CORNEAL ULCERS Diagnosis and Management System requirement: • Windows XP or above • Power DVD player (Software) • Windows Media Player 10.0 version or above • Quick time player version 6.5 or above Accompanying DVD ROM is playable only in Computer and not in DVD player. Kindly wait for few seconds for DVD to autorun. If it does not autorun then please do the following: • Click on my computer • Click the drive labelled JAYPEE and after opening the drive, kindly double click the file Jaypee CORNEAL ULCERS Diagnosis and Management Namrata Sharma MD DNB MNAMS Associate Professor of Ophthalmology Cornea, Cataract and Refractive Surgery Services Dr. Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences, New Delhi India Rasik B Vajpayee MS FRCSEd FRANZCO Head, Corneal and Cataract Surgery Centre for Eye Research Australia Royal Victorian Eye and Ear Hospital University of Melbourne Australia Forewords Hugh R Taylor Peter R Laibson ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad • Kochi • Kolkata • Lucknow • Mumbai • Nagpur Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd B-3 EMCA House, 23/23B Ansari Road, Daryaganj New Delhi 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672 Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683 e-mail: [email protected] Visit our website: www.jaypeebrothers.com Branches • 2/B, Akruti Society, Jodhpur Gam Road Satellite Ahmedabad 380 015, Phones: +91-79-26926233, Rel: +91-79-32988717 Fax: +91-79-26927094, e-mail: [email protected] • 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, +91-80-22372664 Rel: +91-80-32714073 Fax: +91-80-22281761, e-mail: [email protected] • 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089 Fax: +91-44-28193231, e-mail: [email protected] • 4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498 Rel:+91-40-32940929 Fax:+91-40-24758499, e-mail: [email protected] • No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739 +91-484-2395740 e-mail: [email protected] • 1-A Indian Mirror Street, Wellington Square Kolkata 700 013, Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415 Rel: +91-33-32901926, Fax: +91-33-22656075, e-mail: [email protected] • Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar Lucknow 226 016, Phones: +91-522-3040553, +91-522-3040554 e-mail: [email protected] • 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: [email protected] • “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College, Umred Road Nagpur 440 009 (MS), Phone: Rel: +91-712-3245220, Fax: +91-712-2704275 e-mail: [email protected] Corneal Ulcers: Diagnosis and Management © 2008, Namrata Sharma, Rasik B Vajpayee All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editor and the publisher. This book has been published in good faith that the materials provided by authors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition: 2008 ISBN 978-81-8448-217-1 Typeset at JPBMP typesetting unit Printed at Ajanta Dedicated to My parents Dr Ramesh C Sharma and Maitreyi Pushpa, husband Subhash Chandra and daughter Vasavdatta — Namrata Sharma My wife Madhu and children Mihika and Shubhankar — Rasik B Vajpayee Foreword Corneal opacity and scarring is one of the leading causes of vision loss and blindness worldwide. Although cataract may be the leading cause of bilateral blindness, corneal scarring accounts for a significant portion of unilateral and bilateral vision loss. Corneal scarring may result from specific conditions such as trachoma, xerophthalmia or onchocerciasis, or from less specific causes such as microbial keratitis following often relatively trivial trauma. In some areas one quarter of blindness may be due to corneal scarring. One hundred years ago, or even 50 years ago, our ability to treat microbial keratitis was extremely limited. The development of a broad range of antimicrobial agents, anti-inflammatory drugs, and vastly improved and faster diagnostic methods has revolutionized our ability to treat corneal ulcers. The successful outcome for the management of corneal ulceration depends on the prompt use of the appropriate antimicrobials and the careful management of the healing phase. This is easy to say, but is much more involved to achieve. It requires good clinical and diagnostic skills and excellent laboratory services to make the correct diagnosis so as to be able to select the appropriate antimicrobial. The careful management requires the early recognition and correct management of a host of possible complications. Professor Rasik Vajpayee is a corneal surgeon of international renown. He was the Head of the very busy Cornea and Refractive Surgery Services at the RP Centre for Ophthalmic Sciences at the All India Institute of Medical Sciences and recently has taken over as Head of Cornea and Cataract Surgery at Centre for Eye research Australia, University of Melbourne. Both he and Dr Namrata Sharma have a profound knowledge and broad experience in the management of the whole range of corneal diseases and especially corneal ulceration. They have crystallized their experience into a beautiful set of clear and succinct guidelines. This book builds on a systemic approach with a clear statement of the fundamental issues relating to corneal ulceration and the details that are important in the initial assessment. It covers in detail the microbiologic laboratory assessment and treatment options. The section on the surgical management is superb and sets out in a series of simple steps the way to successfully manage the various complications. Professor Vajpayee and Dr Sharma have done us all a real service in compiling so much insight and experience into this easy to follow text. I highly recommend this book to all who have to manage patients with corneal ulceration. Professor Hugh R Taylor AC MD BS FRANZCO FRACS FAAO FACS Ringland Anderson, Professor of Ophthalmology and Head University of Melbourne, Department of Ophthalmology Managing Director, Centre for Eye Research, Australia Foreword Corneal Ulcers: Diagnosis and Management is a must-read reference and resource for every ophthalmologist interested in anterior segment ocular pathology. It contains the most up-to-date information about the recognition and treatment of this very severe and potentially blinding condition. Dr. Rasik Vajpayee and Dr. Namrata Sharma have both published hundreds of papers and chapters in this area and have a vast experience in diagnosing and treating corneal ulcers. They have put their combined knowledge to excellent use by writing an outstanding textbook and guide to the management of these ulcers. From the beginning chapters on the pathogenesis, microbiology and pharmacology of corneal ulcers, the writing is clear, concise and readily absorbed. It is not encyclopedic, but very practical, with superb color photographs and easily read box inserts highlighting the most significant material in the chapters. Their chapter in Section 2 on the work up of a corneal ulcer is particularly illuminating, especially the many color illustrations of microbiological organisms and the havoc they can bring to the cornea. There is an excellent step by step approach to diagnosing and managing corneal ulcers, from the simple ones to the most complex. Drs. Vajpayee and Sharma are particularly gifted in the field of microbiology, and their chapter on investigations of corneal ulcers in Section 2 is extremely well designed, with inclusive but not overwhelming tables on how to proceed with an ulcer work up. In Section 4, the chapters highlight specific types of microbial and immunologic keratitis, including pediatric and peripheral ulcerative keratitis. The writing throughout is again very clear and the photographs complement the text beautifully. The surgical management section includes very high-quality illustrations on the use of glue and bandage contact lenses, conjunctival flaps, therapeutic keratoplasty and phototherapeutic keratectomy, with which both authors have extensive expertise, due to the severe and late-stage ulcerations treated in India. I can strongly suggest, if not emphatically state, that this treatise will be a best-seller around the world and an invaluable aid in addressing the problems of corneal ulceration. Peter R. Laibson MD Professor of Ophthalmology Thomas Jefferson University School of Medicine Director Emeritus Cornea Department Wills Eye Institute Philadelphia, Pennsylvania Preface Corneal ulcer is a major cause of blindness in the developing world. The condition requires early recognition and prompt management