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Fourth edition
International edition
Alastair K.O. Denniston
Consultant Ophthalmologist & Hon. Professor
Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHSFT, & University of Birmingham, UK & NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, UK
Philip I. Murray
Professor of Ophthalmology & Hon. Consultant Ophthalmologist University of Birmingham, UK Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust, UK
This international edition is only for sale in: Afghanistan, Africa, Bangladesh, Bhutan, Cambodia, China, Egypt, India, Indonesia, Iraq, Jordan, Laos, Malaysia, Myanmar, Nepal, Pakistan, Philippines, Syria, Taiwan, Thailand, Turkey, Vietnam, and Yemen (excluding Australia, Canada, Europe, Hong Kong, Ireland, New Zealand, UK, and US); and not for export therefrom. This edition is not for sale in any other country in the world.
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First Edition published in 2006
Second Edition published in 2009
Third Edition published in 2014
Fourth Edition published in 2018
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Foreword
It is my great pleasure to write the foreword for this fourth edition of the Oxford Handbook of Ophthalmology by Alastair Denniston and Phil Murray. It is over a decade since the first edition was launched, a period which has seen spectacular advances which have directly impacted patient care. Previously untreatable diseases are now treatable, with targeted biological therapies delivered on a hitherto unimagined scale, and gene and cell-based therapies becoming a reality. Previously invisible pathology is now revealed through multi-modal imaging with resolution of a few microns and ultrawidefield capture. National datasets offer the evaluation of outcomes from hundreds of thousands of patients on a routine basis and enable previously untestable hypotheses to be assessed.
As we seek to keep pace with this progress, there is an even greater need to retain a clear understanding of the principles and practice of ophthalmology. The Oxford Handbook of Ophthalmology has become a valued and trusted friend for generations of trainees learning their skills, preparing for exams, and delivering excellent clinical care. For the more experienced among us, it continues to be a remarkably useful vade mecum that ensures we are always up-to-date, particularly in areas outside of our subspecialty interest. This new edition of the Oxford Handbook is again fully revised and updated throughout, reflecting the latest scientific knowledge, national guidelines, and international recommendations. Although the text continues to evolve, the handbook remains true to its original aims, and its highly logical format makes it both easier to learn the theory and faster to navigate when you need to put it into practice.
It has always been remarkable to see how much the authors have managed to pack into a relatively small volume, but they seem to have found room for even more in this edition. In addition, it is now supported by an online supplement, allowing the reader to access accompanying clinical images and other material to help the learning experience. Key advances covering every aspect of eye care are included, and there is greater emphasis on the evidence underlying these developments. This is achieved by an excellent authorship team which represents all specialties, with established clinical leaders balanced by senior trainees to ensure that the text is up-to-the-minute and relevant. The scope of the book recognizes the holistic nature of clinical care and the varying domains in which we work. This new edition of the handbook will continue to help you to improve the care of your patients. The patient remains at the heart of all we do. The Oxford Handbook of Ophthalmology has an essential place among the books that help us all learn, enjoy, and deliver the wonderful specialty that is Ophthalmology.
Sir Peng Tee Khaw Professor
& Consultant Ophthalmic Surgeon, Director, National Institute for Health Research Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, 2018
Preface to the fourth edition
This is an exciting, but also transitional, time for all those involved in the care of patients with eye disease. On the one hand, we can do more than ever before for our patients. Scientific advances mean that we can diagnose earlier, treat previously ‘untreatable’ conditions, and monitor disease more precisely. On the other hand, almost every health service in the world has a major capacity problem—the number of patients with sight-threatening disease increases with demographic change; the care of each patient is becoming more costly; and the expectation of patients is rising all the time. Our great challenge for the next 10 years is likely to be less about incremental advances in diagnostics or therapeutics, but more about how to deliver what is already here on the huge scale that is required.
And this brings us to the point of this book.
The Oxford Handbook of Ophthalmology 4E continues to bring together the most up-to-date knowledge of disease, clinical skills, investigations, and treatment, within one portable and easily navigable volume. We hope that it is more than just a repository of knowledge. As we anticipate a future in which the slit-lamp is replaced by whole-eye multi-modal imaging and the human diagnostic process is overtaken by machine-learning algorithms, there is an even greater need to teach both the scientific method that drives innovation and discovery—and the art of ophthalmic care—those critical aspects of human-to-human interaction that enables patients to feel valued and heard as they seek to make sense of their condition and its treatment.
It is our great privilege—on behalf of a wonderful team of authors—to present to you this fourth edition of the Oxford Handbook of Ophthalmology Whatever your role—and wherever you are in the world—we trust that this edition will continue to inform and inspire you as you care for patients suffering with ocular disease.
AKOD, PIM 2018
Preface to the first edition
Welcome to the first edition of the Oxford Handbook of Ophthalmology.
The aspiration of the OHO is to be your portable repository of knowledge, accessible in emergencies and easily dipped in and out of between examining patients. It provides immediate access to the detailed clinical information you need—in casualty, clinic, and theatre, and on the wards. It is also highly suitable for revision for postgraduate examinations. It is not exhaustive and we would expect it to complement, rather than replace, your collection of desktop ophthalmology heavyweights.
The core of the book comprises a systematic synopsis of ophthalmic disease directed towards diagnosis, interim assessment, and ongoing management. Assessment boxes for common clinical conditions and algorithms for important clinical presentations illustrate this practical approach. The information is easily accessed, being presented in standard format with areas of importance being highlighted. Key sections for the trainee include: clinical skills, aids to diagnosis, and investigations and their interpretation. Basic perioperative care and advanced life support protocols are included, since specialists often find their general medical knowledge somewhat hazy at times of crisis.
Primarily intended for ophthalmologists, this handbook is a valuable resource for anyone working with ophthalmic patients, whether optometrists, orthoptists, ophthalmic nurses, or other health professions in ophthalmology. While the earlier pages may be thumbed mainly by the trainee, it is envisaged that even the experienced Consultant will find the OHO useful. We have tried to include information that you would not easily find elsewhere: vision in context (low vision, registration and benefits, driving requirements), management of systemic disease (diabetes, thyroid disorders, systemic immunosuppression), a glossary of eponymous syndromes, and NICE and RCOphth guidelines.
Although we have endeavoured to provide up-to-date, accurate, evidence-based information, any comments would be gratefully received so that we can make future editions even better. Point your web browser to: www.oup.co.uk/academic/medicine/handbooks/ where you will be able to have your say and to download any updates.
We hope the OHO will be an essential addition to your personal library of ophthalmology textbooks and be an invaluable companion to you in your practice of ophthalmology.
Alastair K.O. Denniston, Philip I. Murray 2006
Chapter authors
Clinical skills
Prof Alastair K.O. Denniston
Prof James Wolffsohn
Ms Rosie Auld
Prof Philip I. Murray
Investigations and their interpretation
Miss Susan P. Mollan
Dr Antonio Calcagni
Mr Pearse A. Keane
Ocular trauma
Maj Richard J. Blanch
Miss Saaeha Rauz
Surg Cdr Malcolm Woodcock
Mr Aidan T. Murray
Mr Andrew Coombes
Prof Alastair K.O. Denniston
Lids
Mr Aidan T. Murray
Miss Saaeha Rauz
Lacrimal
Mr Aidan T. Murray
Conjunctiva
Miss Saaeha Rauz
Cornea
Miss Saaeha Rauz
Mr Sai Kolli
Sclera
Prof Philip I. Murray
Mr Carlos E. Pavesio
Prof Alastair K.O. Denniston
Lens
Mr Sai Kolli
Glaucoma
Prof Peter Shah
Miss Freda Sii
Dr Mark Chiang
Ass Prof Graham Lee
Mr Imran Masood
Uveitis
Prof Alastair K.O. Denniston
Prof Philip I. Murray
Vitreoretinal
Mr Kwesi N. Amissah-Arthur
Mr Ash Sharma
Medical retina
Mr Omar Mahroo
Mr Kamron N. Khan
Prof Alastair K.O. Denniston
Mr Pearse A. Keane
Orbit
Mr Matthew Edmunds
Mr Aidan T. Murray
Mr Omar M. Durrani
Intraocular tumours
Mrs Hibba Quhill
Mr Manoj V. Parulekar
Prof Ian G. Rennie
Neuro-ophthalmology
Miss Susan P. Mollan
Strabismus
Mr Sam Gurney
Mr Joseph Abbott
Paediatric ophthalmology
Mr Abdul-Jabbar Ghauri
Mr Joseph Abbott
Miss Lucilla Butler
Refractive ophthalmology
Mr Sai Kolli
Prof James S. Wolffsohn
Aids to diagnosis
Mr Robert J. Barry
Miss Susan P. Mollan
Mr Mike A. Burdon
Prof Philip I. Murray
Prof Alastair K.O. Denniston
Vision in context
Mr Robert J. Barry
Prof Philip I. Murray
Prof Alastair K.O. Denniston
Surgery: anaesthetics and perioperative care
Dr Shashi B. Vohra
Miss Priscilla Mathewson
Prof Alastair K.O. Denniston
Prof Philip I. Murray
Surgery: theatre notes
Miss Priscilla Mathewson
Prof Philip I. Murray
Prof Alastair K.O. Denniston
Laser
Mr Samer Elsherbiny
Prof Alastair K.O. Denniston
Therapeutics
Mr Avinash Manna
Ms Elaine Mann
Miss Vaneeta Sood
Prof Philip I. Murray
Prof Alastair K.O. Denniston
Evidence-based ophthalmology
Prof Alastair K.O. Denniston
Dr Merrick Moseley
Prof Philip I. Murray
Resources
Miss Rupal Morjaria
Mr Andrej Kidess
Prof Philip I. Murray
Prof Alastair K.O. Denniston
Electronic resources
Dr Mark Lane
Prof Alastair K.O. Denniston
Author affiliations
Mr Joseph Abbott
FRCOphth
Consultant Ophthalmologist
Birmingham Children’s Hospital NHSFT
Mr Kwesi N.
Amissah-Arthur
MBChB FRCOphth FGCS
Senior Lecturer & Consultant
Ophthalmologist
University of Ghana Medical School
Korle Bu Teaching Hospital, Ghana
Ms Rosie Auld
CBE
Head of Orthoptic Services
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
Mr Robert J. Barry
BMedSc MBChB FRCOphth PhD
NIHR Academic Clinical Lecturer
University of Birmingham
West Midlands Deanery
Maj Richard J. Blanch
BSc(Hons) PhD MRCS(Ed)
FRCOphth RAMC
RCDM Clinical Lecturer
Royal Centre for Defence Medicine
University of Birmingham
University Hospitals Birmingham NHSFT
Mr Mike A. Burdon
MRCP FRCOphth
Consultant Ophthalmologist
University Hospitals Birmingham NHSFT
Miss Lucilla Butler
MA FRCSEd(Ophth) FRCOphth Consultant Ophthalmologist & Hon. Senior Lecturer
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
Birmingham Women’s NHSFT University of Birmingham
Dr Antonio Calcagni
MD
Consultant Electrophysiologist
Moorfields Eye Hospital NHSFT
Dr Mark Chiang
MBBS MPhil FRANZCO Consultant Ophthalmologist
Queensland Eye Institute & University of Queensland Brisbane, Australia
Mr Andrew Coombes
BSc MBBS FRCOphth Consultant Ophthalmologist
Royal London Hospital Barts Health NHS Trust
Prof Alastair K.O.
Denniston
PhD MRCP FRCOphth Consultant Ophthalmologist & Hon. Professor
University Hospitals Birmingham NHSFT
University of Birmingham
University of Bristol
NIHR Biomedical Research
Centre at Moorfields Eye
Hospital and UCL Institute of Ophthalmology
Mr Omar M. Durrani
MBBS FRCS FRCOphth
Clinical Professor of Ophthalmology
Cleveland Clinic Abu Dhabi
Mr Matthew Edmunds
PhD MRCP FRCOphth FEBO Clinical Lecturer University of Birmingham
Mr Samer Elsherbiny
FRCS(Ed) FRCOphth MMed
Consultant Ophthalmologist
South Warwickshire NHSFT
University Hospitals Birmingham Birmingham and Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
Mr Abdul-Jabbar Ghauri
FRCOphth
Consultant Ophthalmologist
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
Mr Sam Gurney
BSc (Hons) MBChB (Hons)
FRCOphth
Specialist Trainee (Ophthalmology) West Midlands Deanery
Mr Pearse A. Keane
MD FRCOphth
NIHR Clinician Scientist & Hon. Consultant
NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology
Mr Kameron N. Khan
MD PhD FRCOphth
Consultant Ophthalmologist
Leeds Teaching Hospitals NHS Trust
Mr Andrej Kidess
MD
Consultant Ophthalmologist
University Hospitals Birmingham NHSFT
Mr Sai Kolli
MA PhD FRCOphth
Consultant Ophthalmologist
University Hospitals Birmingham NHSFT
Dr Mark Lane
MB BSc
Specialist Trainee (Ophthalmology) West Midlands Deanery
Ass Prof Graham Lee
MBBS MD MMEd Sc (Ophth) FRANZCO
Consultant Ophthalmologist
University of Queensland, Brisbane, Australia Mater Hospital, Brisbane, Australia
Mr Omar Mahroo
MA PhD FRCOphth
Consultant Ophthalmologist
Moorfields Eye Hospital NHSFT
Guy’s and St Thomas’ NHSFT
Ms Elaine Mann
BSc GPhC FRPharmS
Advanced Clinical Pharmacist (Ophthalmology, ENT, Max-Fax and Dental)
Leeds Teaching Hospitals NHS Trust
Mr Avinash Manna
MA MBBS FRCOphth
Consultant Ophthalmologist
University Hospitals
Birmingham NHSFT
Mr Imran Masood
BSc MBChB MRCS(Ed)
FRCOphth
Consultant Ophthalmologist
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
University Hospitals
Birmingham NHSFT
Birmingham Institute for Glaucoma Research
Miss Priscilla Mathewson
MA MBBChir FRCOphth
Specialist Trainee (Ophthalmology)
West Midlands Deanery
Miss Susan P. Mollan
FRCOphth
Consultant Ophthalmologist & Institute Clinical Fellow University Hospitals
Birmingham NHSFT
University of Birmingham
Miss Rupal Morjaria
FRCOphth
Specialist Trainee (Ophthalmology)
West Midlands Deanery
Dr Merrick Moseley
BSc PhD
Hon Senior Research Fellow City, University of London
Mr Aidan T. Murray
FRCOphth
Consultant Ophthalmologist
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
University Hospitals
Birmingham NHSFT
Prof Philip I. Murray
PhD FRCP FRCS FRCOphth
Professor of Ophthalmology & Hon. Consultant Ophthalmologist
University of Birmingham
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
Mr Manoj V. Parulekar
MS FRCS
Consultant Ophthalmologist
Birmingham Children’s Hospital NHSFT
Oxford University Hospitals
NHSFT
Mr Carlos E. Pavesio
MD FRCOphth
Consultant Ophthalmologist & Hon. Senior Lecturer
Moorfields Eye Hospital NHSFT
NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology
Mrs Hibba Quhill
MRCOphth
Specialist Trainee (Ophthalmology)
Yorkshire and the Humber Deanery
Miss Saaeha Rauz
PhD FRCOphth
Clinical Senior Lecturer in Ophthalmology & Hon. Consultant Ophthalmologist
University of Birmingham Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals
NHS Trust
Prof Ian G. Rennie
MBChB FRCS FRCOphth Professor of Ophthalmology
University of Sheffield Royal Hallamshire Hospitals NHSFT
Prof Peter Shah
FRCOphth
Consultant Ophthalmologist & Hon. Professor of Ophthalmology
University Hospitals
Birmingham NHSFT
NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust Birmingham Institute for Glaucoma Research
Mr Ash Sharma
FRCOphth
Consultant Ophthalmologist
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
Miss Freda Sii
FRCOphth
Senior Fellow in Ophthalmology
University Hospitals
Birmingham NHSFT
Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust
Birmingham Institute for Glaucoma Research
NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology
Miss Vaneeta Sood
FRCOphth
Consultant Ophthalmologist
University Hospitals
Birmingham NHSFT
Dr Shashi B. Vohra
FRCA
Consultant Anaesthetist
Birmingham & Midland Eye Centre, Sandwell & West
Birmingham Hospitals
NHS Trust
Prof James S. Wolffsohn
MBA PhD FCOptom
Deputy Dean & Professor of Optometry
Life and Health Sciences
Aston University
Surg Cdr Malcolm
Woodcock
MSc DAvMed MRCOphth
FRCSEd RNR
Consultant Ophthalmologist
Worcestershire Acute Hospitals
NHS Trust
Air Branch Royal Naval Reserve
Acknowledgements
As authors and editors of this book, we are privileged to coordinate a wonderful team of ophthalmologists, orthoptists, optometrists, visual scientists, ophthalmic technicians, and other professionals who care for people with eye disease. These people are not only experts in their fields but are passionate about ensuring that this wisdom is passed on to the rest of us. These authors continue to distil the complexities of their subspecialties in a way that is concise, clear, memorable, and easily applied in clinic, theatre, or eye casualty. We are deeply indebted to them, and the junior authors who assisted them, for all their hard work.
There are also many senior ophthalmologists who, like us, can measure the passage of the years by their contributions to successive editions of this Handbook. Significant contributors to previous editions include: Miss Susan Mollan, Mr Arun Reginald, Mr Geraint Williams, Mr Paul Tomlins, Mr Anil Arilakatti, Miss Rosemary Robinson, Mr Paul Chell, Miss Monique HopeRoss, Mr Graham Kirkby, Miss Fiona Dean, Prof Sunil Shah, Mrs Waheeda Illahi, Sonal Rughani, Mr Vijay Savant, Mr Sumit Dhingra, Mr Rajen Gupta, Mr Joseph Abbott, Mr James Cameron, Mr James Flint, Mr Tahir Masoud, Mr David Lockington, Mr Tom Jackson, Prof Mike Michaelides, Dr Steve Colley, Mr Tim Matthews, Lt Col Andrew Jacks, and Prof Adnan Tufail. We also thank Rizwana Siddiqui, Musarrat Allie, and Dr Peter Good for images. We are grateful to Angela Luck for yet more beautiful anatomical illustrations and her ongoing appreciation of the artistic merits of the slit-lamp. We thank Andrew Miller (Focus Birmingham) and Talia Dewhurst (Eye Clinic Liaison Officer, University Hospitals Birmingham NHSFT) for their expert advice on the ‘Vision in context’ chapter, and Miss Tas Braithwaite for her expertise in Autoimmune Retinopathy. We thank Altomed and John Weiss for kindly giving us permission to include images of their surgical instruments, and to all those who have advised on specific chapters for this edition.
It has been a great pleasure to work with the staff of OUP throughout. We thank Elizabeth Reeve and Michael Hawkes for their enthusiasm and practical assistance, and Joyce Cheung for her superb copy-editing.
AD wishes to thank his wife (Sarah) for her support, patience, and good humour and his two boys (Arran and Ewan) for contributing to the manuscript by manually checking several hundred weblinks throughout the book. AD particularly wants to acknowledge the hard work of the clinical and research teams he is privileged to lead (thank you Jacqui Orpe, Sue Southworth, and teams), and his clinical mentors (Phil Murray, Marie Tsaloumas, Andrew Dick) for their ongoing advice and encouragement.
PIM wishes to thank his family (Tricia, Hannah, Ella) for trying to keep out of his way while attempting to write this book but who really think he is spending his time on ebay bidding for yet another Paul Smith T-shirt. He is grateful to Out of the Blue Big Band and The Soul Providers for keeping him sane, and to Brentford FC who at last seem to be playing reasonable football and are now starting to look like a Championship side. Finally, he thanks
Hercules Stands whose amazing folding baritone sax stand has now allowed him to get his baritone sax and everything needed for a gig into his Porsche. AKOD, PIM 2018
Additional acknowledgements
We are indebted to a number of colleagues from across the UK and the rest of the world who have given us invaluable feedback which has helped direct the development of successive editions. We thank: Mr Ajay Tyagi, Mr Sam Elsherbiny, Mr Sam Mirza, Mr Velota Sung, Dr Zakaria, Dr Hannah Sharma, Mr Maged Nessim, Dr Imran Khan, Dr Anna Gao, Miss Lei Liu, Mr Nachiketa Acharya, Mr James Denniston, Dr Estelle Manson-Whitton, Mr Ali Bell, Dr Ed Moran, Miss Vaneeta Sood, Miss Anne Williams, Miss Katya Tambe, Dr Liz Justice, Mr Pravin Pandey, Miss Dipti Trivedi, Mr Richard Lee, Dr Yih-Horng Tham, Mr Mahmoud Radwan, Mr Noman Nazir Ahmad, Miss Hina Khan, and Dr Maha Said.
Symbols and abbreviations
d decreased
i increased
l leads to
∆ prism dioptre
α alpha
beta γ gamma
female
male
1° primary
2° secondary > greater than
< less than
≥ equal to or greater than
≤ equal to or less than
± plus or minus
7 approximately
°C degree Celsius
°F degree Fahrenheit
® registered trademark
™ trademark
M website address
E cross-reference
5-FU 5-fluorouracil
AA attendance allowance
AACG acute angle-closure glaucoma
AAO American Academy of Ophthalmology
AAPOX adult-onset asthma and periocular xanthogranuloma
AAU acute anterior uveitis
AAV adeno-associated virus
ABiC ab interno canaloplasty
AC anterior chamber
ACCORD Action to Control Cardiovascular Risk in Diabetes
