Editors Ashok Garg MS PHD FIAO (Bel) FRSM ADM FAIMS FICA
International and National Gold Medalist Medical Director Garg Eye Institute and Research Centre
235-Model Town, Dabra Chowk Hisar 125 005, India
Jes N Mortensen MD
Consultant Ophthalmologist Eye Department of Central Hospital
Jonkoping, Sweden
Giorgio Marchini MS DO FRSH FIOS
Chairman and Medical Director Mehta International Eye Institute and Colaba Eye Hospital, Seaside
147, Shahid Bhagat Singh Road Mumbai 400 005, India
Ahmad K Khalil MD PHD
Medical Director Saridar Clinic Building
92, Tahrir St, Dokki, Cairo, Egypt
Shlomo Melamed MD PHD
Profesor of Ophthalmology Sackler Medical School, Tel-Aviv University Head and Chairman Sam Rothberg Glaucoma Centre
Tel-Hashomer, Israel
Jerome Jean-Phillippe Bovet MD
Consultant Ophthalmic Surgeon FMH Clinique de L'oeil,
15, Avenyue Du Bois-de-law Chapelle CH-1213, Onex, Switzerland
Roberto G Carassa MD
Associate Professor of Ophthalmology Director, Glaucoma Service Deptt. of Ophthalmology and Visual Sciences University Hospital, S. Raffaele,
Milano, Italy
Tanuj Dada MD
Additional Professor of Clinical Ophthalmolgoy Dr RP Centre for Ophthalmic Sciences AIIMS,
Ansari Nagar, New Delhi 110 029, India
Cyres K Mehta MS FAGE FSVH FNRERF FSEC
Director and Consultant Ophthalmic Surgeon The Mehta International Eye Institute and Colaba Eye Hospital, Seaside
147, Shahid Bhagat Singh Road Mumbai 400 005, India
Foreword: André Mermoud
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Jaypee Brothers Medical Publishers (P) Ltd
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Mastering the Techniques of Glaucoma Diagnosis and Management
© 2006, Ashok Garg, Shlomo Melamed, Jes Mortensen, Jerome Jean-Phillippe Bovet, Giorgio Marchini, Roberto G Carassa, Keiki R Mehta, Tanuj Dada, Ahmed K Khalil, Cyres K Mehta
All rights reserved. No part of this publication 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 editors and the publisher.
First Edition: 2006
9788180617584
Typeset at JPBMP typesetting unit
Printed at Raplika
6Dedicated to
- My respected Param Pujya Guru Sant Gurmeet Ram Rahim Singh Ji for his blessings and motivation.
- My respected parents, teachers, my wife Dr Aruna Garg, son Abhishek and daughter Anshul for their constant support and patience during all these days of hard work.
- My dear friend Dr Amar Agarwal, a leading International Ophthalmologist from India, for his continued support and guidance.
— Ashok Garg
- To my loving wife Shuvit.
— Shlomo Melamed
- My wife Dr Gunilla Steinwall and my children Sara and Johannes.
— Jes N Mortensen
- Yveric, Luc and Fanny Laure.
- Silvio Korol, who was not only a teacher but also an intellectual guide and a friend.
— Jerome Jean-Phillippe Bovet
- To our magister Prof Luciano Bonomi.
— Giorgio Marchini
- To my collaborators Dr Marina Fiori and Dr Paolo Bettin, for their constant help and support in my clinical work and research.
— Roberto G Carassa
- Zena, the light of my life.
— Keiki R Mehta
- The revered Sufi Saint Hazoor Maharaj Gurmeet Ram Rahim Singh Ji, Dera Sacha Sauda Ashram, Sirsa, Haryana, India.
— Tanuj Dada
- To the memory of a great father, whose open mindedness and guidance will always be there.
- To my mother, my first teacher and supporter, to my wife for her encouragement and patience, to my sons, Hassan and Omar with love.
— Ahmad K Khalil
- My parents for everything.
- To Vini my best friend.
— Cyres K Mehta
7List of Contributors
- Aachal Kotecha phd
- Deptt of Optometry and Visual Science
- City University
- Northampton Square,
- London, EC I V 0HB, UK
- Ahmad K Khalil md phd
- Medical Director, Saridar Clinic Building
- 92, Tahrir St, Dokki, Cairo (Egypt)
- Ahmed Galal md phd
- Vissum/Instituto Oftalmologico
- De Alicante, Alicante, Spain
- Ahmed Mustafa Abdelrahman md
- Asst Professor Ophthalmology
- Cairo University
- 8, Morad Street (Morad Tower)
- Apart, 409, Giza, Egypt
- Amar Agarwal ms frcs frc ophth
- Director
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai 600 086, India
- Amulya Sahu ms
- Sahu Eye Hospital
- A-1, Wimla Apts
- Marve Road, Malad (West)
- Mumbai 400 064, India
- Anand A Bagmar ms
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai 600 086, India
- Anand Agarwal md
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Andre Mermoud md
- Prof of Ophthalmology
- Jules Gonin Eye Hospital
- CH-1004, Lausanne, Switzerland
- Anita Panda md frcs
- Prof of Ophthalmology
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Arun Kshetrapal ms
- Kshetrapal Eye Hospital and Research Centre
- Kutchery Road, Ajmer 305 001, India
- Ashok Garg ms phd fiao (bel) frsm adm faims fica
- Medical Director
- Garg Eye Institute and Research Centre
- 235, Model Town, Dabra Chowk
- Hisar 125 005 (India)
- Athiya Agarwal md do frsh
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai 600 086, India
- Babak Eliassi-Rad md
- University Eye Associates
- Kresga Eye Institute, 4717, St Antonie
- B/vd, Detroit, MI 48201-1423, USA
- BK Nayak md do
- Professor and Head of Ophthalmology
- Deptt., PD Hinduja National Hospital and Medical Research Centre
- Veer Savarkar Marg, Mahim
- Mumbai 400 016
- Bojan Pajic md
- Chief, Cornea and Refractive Surgery
- Deptt, Vision Care, Klinik Pallas,
- Louis Giroud Str 20, 4600 Olten, Switzerland
- Carlos Cortex-Valdes md
- Chairman
- Professor of Ophthalmology
- Deptt of Ophthalmology
- Hospital General Universitario
- Gregorio Maranon, Madrid, Spain
- Chaitra Jayadev mb doms
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No 153, Road No 9
- Major Parmeshwaran Road
- Opp SIWS College, Gate No 3
- Wadala, Mumbai 400 031, India
- Cyres K Mehta ms fage fsvh fnrerf fsec
- Director and Consultant Ophthalmic Surgeon
- The Mehta International Eye Institute and Colaba Eye Hospital, Seaside
- 147, Shahid Bhagat Singh Road
- Mumbai 400 005, India
- Daljit Singh ms dsc
- 57, Joshi Colony, Amritsar, India 143 001
- David Meyer mb ch b m med fcoph
- Professor and Head, Deptt of Ophthalmology
- Faculty of Health Sciences
- University of Stellenbosch, South Africa
- Dong H Shin md
- University Eye Associates
- Kresga Eye Institute, 4717, St Antonie
- B/vd, Detroit, MI 48201-1423, USA
- Ehud I Assia md
- Deptt of Ophthalmology
- Meir Hospital, Sapir Medical Centre
- Tsharnihovski St, 44281, Kafar, Saba, Israel
- FI Hartog mb chb fcoph
- Deptt of Ophthalmology
- Faculty of Health Sciences
- University of Stellenbosch, South Africa
- Giorgio Marchini md
- Head of Eye Clinic
- Deptt of Neurological and Visual Sciences
- University of Verona, Borgo Trento Hospital
- PIe A Stefani, 1, 37126 Verona, Italy
- Guillermo Avalos Urzua md
- Terranova No 676-101, Col Providencia
- Guillermo L Simon-Castellvi md
- Director
- Clinica Oftalmologica Simon
- Simon Eye Clinic, Barcelona, Spain
- Harinder Singh Sethi md frcs
- Assistant Professor
- Dr RP Centre for Ophthalmic Sciences AIIMS, Ansari Nagar, New Delhi 110 029
- Harsh Kumar md
- Chief Glaucoma Service
- Centre for Sight, Safdarjung Enclave
- New Delhi, India
- Hetal Solanki mb doms
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No 153, Road No 9
- Major Parmeshwaran Road
- Opp SIWS College, Gate No 3
- Wadala, Mumbai 400 031, India
- Hijab Mehta ms
- Consultant
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No 153, Road No 9
- Major Parmeshwaran Road
- Opp SIWS College, Gate No 3
- Wadala, Mumbai 400 031, India
- Hitendra B Mehta ms fmrf
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No 153, Road No 9
- Major Parmeshwaran Road
- Opp SIWS College, Gate No 3
- Wadala, Mumbai 400 031, India
- Jairo E Hoyos md phd
- Instituto Oftalmologico Hoyos
- Rambla de Sabadell 62 10
- 08201 Sabadell
- Barcelona, Spain
- Jairo Hoyos-Chacon md
- Instituto Oftalmologico Hoyos,
- Rambla de Sabadell 62 10
- 08201 Sabadell
- Barcelona, Spain
- Jeffrey D Henderer md
- Philadelphia, USA
- Jens Funk md
- Prof of Ophthalmology
- Augenklinik-Universitatsklinikum,
- Killianstr 5, 79106 Freiburg, Germany
- Jerome Jean-Philippe Bovet md
- Consultant Ophthalmic Surgeon, FMH
- Clinique de L'oeil
- 15, Avenyue Du Bois-de-la-Chapelle
- CH-1213, Onex, Switzerland
- Jes N Mortensen md
- Consultant Ophthalmologist
- The Eye Deptt, Orebro University Hospital
- SE-70185, Orebro, Sweden
- Johnny L Gayton md
- Eye Sight Associates
- 216, Corder Road, Warner Robbins
- GA 31088, USA
- Jorge L Alio md phd
- Director
- Instituto Oftalmologico De Alicante
- Avda Denia 111, 03015, Alicante, Spain
- Jose J Martinez-Toldos md phd
- Head of the Ophthalmology Unit in
- the Hospital General Universitario de
- Elche, Alicante, Spain
- Jose L Rodriguez-Prats md phd
- Instituto Oftalmologico De Alicante
- Alicante, Spain
- Jose L Urcelay-Segura md
- Glaucoma Service
- Deptt of Ophthalmology
- Hospital General Universitario
- Gregorio Maranon, Madrid, Spain
- Jose Maria Simon-Castellvi md
- Clinica Oftalmologica Simon
- Simon Eye Clinic, Barcelona, Spain
- Jose Maria Simon-Tor md
- Chairman, Glaucoma Sr Consultant
- Clinica Oftalmologica Simon
- Simon Eye Clinic, Barcelona, Spain
- José Pinós md
- Segorbe 7, 3A, 46004, Valencia, Spain
- JT Lin phd
- 4532, Old Carriage Trail
- OVIEDO, Florida 32765, USA
- Julio Ortega-Usobiaga md
- Glaucoma Service, Deptt of Ophthalmology
- Hospital General Universitario
- Gregorio Maranon, Madrid, Spain
- Kamaljeet Singh ms
- Associate Professor Ophthalmology
- 4A/7, Panna Lal Road, Allahabad, India
- Kaweh Mansouri md
- Jules Gonin Eye Hospital
- Lausanne, Switzerland
- Keiki R Mehta ms do fios
- Chairman and Medical Director
- Mehta International Eye Institute and Colaba Eye Hospital, 147, Shahid Bhagat Singh Road
- Mumbai 400 005, India
- Khristo Takhchide md
- Director General
- SN Fyodorov Eye Microsurgery Complex, Moscow, Russia
- Madhu Nagar ms frcoph
- Consultant Ophthalmologist
- Clayton Eye Hospital
- Wakefield, West Yorkshire, UK
- Mark Wevill mb chb fcs frcs ed
- Consultant Ophthalmologist
- Rosen Eye Associates
- West Pavilion, Harbour City
- Salford Quays, Manchester, M 50 3BH, UK
- Melania Cigales-Jirout md
- Instituto Oftalmologico Hoyos
- Sabadell (Barcelona), Spain
- Michal Schwartz phd
- Professor of Neuroimmunology
- Deptt of Neurobiology
- Weizmann Institute, Israel
- Minudath KB md
- Registrar, Dr RP Centre for Ophthalmic Sciences, AIIMS, Ansari Nagar
- M Marraffa md
- Deptt of Neurological and Visual Sciences
- University of Verona, Borgo Trento Hospital
- PIe A Stefani, 1, 37126 Verona, Italy
- Mohana Majumdar doms fica
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar, New Delhi 110 029
- India
- Mona Pache md
- Augenklinik-Universitatsklinikum
- Killianstr 5, 79106 Freiburg, Germany
- Mordechai Goldenfeld md
- The Sam Rothberg Glaucoma Centre
- Goldschleger Eye Institute
- Sheba Medical Centre, Tel-Hashomer, Israel
- Munish Dhawan md
- Registrar
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Nikolay N Ereskin md
- Consultant
- SN Fyodorov Eye Microsurgery Complex, Moscow, Russia
- Pandelis A Papadopoulos md
- Director Ophthalmological
- Diagnostic and Therapeutic Centre
- Ophthalmo Check Ltd
- 42, Poseidon Avenue, Paleo Faliro
- Athens, Hellas, Greece
- Parul Sony md
- Sr Research Fellow
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar,
- New Delhi 110 029, India
- Pascal Rozot md
- Clinique Monticelli, Marseilles, France
- P Ceruti md
- Deptt of Neurological and Visual Sciences
- University of Verona
- Borgo Trento Hospital
- PIe A Stefani, 1, 37126 Verona, Italy
- Rajamani Murlidhar md
- Consultant
- Shankar Nethralaya, Chennai, India
- Ramanjit Sihota md frcs
- Professor
- Glaucoma Research Facility and Services
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Ramesh Ksheterpal ms
- Kshetrapal Eye Hospital and Research
- Centre, Kutchery Road, Ajmer 305 001, India
- Ranjit H Maniar ms
- 17, Vithal Court, 6th Floor
- 151, August Kranti Marg
- Mumbai 400 036, India
- RC Nagpal ms
- Professor of Ophhalmology
- Himalayan Institute of Medical Sciences Swami Ram Nagar, Jolly Grant
- Dehradun 248 140, Uttaranchal, India
- Richard Fugo md phd
- 100, West Fornance Street
- The Fugo Building
- Norristown, PA 19401, USA
- Richard P Wilson md
- 9th Wallnut Street
- Philadelphia, PA 19107, USA
- R Morbio md
- Deptt of Neurological and Visual Sciences
- University of Verona, Borgo Trento Hospital
- PIe A Stefani, 1, 37126 Verona, Italy
- R Rajalakshmi ms
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai 600 086, India
- Roberto G Carassa md
- Director, Glaucoma Service
- Deptt of Ophthalmology and
- Visual Sciences, University Hospital
- S Raffaele via Olgettina 60
- 20132, Milano, Italy
- Rohit Saxena md
- Assistant Professor
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Ronel van Schalkwyk md
- Deptt of Ophthalmology
- Faculty of Health Sciences
- University of Stellenbosch
- South Africa
- Sanjeev Mittal ms
- Professor of Ophhalmology
- Himalayan Institute of Medical Sciences Swami Ram Nagar, Jolly Grant
- Dehradun 248 140, Uttaranchal, India
- Sarabel Simon-Castellvi md
- Retina Vitreous Department
- Clinica Oftalmologica Simon
- Simon Eye Clinic
- Barcelona, Spain
- Shalini Mohan md
- Senior Resarch Officer
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Shlomo Melamed md ph
- Prof of Ophthalmology
- Sackler Medical School, Tel Aviv Universityu
- Head and Chairman
- Sam Rothberg Glaucoma Centre
- Goldschleger Eye Institute
- Sheba Medical Centre
- Tel-Hashomer, Israel
- S Natarajan ms
- Chairman and Medical Director
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No 153, Road No 9
- Major Parmeshwaran Road
- Opp SIWS College, Gate No 3
- Wadala, Mumbai 400 031, India
- Soosan Jacob md dnb ferc
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Subrata Mandal md
- Registrar
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Sumita Sharma dnb fmrf
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Sunil Choudhary md
- Registrar
- Dr RP Centre for Ophthalmic Sciences
- AIIMS, Ansari Nagar
- New Delhi 110 029, India
- Sunil Moreker ms
- Consultant, Ophthalmology Deptt
- PD Hinduja National Hospital and Medical Research Centre
- Veer Savarkar Marg
- Mahim, Mumbai 400 016
- Sunita Agarwal ms do psvh
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai 600 086, India
- 15, Eagle Street, Langford Town
- Bangalore, India
- Svetlana Toshniwal mb
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No 153, Road No 9
- Major Parmeshwaran Road
- Opp SIWS College, Gate No 3
- Wadala, Mumbai 400 031, India
- Sylvian Roy md
- Jules Gonin Eye Hospital
- CH 1004, Lausanne, Switzerland
- Tanuj Dada md
- Additional Professor of Clinical Ophthalmology, Dr RP Centre for Ophthalmic Sciences, AIIMS
- Ansari Nagar, New Delhi 110 029, India
- T Agarwal force do fics
- Director
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road, Chennai 600 086, India
- Vijay Kumar Dada md
- Sr Consultant
- Ganga Ram Hospital
- Ex-Chief
- Dr RP Centre for Ophthalmic Centre, AIIMS
- Ansari Nagar, New Delhi 110 029, India
- Vivek Kadambi md doms
- Director
- Kadambi Laser Vision Clinic and Research Foundation Pvt Ltd
- 157, Defence Colony, 4th Main Road
- Indira Nagar, Bangalore 560 038, India
- V Velayutham ms
- Regional Institute of Ophthalmology
- Goverment Ophthalmic Hospital
- Egmore, Chennai, India
Rapid evolution of basic sciences, of investigation tools and of medical and surgical management has rendered useful redaction of this new book on glaucoma. For a long time glaucoma was thought as an eye disease involving the intraocular pressure alone with secondary optic nerve head damage and subsequent specific visual field defects. More recently, glaucoma has been defined rather as an optic neuropathy leading to specific changes in the optic nerve head and visual field damage. These typical lesions usually result from a combination of different factors. Elevated intraocular pressure probably being the most important one. Many other risk factors have been proposed and include: vascular disregulation, race, age, congenital disorders, autoimmunity and ganglion cell degeneration. Although in some case, there may be a specific predominant factor, glaucoma usually the result of a combination of risk factors. Good understanding of the mechanisms involved in ganglion cell death could be of paramount importance to allow the most appropriate treatment for each patient. New diagnosis tools are available today and are helping the ophthalmologists to better investigate their glaucomatous patients. Over the last ten years, numerous new therapeutic approaches have also been proposed offering a more efficient therapy with better tolerance and compliance. Topical carbonic anhydrase agents, analogues of prostaglandins and its derivatives, alpha agonists as well as vasodilatators and soon neuroprotective drugs are among the new therapeutic medical agents. New surgical techniques have also been extensively developed in recent years and are well-described in detail in this book.
This book titled Mastering the Techniques of Glaucoma Diagnosis and Management by Dr Ashok Garg and co-editors has 76 excellent chapters divided into four sections. Section I beautifully covers the anatomy, pathophysiology, and diagnostic procedures for glaucoma. Latest techniques specially DCT, SWAP, laser polarimetry and OCT are worth mentioning. Section II essentially covers the various options available in glaucoma management including medical, non-invasive, surgical and laser procedures. This section covers all the surgical and laser techniques in a comprehensive and well-planned manner. Section III elaborates the glaucoma complications and management which is vital for the visual outcome of the patient. Section IV impresses me as it covers recent advances and future hopes in glaucoma management. A number of minimally-invasive glaucoma procedures are explained in a precise manner by International Masters of this field.
The years to come will definitely bring even more rapid advances in our knowledge and therapeutic possibilities. I wish to congratulate Dr Ashok Garg, co-editors and each contributors of the chapters in the book who gave their expertise to promote knowledge of glaucoma. In this way, I hope this book will keep us focus in the search of preventing blindness from glaucoma in the future.
Andre Mermoud
md
Professor in Ophthalmology
Hospital Ophtalmique Gules Gonin and University of Lausanne
Avenue de France, 15
1004, Lausanne, Switzerland
e-mail: andre.mermoud@ophtal.vd.ch
Tel. : +41 21 626 1111
12Preface
According to Latest WHO Survey, Glaucoma is the second largest cause of blindness after cataract worldwide. Glaucoma is multifactorial chronic, progressive disease characterized by increased intraocular pressure resulting in damage to optic nerve and retinal nerve fibers leading to death of retinal ganglion cells with loss of visual function. Early glaucoma diagnosis is imperative so that treatment can be initiated to prevent further damage. Fortunately, the understanding of glaucoma has evolved significantly in last one decade. New technologies and results from various international trials have improved the understanding and management of glaucoma. Latest diagnostic procedures and vast improvement in medical, surgical and laser management of glaucoma has raised the hope to preserve visual function effectively with a minimum side effects at an affordable cost.
This mega book on glaucoma has been written through the collective efforts and hard work of Internationally known glaucoma surgeons with the aim of providing latest knowledge on modern glaucoma diagnosis and management complete in one book which is at present not available at International level. The book contains 76 chapters divided into four sections covering all aspects of glaucoma from classification, pathophysiology to various diagnostic procedures, medical, surgical and laser management of glaucoma, complications management and specially recent advances and future prospects. All latest techniques available for glaucoma diagnosis and management have been included in this book for the benefit of ophthalmologists who do glaucoma work. Minimally invasive glaucoma surgery is special attraction of this book.
Our great appreciations to Shri JP Vij, Chairman and Managing Director, Mr Tarun Duneja, General Manager (Publishing) and all staff members of M/s Jaypee Brothers Medical Publishers Pvt. Ltd. who have put a lot of hard work and efforts to prepare this mega International book and never ruffled to our last minute suggestions and modifications. We are glad to provide a comprehensive and latest information of glaucoma packed in a single book for the ophthalmologists worldwide.
Editors