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
Jitendar P Vij
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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
9788180617751
Typeset at JPBMP typesetting unit
Printed at Gopsons
5Dedicated 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
- My wife of 25 years, Clelia, whose understanding and patience have allowed my time to be dedicated to the discovery of new treatments of dry eye and other severe ocular diseases, and whose own experience with dry eye has provided me with marvelous insight into the human side of patient concerns.
—John Sheppard
- My wonderful wife and children who make everything possible.
—Eric Donnenfeld
- My dear wife Marita who has inspired all three our children Deidre, Riegardt and Adelle to join me in sharing the joys of the medical profession.
—David Meyer
- My parents for everything.
- To Vini my best friend.
- Amar Agarwal ms frcs frc ophth
- Consultant
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086
- India
- Arif Adenwala ms dnb frcs ico
- Consultant Ophthalmologist
- P Box No. 457
- Zulekha Hospital
- Sharjah (UAE)
- A Ducasse md
- France
- Anand Shroff ms
- Shroff Eye Hospital
- 222, SV Road, Bandra (W)
- Mumbai-400050
- A Rahimi md
- Iran
- Ashok Garg ms phd frsm
- Medical Director
- Garg Eye Institute and Research Centre
- 235-Model Town, Dabra Chowk
- Hisar-125005 (India)
- Ashok Grover md mnams frcs
- Chairman, Deptt of Ophthalmology
- Sir Ganga Ram Hospital
- Rajinder Nagar
- New Delhi-110060 (India)
- C Baudouin md
- France
- C Feinbaum md faao
- Spain
- Charlotte Wolley Dod md
- Hospital de la Santa Creu I Sant Pau
- Department of Ophthalmology
- Universitat Autonoma De Barcelona
- Barcelona
- Spain
- Cristina Simon-Castellivi md
- Clinica Oftalmologica Simon
- Simon Eye Clinic
- Barcelona, Spain
- Cyres K Mehta ms fsvh fage
- Director and Consultant
- Mehta International Eye Institute
- Seaside, 147, Colaba Road
- Mumbai-400005, India
- Dan Davis md
- Chu Vision Institute
- Edina, Minn
- Dharmesh Kar mbbs dnb
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No. 153, Road No. 9
- Major Parmeshwaran Road
- Opp. SIWS College, Gate No. 3
- Wadala
- Mumbai - 400031, India
- David Meyer mmed fcophth phd
- Professor and Head
- Deptt of Ophthalmology
- Faculty of Health Sciences
- University of Stellenbosch
- Tygerberg, 7505, South Africa
- David T Vroman md
- Magill Research Centre for Vision
- Correction, Storm Eye Institute-MUSC
- 167, Ashley Avenue
- Charleston, South Carolina, 29425
- USA
- D Spinelli md
- Italy
- Eric D Donnenfeld md facs
- Clinical Associate Professor
- North Shore University Hospital and Nassau County Medical Center
- 2000 North Village Ave.
- Rockville Center, NY 11570
- USA
- F Holly md
- USA
- F Paulsen md
- Germany
- Gebhard Rieger md
- Paracelsus Society for Balneology and Iodine Research
- Bad Hall, Austria
- Guillermo L Simon Castellvi md
- Clinica Oftalmologica Simon
- Simon Eye Clinic
- Barcelona
- Spain
- G Van Setten md
- Sweden
- Henry D Perry md facs
- Chief of Cornea Service
- Nassau University Medical Center
- East Meadow, New York
- 2000 North Village Ave
- Rockville Center, NY 11570
- USA
- H Hoh md
- Germany
- Hijab Mehta ms doms fcps
- Consultant
- Aditya Jyot Eye Hospital Pvt. Ltd.
- Plot No. 153, Road No. 9
- Wadala, Mumbai-400031
- India
- H Soriano md
- Argentina
- J Duran md
- Spain
- Jessica Matsumoto md
- Chu Vision Institute
- Edina, Minn
- Jes Mortensen md
- Consultant
- The Eye Deptt
- Orebro University Hospital
- SE-70185, Orebro, Sweden
- John D Sheppard md mmsc
- Associate Professor of Ophthalmology
- Microbiology and Immunology
- Clinical Director
- Thomas R Lee Centre for Ocular
- Pharmacology
- Eastern Virginia Medical School
- Norfolk, Virginia 23501
- USA
- Jorge L Alio md phd
- Instituto Oftalmologico De Alicante
- Avda. Denia 111, 03015
- Alicante
- Spain
- JM Benitez del Castillo md
- Spain
- J Nemeth md
- Hungary
- Jose M Simon-Castellvi md
- Anterior Segment Surgeon
- Clinica Oftalmologica Simon
- Simon Eye Clinic, Barcelona
- Spain
- Jose M Simon-Tor md
- Chairman
- Glaucoma Senior Consultant
- Glaucoma Deptt
- Clinica Oftalmologica Simon
- Simon Eye Clinic, Barcelona
- Spain
- José L Güell md
- Instituto De Microcirugia Ocular (IMO)
- Universitat Autonoma De Barcelona
- Barcelona
- Spain
- J Nepp md
- Austria
- Jutta Horwath Winter md phd
- Deptt of Ophthalmology
- Medical University Graz
- Auenbruggerplatz 4
- 8036 Graz
- Austria
- Juan Murube md phd
- Professor of Alcala University
- President
- International Society of Dacryology and Dry Eye, Moralzarzal Street 43
- 28034, Madrid
- Spain
- Keiki R Mehta ms do fios
- Chairman and Medical Director
- Mehta International Eye Institute
- 147, Shahid Bhagat Singh Road
- Colaba Road, Mumbai - 400005
- India
- Kerry D Solomon md
- Magill Research Centre for Vision
- Correction, Storm Eye Institute-MUSC
- 167, Ashley Avenue
- Charleston, South Carolina
- 29425
- USA
- L Chen Zhuo md
- China
- Luis E Fernandez de Castro md
- Magill Research Centre for Vision
- Correction, Storm Eye Institute-MUSC
- 167, Ashley Avenue
- Charleston, South Carolina
- 29425
- USA
- Marco Sales-Sanz md
- Department of Ophthalmology
- Hospital Ramon y Cajal
- Carretera de Colmenar Km 9.100
- 28034-Madrid
- Spain
- O Shalaby md
- Egypt
- Oscar Gris md
- Instituto De Microcirugia Ocular (IMO)
- Universitat Autonoma De Barcelona
- Barcelona, Spain
- Otto Schmut md
- Deptt of Ophthalmology
- Medical University Graz
- Austria
- P Kaynak-Hekimhan md
- Turkey
- P Raus md
- Belgium
- P Sieg md
- Germany
- Rituraj Baurah ms
- Consultant
- Sir Ganga Ram Hospital
- Rajinder Nagar
- New Delhi-110060, India
- Rishi Mohan md dnb frcse
- Director
- MM Eyetech
- 29, Link Road
- Lajpat Nagar-III
- New Delhi-24
- India
- R Javate md
- Phillipines
- Robert Latkany md
- Director
- Eye Clinic NY Eye and Ear Infirmary
- Centre for Ocular Tear Film Disorders at Laser and Corneal Surgery
- Manhattan
- USA
- Rudolf Winkler md
- Paracelsus Society for Balneology and Iodine Research
- Bad Hall
- Austria
- Sabrina Shah-Desai ms frcs
- Adnexal Associate Specialist
- Moorfields Eye Hospital
- City Road
- London EC 1 V2PD
- UK
- Sarabel Simon-Castellvi md
- Retina Vitreous Deptt
- Simon Eye Clinic
- Barcelona
- Spain
- S Cervenka md
- Czech Republic
- Shaloo Bageja ms
- Consultant
- Sir Ganga Ram Hospital
- Rajinder Nagar
- New Delhi-110060, India
- SH Ugurbas md
- Turkey
- S Natarajan ms frvs
- 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-400031
- India
- Steve Pflugfelder md
- Professor and Director of Ocular Surface Center, Department of Ophthalmology
- Baylor College of Medicine
- 6550 Fannin, Suite 1501
- Houston, Texas 77030
- USA
- Sunita Agarwal ms do psvh
- Dr Agarwal's Eye Hospital
- 19, Cathedral Road
- Chennai-600086
- India
- 15, Eagle Street, Langford Town
- Bangalore
- India
- Susmita G Shah ms dnb fico
- Consultant
- Gaurav Laser Academy
- 105-A, Patel Shopping Centre
- Chandavarkar Road, Borivli (W)
- Mumbai-400092
- India
- Svetelana Toshniwal mbbs dnb
- Aditya Jyot Eye Hospital Pvt Ltd
- Plot No. 153, Road No. 9
- Major Parmeshwaran Road,
- Opp. SIWS College
- Gate No. 3, Wadala
- Mumbai - 400031, India
- Tarjani Y Shah mbbs
- Gaurav Laser Academy
- 105-A, Patel Shopping Centre
- Chandavarkar Road, Borivli (W)
- Mumbai - 400092, India
- Yogesh C Shah ms fcps doms
- Medical Director
- Gaurav Laser Academy
- 105-A, Patel Shopping Centre
- Chandavarkar Road, Borivli (W)
- Mumbai - 400092
- India
- Y Ralph Chu md
- Medical Director
- Chu Vision Institute
- Edina
- Minn
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
E-mail : murubejuan@terra.es
15Preface
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.
Editors