Table Of Content

.! / ; r , of, ~ f -\ ~; I 1 I .1 r Dedication Tothe valiant Polishfighter pilots in the Battle of Britain. .;' .',,:\: For Elscvicr Huttcrworth-Ilcincmilnn: Commissioning Editor: Roherl Edwards Dcvclopmcnt Editor: Kim IkllSOll Production Managcr: Frallcesiljjleck Dcsign: SlIwarl Larkill!1 I l SIXTH EDITION Clinical Ophthalmology A SYSTEMATIC APPROACH Jack J Kanski MD, MS, FRCS, FRCOphth Honorary Consultant Ophthalmic Surgeon Prince Charles Eye Unit King Edward VII Hospital Windsor, UK Artists Terry RTarrant Phil Sidaway ELSEVIER EDINBURGH lONDON NEWYORK OXFORD PHILADELPHIA ST lOUIS SYDNEYTORONTO 2007 r wtv 100 1M I C J rt I Cc' /~ 't BUHERWORTH HEINEMANN ELSEVIER \... ,1 .~2()()7. ElsevierLimited.Allrights reserved. Nopart of this publication may bereproduced, stored inaretrieval system. or transmitted inany form or byany means. electronic. mechanical. photocopying. recording or otherwise. without the prior permission ofthe Publishers. Permissions may besought directly from Elsevier's Health Sciences Rights Department. 16()()John EKennedy Boulevard. Suite 18()().Philadelphia. 1'1\191()3-2899. USA:phone: (+I) 21:; 239\8()4: fax:(+]) 21:; 239 380:;: or,e-mail: [email protected]. Youmay also complete your request on-line viathe Elsevierhomepage (http://www. elsevier.com). byselecting 'Support and contact' and then 'Copyright and Permission'. First published 1984 Second edition 1989 Reprinted 199() (twire). 1992. 1993 Third edition 1994 Reprinted 199:;. 19%. 1997. 1998 Fourth edition 1999 Reprinted 2000. 20m Filth edition 2()()\ Reprinted 20m. 20()6 ISBN-I 3:978-()-08-()44%9-2 ISBN-I():()-08-()44%9-7 British Library Cataloguing in Publication Data Acatalogue record I<)rthis book isavailable from the British Library. Library of Congress Cataloging in Publication Data Acatalog record for this book isavailable from the Library of Congress. Note Knowledge and best practice inthis lIeldarc constantly changing. }\snew research and experience broaden our knowledge. changes inpractice. treatment and drug therapy may become necessary or appropriate. Readers arc advised tocheck the most current in!<JrInationprovided (i)on procedures featured or(ii)bythe manufacturer ofeach product tobeadministered. toverifythe recommended doseor formula. the method and duration ofadministration. and contraindications. Itisthe responsibility ofthe practitioner. relying on their own experience and knowledge ofthe patient. tomake diagnoses. todetermine dosages and the best treatment foreach individual patient. and totake allappropriate safety precautions. Tothe fullestextent ofthe law.neither the P.ublish.er nor the Author assumes any liability forany injury and/or damage to persons or property arising out ofor related toany use of the material contained inthis book. rlw I'lll"islwr your source for books. . journols and multimedia inthe health sciences www.elsevierhealth.com 1M Working together to grow publisher's policyis10use libraries in developing countries papermanufKtured tJOmsustainabIietorests www.dst'vier.com Iwww.bookJid.org I\VWW.sabre.org ELSEVIER ~?"?~,~~~ Sabre Foundation Printed in China Contents Preface to the Sixth Edition .VIII Evaluation ...........................152 Acknowledgements .ix Acquired obstruction. .......................156 Congenital obstruction .158 Ocular Examination Techniques 1 Lacrimalsurgery. ...........................160 Slit-lampbiomicroscopy of the anterior Chronic canaliculitis .........................162 segment 1 Dacryocystitis. .............................163 Fundus examination ... ........................2 Tonometry 8 6 Orbit .165 Gonioscopy .11 Introduction .165 Psychophysicaltests ..........................15 Thyroid eye disease .170 Electrophysical tests ..........................20 Infections .175 Perimetry .24 Inflammatory disease .177 Vascularmalformations .180 2 Imaging Techniques .33 Cystic lesions .. ............................185 Cornea .. ..................................33 Tumours .............................189 Fundus angiography .35 Ultrasonography. ............................44 7 Dry Eye Disorders .205 Optical coherence tomography. ................47 Definitions .205 Imaginginglaucoma ..........................48 Physiology. ................................205 Neuroimaging ...............................52 Classification. ..............................206 Clinicalfeatures .207 3 Developmental Malformations and Specialinvestigations .208 Anomalies. . . . . .. . .. . . . . . . . . . .. . . .. . . . .59 Treatment. ................................211 Eyelids.....................................60 Craniosynostoses ............................64 8 Conjunctiva .215 Mandibulofacialdysostoses .66 Introduction. ..............................215 Cornea. ...................................67 Bacterial conjunctivitis .219 Lens 70 Viralconjunctivitis .226 Iridocorneal dysgenesis 72 Allergicconjunctivitis. .......................229 Globe 78 Cicatrizing conjunctivitis .235 Retina and choroid. ..........................79 Miscellaneous conjunctivitis. ..................239 Optic nerve .82 Degenerations .242 Vitreous .89 Benignpigmented lesions. ....................245 4 Eyelids .93 9 Cornea .249 Introduction .94 Introduction .250 Benign nodules and cysts. .....................95 Bacterial keratitis .. .........................254 Benign tumours .98 Fungalkeratitis ... ..........................260 Malignant tumours ......................109 Viralkeratitis .262 Disorders of lashes .119 Interstiti keratitis .270 Allergic disorders. ..........................123 Protozoan keratitis. .........................270 Bacterial infections ..........................124 Bacterial hypersensitivity-mediated corneal Viral infections .126 disease .274 Blepharitis. ................................128 Rosacea keratitis .277 Ptosis .133 Severe peripheral corneal ulceration .277 Ectropion .140 Neurotrophic keratitis. ......................280 Entropion .145 Exposure keratitis .281 Miscellaneous acquired disorders .146 Miscellaneous keratitis. ......................283 Corneal ectasias ............................288 5 lacrimal Drainage System .151 Corneal dystrophies. ........................290 Anatomy. .................................151 Corneal degenerations .303 Physiology .................................151 Metabolic keratopathies ......................308 Causes of awatering eye. ....................152 Contact lenses ... ..........................310 r vi Contents 10 Corneal and Refractive Surgery .313 Uveitis in bowel disease. .....................462 Keratoplasty. ..............................313 Uveitis in renal disease .462 Keratoprostheses ...........................317 Sarcoidosis .462 Refractive surgery .317 Beh~et syndrome ...........................465 Vogt-Koyanagi-Harada syndrome. .............466 11 Episclera and Sclera ....................323 Parasitic uveitis .............................468 Anatomy..................................323 Viral uveitis. ...............................477 Episcleritis.................................324 Fungal uveitis .483 Scleritis ...................................325 Bacterial uveitis .485 Scleraldiscoloration. ........................334 Primary idiopathic inflammatory choriocapillaropathies (white dot 12 Lens .337 syndromes) ................................492 Introduction .337 Miscellaneous anterior uveitis ............501 Acquired cataract. ..........................337 Miscellaneous posterior uveitis ............504 Management ofage-related cataract ............343 Congenital cataract .361 15 Ocular Tumours and Related Conditions. . .509 Ectopia lentis .367 Benign conjunctival tumours ..................510 Malignant conjunctival tumours ................514 13 Glaucoma .371 Iris tumours .518 Basic sciences. .............................372 Iris cysts .523 Optic nerve head ...........................376 Ciliary body tumours ........................524 Ocular hypertension .380 Tumours of the choroid. .....................527 Primary open-angle glaucoma .382 Tumours of the retina .542 Normal tension glaucoma .380 Tumours of the retinal pigment epithelium. ......557 Primary angle-closure glaucoma .391 Paraneoplastic syndromes .561 Pseudoexfoliation ...........................397 Pigment dispersion ..........................400 16 Retinal Vascular Disease .565 Neovascular glaucoma .......................402 Retinal circulation .566 Inflammatory glaucoma .404 Diabetic retinopathy .566 Lens-related glaucoma .......................408 Retinal venous occlusive disease ...............584 Traumatic glaucoma. ........................411 Retinal arterial occlusive disease. ..............591 Iridocorneal endothelial syndrome 412 Ocular ischaemic syndrome .597 Glaucoma in intraocular tumours ..............414 Hypertensive disease ........................598 Glaucoma in epithelial ingrowth .415 Sickle-cell retinopathy .601 Glaucoma in iridoschisis .415 Retinopathy of prematurity .. .................605 Primary congenital glaucoma. .................417 Retinal artery macroaneurysm .610 Phacomatoses ..............................420 Primary retinal telangiectasis. .................612 Glaucoma medications. ......................421 Eales disease ...............................620 Laser therapy .427 Radiation retinopathy. .......................621 Trabeculectomy .430 Purtscher retinopathy .622 Non-penetrating surgery. ....................437 Benign idiopathic haemorrhagic retinopathy. .....622 Antimetabolites infiltration surgery ............438 Valsalva retinopathy .622 Drainage implants .439 Lipaemia retinalis .622 Takayasu disease. ...........................623 14 Uveitis .441 High-altitude retinopathy. ....................624 Introduction .442 Retinopathy in blood disorders. ...............624 History ...................................443 Specialinvestigations .443 17 Acquired Macular Disorders and Related Clinicalfeatures .447 Conditions. . . .. . . .. . . .. . . . . .. . . .. . . .. .627 Treatment. ................................451 Introduction .627 Intermediate uveitis ...................456 Age-related macular degeneration .629 Uveitis inspondyloarthropathies ...............459 Polypoidalchoroidal vasculopathy ..............644 Uveitis injuvenilearthritis. ...................459 Age-related macular hole. ....................644 Contents vii Central serous retinopathy .647 21 Neuro-ophthalmology .785 Cystoid macular oedema. ....................651 Optic nerve disease .........................786 Macular epiretinal membrane .654 Pupillaryreactions .802 Degenerative myopia ... .....................654 Chiasm .807 Angioid streaks. ............................656 Optic tract ..812 Choroidal folds. ............................659 Optic radiations ............................813 Hypotony maculopathy .659 Striate cortex ..............................815 Vitreomacular traction syndrome ..............660 Higher visualfunction .815 Idiopathic choroidal neovascularization .661 Third nerve .816 Solar retinopathy .662 Fourth nerve .820 Sixth nerve ................................822 18 Fundus Dystrophies .663 Supranuclear disorders of ocular motility. .......825 Retinal dystrophies. .........................663 Chronic progressive external ophthalmoplegia .. .827 Vitreoretinopathies .684 Intracranial aneurysms. ......................828 Choroidal dystrophies ..............690 Nystagmus .830 Migraine .833 19 Retinal Detachment. . . . . . .. . . . . . .. . . . . .695 Facialspasm .836 Introduction .695 Pathogenesis of rhegmatogenous retinal 22 Drug-induced disorders ... . . . . .. . .. . . . . .839 detachment. ...............................701 Keratopathy .839 Pathogenesis of tractional retinal detachment ... .708 Cataract .840 Pathogenesis of exudative retinal detachment 710 Uveitis. ...................................841 Diagnosis of rhegmatogenous retinal detachment .710 Retinopathy .841 Diagnosis of tractional retinal detachment. ......712 Optic neuropathy. ..........................845 Diagnosis of exudative retinal detachment. ......714 Differential diagnosis of retinal detachment ......714 23 Trauma .847 Prophylaxis of rhegmatogenous retinal Eyelid trauma .847 detachment. ...............................717 Orbital fractures .848 Surgery of rhegmatogenous retinal Trauma to the globe .852 detachment. ...............................720 Chemical injuries .864 Pars planavitrectomy ........................726 ........... ... ........869 24 Systemic diseases 20 Strabismus 735 Connective tissue diseases .870 Introduction .735 Spondyloarthropathies ............ ...........882 Amblyopia. ................................746 Inflammatory bowel disease .884 Clinicalevaluation .746 Non-infectious multisystem diseases. ...........885 Heterophoria and vergence abnormalities .766 Systemic infections and infestations .889 Esotropia .767 Mucutaneous diseases .902 Exotropia 772 Metabolic diseases .907 Specialsyndromes .774 Myopathies. ...............................911 Alphabet patterns .778 Neurology .915 Surgery. ..................................780 Leukaemia. ................................921 Index .923 r Preface to the sixth edition Four years have elapsed since the publication of the nfth processes and forthe nrst time descriptions of histology have edition of ClilliCll/Opl1t1w/IIIO/0!l!/. Sincethen many advances been included. have occurred in the speciality including the discovery of The aim of this book is not to replace the many excellent new disease processes as well as treatment modalities and encyclopaedic multi-author texts and exhaustive bibliogra- diagnostic methods. This edition has therefore been phies that are readily available in other publications but to completely revised and expanded to include much new provide the trainee with asystematic. concisely written. well- material. The number of illustrations has been considerably illustrated and easily assimilated single-volume text that increased so that the vast majority of clinical conditions are provides basic knowledge and acts as a stepping-stone from illustrated. The number of chapters has been increased from which the reader can further expand his knowledge of 20 to 24 with new chapters on examination. imaging opht halmology. techniques. congenital anomalies and drug-induced conditions. JJK Emphasis isplaced on understanding pathogenesis of disease Windsor 2007 Acknowledgements I am greatly indebted to many colleagues and ophthalmic ONCOLOGY photographic departments forsupplying images forthis book. Bertil Damato, PhD.FRCS.FRCOphth The source of each image is acknowledged in the legend. I Professor of Ophthalmology. Director Ocular Oncology would also thank my publishers. Caroline Makepeace in Service. Royal Liverpool University Hospital. Liverpool. UK particular. for their support and encouragement over the years. I am very grateful to the following colleagues for NEUROIMAGING reviewing the manuscript and providing many helpful Naomi Sitbain, MRCP,FRCR suggestions: Consultant Radiologist. St.Thomas' and King's College Hospitals. London. UK PATHOLOGY john Harry, FRCPath,FRCOphth CATARACT Honorary Consultant Ophthalmic Pathologist. Academic Richard Packard, MD.FRCS,FRCOphth Unit of Ophthalmology. Birmingham and Midland Eye Consultant Ophthalmic Surgeon. Prince Charles EyeUnit. Centre. Birmingham. UK Windsor. UK ADNEXAL DISEASE PAEDIATRIC OPHTHALMOLOGY Andrew Pearson, MRCp,FRCOphth Ken Nischal, FRCOphth Consultant Ophthalmic Surgeon. Prince Charles EyeUnit. Consultant Ophthalmic Surgeon. Creat Ormond Street Windsor. and Royal Berkshire Hospital. Reading. UK Hospital forChildren. London. UK STRABISMUS NEURO-OPHTHALMOLOGY john Sloper, D.Phil,FRCS,FRCOphth Ben Burton, MA.MRCP,FRCOphth Consultant Ophthalmic Surgeon. Moorl1elds EyeHospital. Fellow in Neuro-ophthalmology. King's College Hospital. London. UK London. UK Ann Mcintyre, DBO.T,BA(Hens) REFRACTIVE SURGERY Former Principal Orthoptist. Moorllelds EyeHospital. Paul Rosen, FRCOphth London. UK Consultant Ophthalmic Surgeon. OxfordEyeHospital. Oxford.UK EXTERNAL DISEASE Stephen Tuft, MA.MChir,MD,FRCOphth GLAUCOMA Consultant Ophthalmic Surgeon. Moorllelds EyeHospital. john Salmon, MD,FRCS,FRCOphth London. UK Consultant Ophthalmic Surgeon. Oxford EyeHospital. Oxford. UK UVEITIS AND SCLERITIS Carlos Pavesio, MD,FRCOphth OVERALL REVIEWER Consultant Ophthalmic Surgeon. Moorllelds EyeHospital. Aasheet Desai, DOMS.FRCS(Ed) London. UK Ophthalmic Surgeon. Prince Charles EyeUnit. Windsor. UK RETINAL DISEASE Vaughan Tanner, BSc,FRCOphth Consultant Ophthalmic Surgeon. Prince Charles EyeUnit. Windsor. and Royal Berkshire Hospital. Reading. UK

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CLINICAL OPHTHALMOLOGY has been a trusted reference through five editions for thousands of students and practitioners. Established as one of the world's leading ophthalmic resources it has now been updated for a new generation of readers with online materials including full text, downloadable images