Clinical Diagnosis and Management of Dry Eye and Ocular Surface Disorders (Xero-Dacryology) Ashok Garg, John D Sheppard, David Meyer, Cyres K Mehta
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1Clinical Diagnosis and Management of DRY EYE and OCULAR SURFACE DISORDERS (Xero-Dacryology)
3Clinical Diagnosis and Management of DRY EYE and OCULAR SURFACE DISORDERS (Xero-Dacryology)
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 125005 India John D Sheppard MD MMSc Clinical Director-Thomas R Lee Center for Ocular Pharmacology Ophthalmology Program Director Associate Professor of Ophthalmology Eastern Virginia Medical School Norfolk, Virginia 23501, USA Eric D Donnenfeld MD FACS Clinical Associate Professor North Shore University Hospital and Nassau County Medical Center Founding Partner Ophthalmic Consultants of Long Island Rockville Center, New York, USA David Meyer M Med FCOphth PhD Professor and Head Department of Ophthalmology Faculty of Health Sciences University of Stellenbosch Tygerberg, 7505 South Africa Cyres K Mehta MS FAGE FSVH FNRERF FSEC Director and Consultant Ophthalmic Surgeon Dr Mehta's International Eye Institute 147, Shahid Bhagat Singh Road Colaba, Mumbai 400005 India Foreword: Juan Murube
4Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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
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Clinical Diagnosis and Management of Dry Eye and Ocular Surface Disorders (Xero-Dacryology)
© 2006, Ashok Garg, John D Sheppard, Eric D Donnenfeld, David Meyer, Cyres K Mehta
All rights reserved. No part of this publication and Interactive 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 editors and the publisher.
First Edition : 2006
Typeset at JPBMP typesetting unit
Printed at Gopsons
5Dedicated to
—Ashok Garg
—John Sheppard
—Eric Donnenfeld
—David Meyer
—Cyres K Mehta6
7Contributors 13Foreword
When more than three hundred million years ago crossopterygian fish gave rise to amphibians—our ancestors—they needed to maintain their very complex corneo-lenticular eyes wet, not only for cornea maintenance and metabolism, but also to allow a smooth refractive tear film able to give the best possible retinal images. So, they modified and developed different glands, mainly of naso-buccal origin, to produce tear, a complex palpebral system, to spread and protect the lacrimal film, and a complex emunctory lacrimal pathway. Hence the first two types of tear appeared: basal and reflex tears. Much more recently, a third type of tear appeared in humans, the emotional tear, which was for expressing intercommunication with other humans. How and why? when mammals meet other animals the first thing they look at is their face. They know that the two most important organs for forming an interrelation are the eyes, used for observing and sizing each other up, and the mouth, used for attacking. These two organs made the face the most important point of their mutual attention when they met. Therefore, little by little the face became the most important organ of interrelation, and the muscles of the face developed a great number of contractions, mainly related with the eyes and the mouth, in order to express hundreds of expressions: friendship, attention, happiness, fury, sadness, anguish…. Our ancestors manifested so many different things with different combinations of their facial musculature, that they needed to introduce non-muscular signs to exhibit other sentiments using mime language. So, humans, who had used up practically all their combination of facial mimes to manifest different expressions, began to shed emotional tears, to express an appeal for help, or just the opposite, solidarity, offering help. The reason why they chose this new way to express these sentiments could be that they took as point of reference the reflex tears produced due to pain of the ocular surface as a result of wounds or foreign bodies, as manifestation of affliction and grief.
The complex organ of tearing has a concomitant pathology. It began to be known little by little from the prehistory of humans, and it was mentioned in the first written literature. As in other branches of human 14pathology, medical, psychological and surgical treatments merged in a common profession. Ophthalmology was developed among quacks, sorcerers, physicians and surgeons, and was mainly comprised by ocular surface and dacryology.
Scientific medicine reached a good level and complexity in the last centuries, as logic rejected extranatural concepts and based its conceptions in reasonable deductions and verifiable experiences. Medicine began to develop specialties because of the impossibility of a single person to domain the many different fields of pathology. One of these specialties is ophthalmology. Specialties or proto-specialties have recently become more and more complex, and the necessity of good results, made these proto-specialties divide into deutero-specialties or second generation specialties, also named super-specialties, subspecialties, hyper-specialties, or ultra-specialties, including in ophthalmology many, such as glaucomatology, retinology, strabology, cataractology, infections … and among these in the last years of the last century appeared the deutero-speciality of dacryology. Deutero-specialties are gradually dividing into new branches named trito-specialties or third generation specialties. In dacryology the two that are clearest at this moment are xero-dacryology (Gr. xeros = dry), dedicated to the dry eye, and odo-dacryology (Gr. odos = way), dedicated to lacrimal pathways.
Dry eye is the most frequent pathology of ophthalmology, that in its mild grade of severity will affect practically 100 percent of the population. So, xero-dacryology is becoming a very important branch of ophthalmology. The present book is an expression of the increasing interest in this condition, not only because of its topic on dry eye, but because of the good selection of the topics, and the efficacy and clarity with which they have been treated. In this book, the physiology of the tear film and ocular surface has been explained, the etiopathogenesis of the problems clearly and easily shown, and the treatments didactically expounded with great clarity. I hope this book by Dr Ashok Garg and Co-editors will be a landmark in the field of xero-dacryology.
Dr Juan Murube MD PhD
Professor of Alcala University
President, International Society of Dacryology and Dry Eye
President, Spanish Society of Ophthalmology,
C / Moralazarzal Steet 43,28034, Madrid, SPAIN
Tel. 34-917350760
Tear film which covers the exposed part of the ocular globe is a complex trilaminar structure which is clinically important for the optical integrity and normal functions of the eye. The tear film plays an important role in visual acuity. Decrease in quality/quantity of the tear film may introduce optical aberrations which leads to poor retinal image quality.
Dry Eye syndrome is an extremely common and often unrecognized disease. Due to wide variety of presentations and symptoms it often frustrates the ophthalmologists as well as patients. Due to multifactorial and elusive etiology it is often challenging to treat Dry Eye. Ocular surface disorders are also clinically important to treat specially in term of visual acuity to the satisfaction of patients.
In this International Book 32 chapters contributed by leading International experts of this field cover all aspects of Dry Eye and Ocular Surface disorders. New therapeutic options beyond the customary aqueous tear replacement, latest surgical options have been included in this book for the benefit of practising ophthalmologist. Latest amniotic membrane transplantation techniques and stem cell surgery to treat ocular surface disorders are added attraction of this book.
We are highly thankful to Shri JP Vij (CEO) Jaypee Brothers Medical Publishers, Mr Tarun Duneja (General Manager Publishing) and all staff members of the publishing house who extended every possible help in the preparation of this International Book at a short notice.
At the last we are quite hopeful to provide complete information on Dry Eye and Ocular Surface Disorders (Xero-Dacryology) to our readers in this compact and handy book.