in

TIFF,BMP or JMEG format .5. References. References should be written in çVancouveré style. If the reference is from the internet, the

authors should provide the URL and the access date.Reference from Journal: The authors should list up to 6 authors. If the referred article have more than 6authors, list only 6 authors and followed by et al.Eg. Dogru M, Katakami C, Miyashita M, Hida E, Uenishi M, Tetsumoto K, et al. Ocular surface changes afterexcimer laser phototherapeutic keratectomy. Ophthalmology 2000;107:1144-52.

from book :Asdourian GK, Lewis RA. The phakomatoses. In : Peyman GA, Sanders DR, Goldberg MF, eds. Principlesand practice of ophthalmology vol II. Philadelphia: WB Saunders,1980:1186-204.

from CD-ROM:Duaneûs Clinical Ophthalmology (CD-ROM). William Tasman, Edwars A Jaeger. Lippincott Williams &Wilkins. 2004

from website:Daiger SP, Rossiter BJF, Greenberg J, Christoffels A, Hide W.Data servicwe and software for indentifyinggenes and mutations causing retinal degeneration. Invest Ophthalmol Vis Sci 1998;39:295 (availablefrom:URL:http://www.sph.uth.tmc.edu/retnet)


‡√◊ËÕß∑’Ë 2 Àπâ“ 90

Figure 1. Preoperative, 1-month and 3-month postoperative astigmatism (diopter)

Figure 2. Preoperative and postoperative vertical component (K1) of the vector analysis ofastigmatism


‡√◊ËÕß∑’Ë 2 Àπâ“ 91

Figure 3. Preoperative and postoperative horizontal component (K2) of the vector analysis ofastigmatism

Figure 4. Preoperative and postoperative astigmatism (diopter) categorized by severity ofpreoperative astigmatism


‡√◊ËÕß∑’Ë 3 Àπâ“ 98

Figure 2. Nasal pterygium

Figure 1. Age-pterygium


‡√◊ËÕß∑’Ë 3 Àπâ“ 99

Figure 3. Asso factor-pterygium

√Ÿª∑’Ë 1 ≈—°…≥–∑“ß°“¬¿“æ¢ÕßÀ≈Õ¥‡≈◊Õ¥∫π„∫Àπâ“ (®“° Carruthers JD Blindness caused by cosmetic filler injection:a review of cause and therapy. Plast Reconst Surg 2014;134:1197-201)

‡√◊ËÕß∑’Ë 4 Àπâ“ 103


√Ÿª∑’Ë 2 · ¥ßÀ≈Õ¥‡≈◊Õ¥·¥ß ophthalmic ·≈– “¢“ √«¡∂÷ßμ”·Àπàß∑’Ë‡°‘¥°“√Õÿ¥μ—π‰¥â (®“° Kyu Hyung P. Iatrogenic Occlu-sion of the Ophthalmic Artery After Cosmetic Facial Filler Injections A National Survey by the KoreanRetina Society. JAMA Ophthalmol. 2014;132(6):714-723)

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√Ÿª∑’Ë 3 μ”·Àπàßμà“ßÊ ¢Õß°“√©’¥ “√ filler ∫π„∫Àπâ“ ‰¥â·°à μ”·Àπàß®ÿ¥ ’ â¡ ·°â√‘È«√Õ¬∑’ËÀπâ“º“°,μ”·Àπàß®ÿ¥ ’·¥ß ·°â√‘È«√Õ¬∑’ËÀ—«§‘È«, μ”·Àπàß®ÿ¥ ’‡À≈◊Õß ·°â√‘È«√Õ¬∑’Ë‡ª≈◊Õ°μ“, μ”·Àπàß®ÿ¥ ’™¡æŸ ·°â√‘È«√Õ¬μ’π°“, μ”·Àπàß®ÿ¥ ’‡¢’¬«ÕàÕπ ·°â√‘È«√Õ¬∑’Ë‡ª≈◊Õ°μ“≈à“ß, μ”·Àπàß®ÿ¥ ’‡¢’¬«‡¢â¡ ·°â ‰¢·°â¡À¬àÕπ§≈âÕ¬, μ”·Àπàß®ÿ¥ ’πÈ”‡ß‘π ‡ √‘¡®¡Ÿ°, μ”·Àπàß®ÿ¥ ’øÑ“‡μ‘¡√àÕß·°â¡, μ”·Àπàß®ÿ¥ ’πÈ”‡ß‘π‡¢â¡ ‡μ‘¡ª“°„ÀâÕ«∫Õ‘Ë¡, μ”·Àπàß®ÿ¥ ’‡∑“ ·°â ‰¢√Õ¬¬àπ ∑’Ë§“ß ·≈–μ”·Àπàß®ÿ¥ ’¥”ª√—∫√ŸªÀπâ“„ÀâÕ«∫Õ‘Ë¡ (From ; Avoiding and Treating Blindness from filler: A review of the world literature. KatieB. Dermatol surg 2015;41L1097-1117)

√Ÿª∑’Ë 1 ¿“æ∂à“¬®Õμ“¢â“ß¢«“· ¥ß choroidal granuloma „πºŸâªÉ«¬‡Õ¥ å∑’Ë¡’°“√μ‘¥‡™◊ÈÕ«—≥‚√§∑’ËªÕ¥

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√Ÿª∑’Ë 2 ¿“æ∂à“¬®Õμ“¢â“ß¢«“· ¥ß serpiginous-like choroiditis °àÕπ·≈–À≈—ß°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§°. · ¥ß multifocal choroiditis ¡’≈—°…≥–‡ªìπ serpiginous-like choroiditis √à«¡°—∫«ÿâπμ“Õ—°‡ ∫ „πºŸâªÉ«¬™“¬Õ“¬ÿ

50 ªï∑’Ë¡’º≈∑¥ Õ∫ QuantiFERON˙-TB Gold ‡ªìπ∫«°∑’Ë√–¥—∫ 2.62 IU/mL ·≈– tuberculin skin test æ∫∫√‘‡«≥°√–¥â“ß (induration) ‡ âπºà“»Ÿπ¬å°≈“ß¢π“¥ 25 ¡‘≈≈‘‡¡μ√ ‚¥¬∑’Ë X-ray ªÕ¥‡ªìπª°μ‘

¢. · ¥ß multifocal choroidal atrophy ·≈– scar ¿“¬À≈—ß°“√√—°…“¥â«¬¬“μâ“π«—≥‚√§

°. ¢.

‡√◊ËÕß∑’Ë 5 Àπâ“ 111

√Ÿª∑’Ë 3 ¿“æ∂à“¬®Õμ“¢â“ß¢«“· ¥ß retinal periphlebitis „πºŸâªÉ«¬™“¬Õ“¬ÿ 34 ªï∑’Ë¡’º≈∑¥ Õ∫ QuantiFERON˙-TB Gold‡ªìπ∫«°∑’Ë√–¥—∫ 3.5 IU/mL ‚¥¬∑’Ë tuberculin skin test ·≈– X-ray ªÕ¥‡ªìπª°μ‘

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Documents

00 Roman 2/2016 OKrcopt.org/images/uploads/Ophthalmo J 30_2_2016.pdf · Recommendations on screening for chloroquin and hydroxychloroquin retinopathy Phenpan Hirunyachote, M.D. Editorial