Clinical Ophthalmology

M edical and S urgical  A pproach

Clinical Ophthalmology
M edical and S urgical  A pproach
Second Edition

Editor
Sandeep Saxena MS MAMS
Member, National Academy of Medical Sciences, India
DAAD Visiting Professor, University of Bonn, Bonn, Germany
Visiting Professor, UNC-Chapel Hill, Chapel Hill, USA
Fellow, Barnes Retina Institute and Anheuser-Busch Eye Institute, St Louis, USA
Fellow, New York-Presbyterian Hospital, New York, USA

Professor, Department of Ophthalmology

CSM Medical University
(Erstwhile, King George’s Medical University)
Lucknow, Uttar Pradesh, India
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd

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Clinical Ophthalmology: Medical and Surgical Approach

© 2010, Sandeep Saxena

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
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publisher.

This book has been published in good faith that the material provided by the contributors is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and the editor will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 2003

Second Edition: 2011

ISBN 978-93-5025-004-4

Typeset at JPBMP typesetting unit

Printed at
 To

My parents
Dr R C Saxena and Mrs Madhu Saxena
&
My family
Sangeeta, Shreeya and Aishwarya
Contributors
Leonardo Akaishi, MD Taraprasad Das, MD, FRCS Albrecht Hennig, MD
Director Director Program Director
Hospital Oftalmólogico de Brasília Head, Retina Service Sagarmatha Choudhary Eye Hospital
Modulo G, Brazil LV Prasad Eye Institute Lahan, Nepal
Harmohina Bagga, MD Bhubaneswar, Orissa, India
Santosh G Honavar, MD, FACS
Formerly, Glaucoma Fellow Sachi Devi, MS Director, Ophthalmic Plastic Surgery
VST Center for Glaucoma Care Glaucoma Service Orbital Diseases and Ocular Oncology
LV Prasad Eye Institute Sankara Nethralaya LV Prasad Eye Institute
Hyderabad, Andhra Pradesh, India Chennai, Tamil Nadu, India Hyderabad, Andhra Pradesh, India
Samar K Basak, MD, DNB
Kumar Doctor, MS Chanda Hingorani, MS
Disha Eye Hospital and Research Center
Doctor Eye Institute Doctor Eye Institute
Barrackpore, Kolkata, West Bengal, India
Mumbai, Maharashtra, India Mumbai, Maharashtra, India
M Baskaran, DO, DNB
Consultant, Glaucoma Service Satpal Garg, MD Subhadra Jalali, MS
Sankara Nethralaya Professor Head, Smt Kanuri Santhamma Retina
Chennai, Tamil Nadu, India Dr Rajendra Prasad Center for Vitreous Center
Ophthalmic Sciences LV Prasad Eye Institute
Arnab Biswas, DOMS, FRCS All India Institute of Medical Sciences Hyderabad, Andhra Pradesh, India
Consultant Oculoplastic and Orbital
New Delhi, India
Surgeon Apjit Kaur, MS
Alo Eye Care Ronnie George, MS, DO, DNB Professor
Kolkata, West Bengal, India Consultant, Glaucoma Service Department of Ophthalmology
Jyotirmay Biswas, MS, FAMS Sankara Nethralaya CSM Medical University
Head, Uveitis Service Chennai, Tamil Nadu, India Lucknow, Uttar Pradesh, India
Sankara Nethralaya Lingam Gopal, MS, DNB, FRCS, FAMS Sushmita Kaushik, MS
Chennai, Tamil Nadu, India Director of Research Assistant Professor
Gagandeep S Brar, MS Medical and Vision Research Foundation Advanced Eye Center
Formerly, Assistant Professor Sankara Nethralaya Postgraduate Institute of Medical
Advanced Eye Center Chennai, Tamil Nadu, India Education and Research
Postgraduate Institute of Medical Chandigarh, India
Education and Research Amod Gupta, MS, FAMS
Chandigarh, India Professor and Head Mohit Khattri, MS
Advanced Eye Center Department of Ophthalmology
Arindam Chakravarti, MS Postgraduate Institute of Medical CSM Medical University
Vitreoretinal Consultant Education and Research Lucknow, Uttar Pradesh, India
Aditya Jyot Eye Hospital Private Limited Chandigarh, India
Mumbai, Maharashtra, India Atul Kumar, MD, FAMS
Preeti Gupta, MS Professor
Sunita Chaurasia, MS
Department of Ophthalmology Dr Rajendra Prasad Center for
Consultant, Cornea Service
CSM Medical University Ophthalmic Sciences
LV Prasad Eye Institute
Lucknow, Uttar Pradesh, India All India Institute of Medical Sciences
Hyderabad, Andhra Pradesh, India
New Delhi, India
Tanuj Dada, MD Vishali Gupta, MS
Associate Professor Associate Professor Poonam Kishore, MS
Dr Rajendra Prasad Center for Advanced Eye Center Professor
Ophthalmic Sciences Postgraduate Institute of Medical Department of Ophthalmology
All India Institute of Medical Sciences Education and Research CSM Medical University
New Delhi, India Chandigarh, India Lucknow, Uttar Pradesh, India
 Ajit B Majji, MD Surinder S Pandav, MS Parveen Sen, MS
Consultant, Smt Kanuri Santhamma Additional Professor Consultant, Vitreoretinal Service
Retina Vitreous Center Advanced Eye Center Sankara Nethralaya
LV Prasad Eye Institute Postgraduate Institute of Medical Chennai, Tamil Nadu, India
Hyderabad, Andhra Pradesh, India Education and Research
Chandigarh, India Mahesh P Shanmugam, DO, DNB,
J Manju, B Opt PhD, FRCS
Electrodiagnostic Department R Priya, M Phil (Opt) Formerly, Consultant Vitreoretinal
Sankara Nethralaya Electrodiagnotic Department Service
Chennai, Tamil Nadu, India Sankara Nethralaya Sankara Nethralaya
Clinical Ophthalmology: Medical and Surgical Approach

Chennai, Tamil Nadu, India Chennai, Tamil Nadu, India

Kanwar Mohan, MS
Jagat Ram, MS Namrata Sharma, MD
Formerly, Associate Professor Professor
Department of Ophthalmology Associate Professor
Advanced Eye Center Dr Rajendra Prasad Center for
Postgraduate Institute of Medical Postgraduate Institute of Medical
Education and Research Ophthalmic Sciences
Education and Research All India Institute of Medical Sciences
Chandigarh, India Chandigarh, India New Delhi, India
R Muralidhar, MS Kavita Rao, MS Rashmi Shetty, MBBS, FRSH
Consultant, Cornea Service Consultant Consultant Cosmetic Physician
LV Prasad Eye Institute Aditya Jyot Eye Hospital Private Limited Revival Clinic
Hyderabad, Andhra Pradesh, India Mumbai, Maharashtra, India Mumbai, Maharashtra, India
Krishna R Murthy, MS Srinivas K Rao DO, DNB, FRCS
Kirti Singh MD, DNB, FRCS
Vitreoretinal Department Formerly, Consultant Cornea Service
Professor, Glaucoma Division
Sankara Nethralaya Sankara Nethralaya
Guru Nanak Eye Center
Chennai, Tamil Nadu, India Chennai, Tamil Nadu, India
Maulana Azad Medical College
Praveen R Murthy, MS, DNB Ritika Sachdev, MS New Delhi, India
Vitreoretinal Department Dr Rajendra Prasad Center for
Ophthalmic Sciences Vinita Singh, MS
Sankara Nethralaya Professor and Head
Chennai, Tamil Nadu, India All India Institute of Medical Sciences
New Delhi, India Department of Ophthalmology
CSM Medical University
Milind N Naik, MS Chinmaya Sahu, MS Lucknow, Uttar Pradesh, India
Consultant, Division of Ophthalmic Uveitis Service
Plastic Surgery, Facial Aesthetic Surgery, Sankara Nethralaya Rajesh Sinha, MD, FRCS
Orbit and Ocular Oncology Chennai, Tamil Nadu, India Assistant Professor
L V Prasad Eye Institute Dr Rajendra Prasad Center for
Hyderabad, Andhra Pradesh, India Virender Sangwan, MS Ophthalmic Sciences
Associate Director All India Institute of Medical Sciences
Arun Narayanaswamy, DNB Director, Cornea and Uveitis Services New Delhi, India
Consultant, Glaucoma Service L V Prasad Eye Institute
Sankara Nethralaya Hyderabad, Andhra Pradesh, India Subijoy Sinha, MD
Chennai, Tamil Nadu, India Dr Rajendra Prasad Center for
Puneet Saxena MS, MBA
Ophthalmic Sciences
S Natarajan, DO Director, Industry Strategy
All India Institute of Medical Sciences
Chairman and Managing Director JDA
New Delhi, India
Aditya Jyot Eye Hospital Private Limited Dallas, USA
Mumbai, Maharashtra, India Sandeep Saxena MS MAMS Late G Sitalakshmi, DO, FRCS
Professor Consultant, Cornea Service
Aditya Neog, DO, DNB Sankara Nethralaya
Department of Ophthalmology
Glaucoma Service Chennai, Tamil Nadu, India
CSM Medical University
Sankara Nethralaya Lucknow, Uttar Pradesh, India
Chennai, Tamil Nadu, India Parul Sony, MD
G Chandra Sekhar, MD Formerly, Senior Research Associate
Canrobert Oliveira, MD Director Dr Rajendra Prasad Center for
Director, Refractive Surgery Head, VST Center for Glaucoma Care Ophthalmic Sciences
Hospital Oftalmólogico de Brasília LV Prasad Eye Institute All India Institute of Medical Sciences
Modulo G, Brazil Hyderabad, Andhra Pradesh, India New Delhi, India
viii
S Sudharshan, DO Hem K Tewari, MD Geeta K Vemuganti, MD
Consultant, Uveitis Service Formerly, Professor and Chief Ophthalmic Pathology Division
Sankara Nethralaya Dr Rajendra Prasad Center for L V Prasad Eye Institute
Chennai, Tamil Nadu, India Ophthalmic Sciences Hyderabad, Andhra Pradesh, India
All India Institute of Medical Sciences Pradeep Venkatesh, MD
Radhika Tandon, MD New Delhi, India Associate Professor
Professor
Dr Rajendra Prasad Center for
Dr Rajendra Prasad Center for Jeewan S Titiyal, MD
Ophthalmic Sciences
Ophthalmic Sciences Professor All India Institute of Medical Sciences

Contributors
All India Institute of Medical Sciences Dr Rajendra Prasad Center for New Delhi, India
New Delhi, India Ophthalmic Sciences
All India Institute of Medical Sciences Lalit Verma, MD
Mukesh Taneja, MS Formerly, Additional Professor
New Delhi, India
Consultant, Cornea Service Dr Rajendra Prasad Center for
L V Prasad Eye Institute Vasumathy Vedantham, MS, FRCS Ophthalmic Sciences
Hyderabad, Andhra Pradesh, India Former Retina Fellow All India Institute of Medical Sciences
Smt Kanuri Santhamma New Delhi, India
Manoj K Tangri, MS
Senior Partner Manager Retina Vitreous Center Lingam Vijaya, MS
Hewlett-Packard Company L V Prasad Eye Institute Head, Glaucoma Service
Fort-Collins, USA Hyderabad, Andhra Pradesh, India Sankara Nethralaya
Chennai, Tamil Nadu, India

ix
Foreword

The pace of change in ophthalmology is rapid and requires us to constantly update our skills and knowl-
edge. We are subspecialized to a degree that demands that we must stay in close communication with our
colleagues to be able to follow the advances occurring in the separate subdivisions of our specialty. In this
challenging intellectual environment, a text bringing together respected authors from multiple disciplines
is particularly welcome, and Dr Saxena has accomplished this task with great success. Twenty-one chapters
cover new concepts and technological advances in the diagnosis and management of common ophthalmic
disorders. Several chapters deal with advances in lens surgery, and several authorities cover new concepts in
retinal disease including macular and submacular surgery. Modern concepts in corneal disease, glaucoma,
oculoplastics, ocular oncology, infectious and inflammatory diseases, strabismus, trauma, and optic nerve
disorders are each presented by experts in ophthalmology. As ophthalmology has become more complex, we are driven to estab-
lish higher standards of scientific proof for our treatments and simultaneously to run our practices with greater efficiency to be
able to bring the best of high technology to bear on our patients’ problems while being mindful of cost. Thus, I was particularly
pleased to see practice management and clinicial trials covered in this text. Dr Saxena is an extraordinarily gifted and energetic
physician and academician who, along with his fellow authors, has produced a book, which is an important contribution to con-
temporary ophthalmic education. Readers will benefit greatly from this accomplishment.

Travis A Meredith MD
Sterling A Barrett Distinguished Professor
Chairman, Department of Ophthalmology
University of North Carolina
Chapel Hill, USA
Preface to the Second Edition

Ophthalmology is a continuously advancing field. As new technologies are being introduced at a rapid
pace, the ophthalmologist must learn their intricacies as one begins to apply them to the treatment of
ocular diseases. The adoption of new technology, in turn, brings with it the need to learn new skills and
develop new treatment algorithms. Old concepts change and new ideas are plentiful. Everything is difficult
before it becomes easy.
Clinical Ophthalmology: Medical and Surgical Approach is being launched as the second edition of Clinical
Practice in Ophthalmology. This text attempts to update the state-of-the-art ophthalmology in a lucid,
authoritative and well-illustrated manner. Ten sections encompassing forty-four chapters provide a new
insight into the subject.
In this challenging intellectual environment Clinical Ophthalmology: Medical and Surgical Approach brings together a distinguished
group of seventy-one experts and provides a comprehensive text combined with integrated visual reference, in the form of black
and white and colored figures. The value of this book lays in the quality and expertise of the text chapter contributors. This book
is intended for the experienced ophthalmologists, postgraduates as well as those in training. It is hoped that this book will be suf-
ficiently comprehensive to aid the ophthalmologist in making diagnosis of common ophthalmic conditions as well as in perform-
ing competent surgeries. This pragmatic book provides an understanding of ophthalmology, important to the everyday practice.
I hope this book will find a meaningful and valued place in the libraries of ophthalmologists, today and in future.

Sandeep Saxena
Preface to the First Edition

With the evolution of new diagnostic and therapeutic modalities, the ophthalmologist has become more involved in decision-
making for patients. The challenge facing the ophthalmologist lies in maintaining an up-to-date practical knowledge. This thirst
for knowledge is typical of those who are fascinated by the subject, but is also true of those who develop a great understanding
of the subject.
Clinical Practice in Ophthalmology, a multi-authored text, was conceptualized in New York, USA. The publisher and the con-
tributing authors were contacted on Internet to lay the groundwork. This book summarizes the present knowledge of clinical
ophthalmology and practice management. The value of this book lies in the quality and expertise of the authors of the selected
subjects. The authors have presented the material to provide the reader with a quick, but comprehensive review of the major
ophthalmological issues. This pragmatic book provides an understanding of diseases so important to the everyday practice of
ophthalmology. I hope this book will find a meaningful and valued place in the libraries of ophthalmologists, today and in future.
This book would not have been possible without the guidance of my mentors, cooperation of my family and help of
Dr SK Bhasker.

Sandeep Saxena
Contents
Section-1 Corneal and External Diseases 1

1. Investigations for Corneal and External Diseases 3

Poonam Kishore, Preeti Gupta
2. External Eye Diseases 14
Samar K Basak
3. Diseases of Cornea 44
Sunita Chaurasia, R Muralidhar, Mukesh Taneja, Virender Sangwan
4. Corneal Surgeries 70
Srinivas K Rao, Late G Sitalakshmi
5. Refractive Surgeries 120
Ritika Sachdev, Namrata Sharma, Rajesh Sinha, Jeewan S Titiyal

Section-2 Glaucoma 137

6. Automated Visual Field Assessment, Optic Nerve and Nerve Fiber Layer Imaging 139
M Baskaran, Arun Narayanaswamy, Lingam Vijaya
7. Optic Disc Assessment 158
Harmohina Bagga, G Chandra Sekhar
8. Primary Congenital Glaucoma 164
Sushmita Kaushik, Surinder S Pandav
9. Primary Angle-Closure Glaucoma 168
Harmohina Bagga, G Chandra Sekhar
10. Primary Open-Angle Glaucoma 177
M Baskaran, Arun Narayanaswamy, Lingam Vijaya
11. Secondary Glaucoma 189
Kirti Singh
12. Investigative Techniques Helpful in Glaucoma Surgeries 217
Tanuj Dada, Parul Sony
13. Glaucoma Surgeries 229
Lingam Vijaya, M Baskaran, Ronnie George, Arun Narayanaswamy, Sachi Devi, Aditya Neog
14. Non-Penetrating Glaucoma Surgeries 261
Kirti Singh
15. Nd:YAG Laser Iridotomy, Selective Laser Trabeculoplasty and Cyclophotocoagulation 266
Sushmita Kaushik, Surinder S Pandav
 Section-3 Cataract 273

16. Technological Advances in Intraocular Lenses and Instrumentation 275

Jagat Ram, Gagandeep S Brar
17. Phacoemulsification 283
Kumar Doctor
Clinical Ophthalmology: Medical and Surgical Approach

18. Microincision Cataract Surgery 317

Kumar Doctor, Chanda Hingorani
19. Multifocal Intraocular Lenses 321
Leonardo Akaishi, Canrobert Oliveira
20. Small Incision Cataract Surgery 326
Albrecht Hennig, Vinita Singh
21. Pediatric Cataract Surgery and Intraocular Lens Implantation 339
Jagat Ram, Gagandeep S Brar

Section-4 Uveitis 347

22. Uveitis 349

Chinmaya Sahu, S Sudharshan, Jyotirmay Biswas
23. Surgery in Uveitis: Diagnostic and Therapeutic 397
Vishali Gupta, Sushmita Kaushik, Amod Gupta

Section-5 Vitreoretinal Diseases 407

24. Investigations in Retinal Diseases 409

Sandeep Saxena
25. Spectral-Domain Optical Coherence Tomography in Macular Diseases 422
Sandeep Saxena
26. Macular and Allied Disorders 431
Pradeep Venkatesh, Lalit Verma, Hem K Tewari
27. Retinal Vascular Disorders 454
Taraprasad Das, Subhadra Jalali, Vasumathy Vedantham, Ajit B Majji
28. Laser Treatment in Posterior Segment Disorders 473
Pradeep Venkatesh, Satpal Garg
29. Anti-Vascular Endothelial Growth Factor Therapy 499
Atul Kumar, Subijoy Sinha
30. Vitreoretinal Surgeries 509
Lingam Gopal
31. Macular Surgeries 563
Sandeep Saxena

xviii
32. Hereditary Vitreoretinal Diseases 593
Parveen Sen, R Priya, J Manju
33. Ocular Oncology 647
Mahesh P Shanmugam, Praveen R Murthy, Krishna R Murthy

Section-6 Diseases of Optic Nerve 671

Contents
34. Optic Nerve Disorders 673
Radhika Tandon, Lalit Verma

Section-7 Diseases of Lid, Orbit and Lacrimal System 687

35. Orbital Imaging 689

Apjit Kaur, Mohit Khattri
36. Diseases of the Eyelid and Orbit 697
Santosh G Honavar, Milind N Naik, Geeta K Vemuganti, G Chandra Sekhar
37. Diseases of Lacrimal Drainage System 720
Arnab Biswas
38. Eyelid and Lacrimal Surgeries 727
Milind N Naik, Santosh G Honavar
39. Periorbital Rejuvenation 759
Milind N Naik, Rashmi Shetty
40. Orbital Surgeries 765
Santosh G Honavar, Milind N Naik

Section-8 Strabismus 775

41. Strabismus 777

Kanwar Mohan
42. Surgical Treatment of Strabismus 796
Vinita Singh

Section-9 Trauma 817

43. Ocular Trauma 819

S Natarajan, Kavita Rao, Arindam Chakravarti

xix
 Section-10 Practice Management 835

44. Ophthalmology Practice Management 837

Sandeep Saxena, Puneet Saxena, Manoj K Tangri

Index 847
Clinical Ophthalmology: Medical and Surgical Approach

Index 847

xx