CORNEAL ULCERS

Diagnosis and Management

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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