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Ophthalmic
Signs in Practice
ofMedicine
AmodGupta
ReemaBansal
AmanSharma
ArunKapil
123

Ophthalmic Signs in Practice of Medicine

AmodGupta • ReemaBansal
AmanSharma • ArunKapil
Ophthalmic Signs
in Practice of Medicine

AmodGupta
Advanced Eye Centre, Chandigarh
Post Graduate Institute of Medical
Education and Research
Chandigarh, India
ReemaBansal
Advanced Eye Centre, Chandigarh
Post Graduate Institute of Medical
Education and Research
Chandigarh, Chandigarh, India
AmanSharma
Department of Internal Medicine
Post Graduate Institute of Medical
Education and Research
Chandigarh, India
ArunKapil
Advanced Eye Centre, Chandigarh
Post Graduate Institute of Medical
Education and Research
Chandigarh, India
ISBN 978-981-99-7922-6 ISBN 978-981-99-7923-3 (eBook)
https://doi.org/10.1007/978-981-99-7923-3
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Singapore Pte Ltd. 2023
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Paper in this product is recyclable.

Dedicated to my wife Gunita, daughter Sumedha, and son-in-
https://t.me/medicina_free
law Sachin for always standing by me; my students for keeping
me au courant for more than 45 years of my academic career
and above all, my patients, who reposed their complete trust in
my ability to serve them and learn from them.
—Amod Gupta
Dedicated to my mentor, Prof Amod Gupta, who taught and
inspired me at every step of my training in uveitis and vitreoretina, for his constant support and motivation; my family for
being proud of me and for being my pillar of strength; my
friends for their love and trust; and my patients for believing
me and my abilities to treat them, and for also being a constant
source of my learning.
—Reema Bansal
Dedicated to my father, Balbir Parkash Sharma, my guiding
light; my mother, Sudesh Sharma, my pillar of strength; my
sister, Kusum Sharma, who thinks her brother can do anything;
my wife, Sushmita Sharma, who always stood by me and dealt
with my absence without any complaints and my loving
daughters, Ananya and Sharanya, who are my lifelines.
—Aman Sharma
To my Mentor, Prof. Amod Gupta for raising me to believe that
anything is possible. I feel blessed and proud of working under
his guidance for over 30 years. To Prof. Vishali Gupta, Retina
Head, for her continuous motivation.

To my wife, Suman Kapil, for continuous support and
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encouragement in every step of my life. To my daughter, son-inlaw, son, daughter-in-law, family and friends, and grandsons.
—Arun Kapil

Foreword
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The quest to become an ophthalmologist has become increasingly popular
and competitive. This may be because vision is our most precious sense. An
ophthalmologist has the skill to preserve vision and, in some instances, to
restore vision with just a few delicate motions in an operating theatre. The
attraction lies in the fact that ophthalmology has a major role in some of the
greatest recent medical advances, such as gene therapy and the application of
technology to image anatomy and pathology. For many, ophthalmology
affords the rewards of internal medicine and surgery. The cornea’s clarity
allows the retina and brain to process light and the curious physician to look
inward. And if that physician is knowledgeable and prepared, properly examining a tiny space, 2.5cm from cornea to optic nerve, might reveal many
secrets hidden elsewhere in the body.
In Ophthalmic Signs in the Practice of Medicine, four experts from the
Postgraduate Institute of Medical Education and Research in Chandigarh,
India, share their considerable wisdom and experience so that others may also
skilfully interrogate the eye for clues to diagnosis and therapy. It is vital to
understand that this is an interdisciplinary group led by Amod Gupta, a distinguished emeritus Professor of Ophthalmology. He is assisted by another
talented ophthalmologist, Reema Bansal, a prolic rheumatologist, Aman
Sharma, and an expert in capturing images of the eye, Arun Kapil. Their
insights provide a comprehensive resource which will be of value to the experienced practitioner who has examined the eye for decades, the internist who
wishes to understand more fully the secrets of the eye, or the novice who is
still in training and unsure if ophthalmology is the discipline most attractive
to pursue.
We should be grateful to these authors for the considerable effort to assemble this volume. I am condent that patients will be among the many beneciaries of their insights.
Legacy Devers Eye Institute
JamesT.Rosenbaum
Portland, OR, USA, Corvus Pharmaceuticals
Burlingame, CA, USA
February 28, 2023
vii

Foreword
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Ophthalmology is one of the areas more internists nd most difcult to assess
and interpret. This book Ophthalmic Signs in the Practice of Medicine is a
much-needed book for all general physicians and internists.
The eye is an organ that offers a window into many disease processes. The
absence of ophthalmic signs in many books on Medicine is serious lacunae
that the authors are addressing with this book.
The book authored by Amod Gupta, Reema Bansal, Aman Sharma, and
Arun Kapil is nicely structured with chapters on all signs. The extensive
emphasis on retinal vasculature is excellent and offers the reader clear guidance on interpreting these signs.
The extensive use of high-quality illustrations makes this book stand out
for me.
Ophthalmic signs are spotters; like skin, clinical examination skills are
paramount. Ophthalmology is the last bastion where clinical examination
skills still reign supreme as the rest of Medicine is taken over by emphasis on
laboratory tests and imaging over clinical examination skills.
This book is of value to medical students, postgraduate trainees in general
medicine, trainees in ophthalmology and general practitioners.
The authors are to be congratulated for bringing this book to help diagnose
and assess ocular signs. In the new era of “precision medicine”, it is more
important that clinicians (internists and ophthalmologists) understand each
other’s language and work closely to improve the outcome of multisystem
disease with ocular manifestations.
Paediatric Rheumatology, Bristol Royal Hospital for Children
AthimalaipetV.Ramanan,
Bristol, UK
February 27, 2023
ix

Foreword
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It gives me great pleasure to write the foreword to Ophthalmic Signs in
the Practice of Medicine not only because one of the authors, Professor
Amod Gupta, is a friend of many years but also because this book enables
us to share the vast knowledge and expertise of an internationally
renowned authority in the fields of uveitis and retinal diseases. He is
joined by prolific contributors to the medical sciences, Prof. Reema
Bansal, a professor of Ophthalmology; Prof. Aman Sharma, a Professor
of Rheumatology and internal medicine and Arun Kapil, one of the most
experienced clinical photographers.
Whereas most ophthalmic textbooks are organised according to anatomic or pathogenetic classications, this takes a different approach. Each
chapter focuses on a specic sign (e.g. cotton wool spots) and describes its
signicance, clinical features and pathogenesis. A differential diagnosis of
the sign itself (e.g. cotton wool spots versus medullated nerve bres) is followed by the list of ocular or systemic conditions associated with the presence of the sign in question. Most of these conditions are listed and the
subject of a comprehensive overview of their pathogenesis, clinical features
and, when relevant, therapeutic possibilities. Therefore, more than being a
guide to the differential diagnosis of retinal conditions based on clinical
signs, this book also doubles as an excellent and up-to-date treatise of retinal diseases. For instance, reading and absorbing the chapters on cotton
wool spots, hard exudates, microaneurysms and new vessels will provide
the reader with solid knowledge of the pathogenesis, clinical features and
treatment of diabetic retinopathy.
Each chapter is extensively referenced and profusely illustrated. The many
recent papers from 2020, 2021 and 2022 testify to the authors’ successful
effort to include the most recent knowledge. The high quality of the illustrations (colour photographs, wide eld fundus imaging, uorescein angiography, OCT and OCT-A) substantially adds to the book’s quality.
Without hesitation, I would recommend this textbook to train residents:
starting from observing a clinical sign in their patient, this textbook will take
them on a fascinating journey to explore the rich world of retinal pathology.
xi

xii
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The established practitioner who wants to update his or her knowledge on
retinal pathology will not nd a better source. As an additional bonus, he or
she will benet from the many clinical pearls the authors share with the
reader, wisdom collected during distinguished careers as clinician-scientists.
University of Ghent PhilippeKestelyn,
Ghent, Belgium
March 26, 2023
Foreword
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