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THE MASSACHUSETTS
EYE AND EAR INFIRMARY
ILLUSTRATED MANUAL OF
OPHTHALMOLOGY
THE MASSACHUSETTS
EYE AND EAR INFIRMARY
ILLUSTRATED MANUAL OF
OPHTHALMOLOGY
FIFTH EDITION
NEIL J. FRIEDMAN, MD PETER K. KAISER, MD

Adjunct Clinical Professor Chaney Family Endowed Chair in
Department of Ophthalmology Ophthalmology Research
Stanford University School of Medicine Professor of Ophthalmology
Stanford, CA, USA Cleveland Clinic Lerner College of
Partner Medicine
Mid-Peninsula Ophthalmology Medical Cole Eye Institute
Group Cleveland, OH, USA
Menlo Park, CA, USA
Associate author
ROBERTO PINEDA II, MD
Thomas Y. and Clara W. Butler Chair in Ophthalmology
Associate Professor of Ophthalmology
Harvard Medical School
Cornea and Refractive Surgery Service
Massachusetts Eye and Ear Infirmary
Boston, MA, USA
For additional online content visit ExpertConsult.com
Edinburgh London New York Oxford Philadelphia St. Louis Sydney 2021
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
THE MASSACHUSETTS EYE AND EAR INFIRMARY ISBN: 978-0-323-61332-3

ILLUSTRATED MANUAL OF OPHTHALMOLOGY, Fifth Edition e-Book ISBN: 978-0-323-61333-0

© 2021, Elsevier Inc. All rights reserved.
Videos for Chapter 2: Ocular Motility and Cranial Nerves and Chapter 3: Lids, Lashes, and Lacrimal
System Y. Joyce Liao retains copyright to her original videos.
No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and
retrieval system, without permission in writing from the publisher. Details on how to seek
permission, further information about the Publisher’s permissions policies and our arrangements
with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility
is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons
or property as a matter of products liability, negligence or otherwise, or from any use or
operation of any methods, products, instructions, or ideas contained in the material herein.
Previous editions copyrighted 2014, 2009, 2004, and 1998.
International Standard Book Number: 978-0-323-61332-3
Content Strategist: Kayla Wolfe

Content Development Specialist: Nani Clansey
Publishing Services Manager: Deepthi Unni
Project Manager: Radjan Lourde Selvanadin
Design: Renee Duenow
Illustration Manager: Teresa McBryan
Marketing Manager: Claire McKenzie
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Contents
Video Table of Contents ix Vertical Motility Disorders 63

Preface xi Myasthenia Gravis 65
Contributors xii
Acknowledgements xiii CHAPTER 3
Figure Courtesy Lines xiv
Introduction xvii Lids, Lashes, and Lacrimal
System 69
CHAPTER 1 Eyelid Trauma 69

Eyelid Infections 73
Orbit 1 Eyelid Inflammations 80
Trauma 1 Eyelid Malpositions 86
Globe Subluxation 7 Blepharospasm 94
Carotid–Cavernous and Dural Bell’s Palsy 95
Sinus Fistulas 8 Floppy Eyelid Syndrome 97
Infections 10 Trichiasis 98
Inflammation 13 Congenital Eyelid Anomalies 99
Congenital Anomalies 17 Benign Eyelid Tumors 103
Pediatric Orbital Tumors 19 Malignant Eyelid Tumors 110
Adult Orbital Tumors 24 Systemic Diseases 116
Acquired Anophthalmia 29 Canaliculitis 120
Atrophia Bulbi and Phthisis Nasolacrimal Duct Obstruction 123
Bulbi 30 Dacryoadenitis 125
Lacrimal Gland Tumors 128
CHAPTER 2
Ocular Motility and Cranial CHAPTER 4
Nerves 33 Conjunctiva and Sclera 131
Strabismus 33 Trauma 131
Horizontal Strabismus 35 Telangiectasia 135
Vertical Strabismus 40 Microaneurysm 136
Miscellaneous Strabismus 43 Dry Eye Disease (Dry Eye
Nystagmus 45 Syndrome, Keratoconjunctivitis
Third Cranial Nerve Palsy 48 Sicca) 136
Fourth Cranial Nerve Palsy 51 Inflammation 142
Sixth Cranial Nerve Palsy 54 Conjunctivitis 145
Multiple Cranial Nerve Palsies 56 Degenerations 154
Chronic Progressive External Ocular Cicatricial Pemphigoid 156
Ophthalmoplegia 59 Stevens–Johnson Syndrome (Erythema
Horizontal Motility Disorders 61 Multiforme Major) 158
vi Contents
Graft-versus-Host Disease 160 Peripheral Anterior Synechiae 273

Tumors 161 Rubeosis Iridis 275
Episcleritis 170 Neovascular Glaucoma 276
Scleritis 171 Pigment Dispersion Syndrome 277
Scleral Discoloration 173 Pigmentary Glaucoma 278
Iris Heterochromia 279
CHAPTER 5 Anisocoria 281
Adie’s Tonic Pupil 283
Cornea 177 Argyll Robertson Pupil 284
Trauma 177 Horner’s Syndrome 285
Limbal Stem Cell Deficiency 182 Relative Afferent Pupillary Defect
Peripheral Ulcerative Keratitis 184 (Marcus Gunn Pupil) 287
Contact Lens–Related Problems 187 Leukocoria 289
Miscellaneous 193 Congenital Anomalies 290
Corneal Edema 198 Mesodermal Dysgenesis Syndromes 292
Graft Rejection and Failure 199 Iridocorneal Endothelial Syndromes 295
Infectious Keratitis (Corneal Ulcer) 201 Tumors 297
Interstitial Keratitis 210
Pannus 212 CHAPTER 8
Degenerations 213
Ectasias 217 Lens 303
Congenital Anomalies 220 Congenital Anomalies 303
Dystrophies 224 Congenital Cataract 306
Metabolic Diseases 233 Acquired Cataract 310
Deposits 235 Posterior Capsular Opacification 316
Enlarged Corneal Nerves 240 Aphakia 318
Tumors 240 Pseudophakia 319
Exfoliation 320
CHAPTER 6 Pseudoexfoliation Syndrome 321
Pseudoexfoliation Glaucoma 322
Anterior Chamber 243 Lens-Induced Glaucoma 324
Primary Angle-Closure Glaucoma 243 Dislocated Lens (Ectopia Lentis) 325
Secondary Angle-Closure Glaucoma 245
Hypotony 248 CHAPTER 9
Hyphema 250
Cells and Flare 251 Vitreous 329
Hypopyon 253 Amyloidosis 329
Endophthalmitis 254 Asteroid Hyalosis 330
Anterior Uveitis (Iritis, Iridocyclitis) 258 Persistent Hyperplastic Primary Vitreous
Uveitis–Glaucoma–Hyphema (Persistent Fetal Vasculature
Syndrome 265 Syndrome) 331
Posterior Vitreous Detachment 332
CHAPTER 7 Synchesis Scintillans 334
Vitreous Hemorrhage 334
Iris and Pupils 267 Vitritis 335
Trauma 267
Corectopia 271
Seclusio Pupillae 272
Contents vii
CHAPTER 10 Solar and Photic Retinopathy 407

Toxic (Drug) Maculopathies 408
Retina and Choroid 337 Lipid Storage Diseases 417
Trauma 338 Peripheral Retinal Degenerations 418
Hemorrhages 342 Retinoschisis 420
Cotton-Wool Spot 344 Retinal Detachment 423
Terson Syndrome 345 Choroidal Detachment 427
Branch Retinal Artery Occlusion 345 Chorioretinal Folds 428
Central Retinal Artery Occlusion 347 Chorioretinal Coloboma 429
Ophthalmic Artery Occlusion 350 Proliferative Vitreoretinopathy 430
Branch Retinal Vein Occlusion 351 Intermediate Uveitis and Pars
Central or Hemiretinal Vein Planitis 430
Occlusion 354 Neuroretinitis (Leber’s Idiopathic
Venous Stasis Retinopathy 358 Stellate Neuroretinitis) 432
Ocular Ischemic Syndrome 358 Posterior Uveitis: Infections 433
Retinopathy of Prematurity 360 Posterior Uveitis: White Dot
Coats Disease and Leber’s Miliary Syndromes 447
Aneurysms 362 Posterior Uveitis: Other Inflammatory
Familial Exudative Vitreoretinopathy Disorders 455
and Norrie Disease 364 Posterior Uveitis: Evaluation and
Incontinentia Pigmenti 364 Management 464
Eales Disease 364 Hereditary Chorioretinal
Macular Telangiectasia (MacTel, Dystrophies 466
Idiopathic Juxtafoveal, and Perifoveal Hereditary Macular Dystrophies 476
Telangiectasia) 365 Hereditary Vitreoretinal
Retinopathies Associated with Blood Degenerations 484
Abnormalities 367 Leber Congenital Amaurosis 490
Diabetic Retinopathy 370 Retinitis Pigmentosa 493
Hypertensive Retinopathy 377 Albinism 501
Toxemia of Pregnancy 378 Phakomatoses 503
Acquired Retinal Arterial Tumors 509
Macroaneurysm 379 Paraneoplastic Syndromes 523
Radiation Retinopathy 380
Age-Related Macular Degeneration 381 CHAPTER 11
Retinal Angiomatous Proliferation 388
Polypoidal Choroidal Vasculopathy 390 Optic Nerve and Glaucoma 525
Age-Related Choroidal Papilledema 525
Atrophy 392 Idiopathic Intracranial Hypertension
Myopic Degeneration and Pathologic and Pseudotumor Cerebri 527
Myopia 393 Optic Neuritis 529
Angioid Streaks 395 Anterior Ischemic Optic
Central Serous Chorioretinopathy 396 Neuropathy 530
Cystoid Macular Edema 399 Traumatic Optic Neuropathy 533
Macular Hole 401 Other Optic Neuropathies 535
Vitreomacular Adhesion and Congenital Anomalies 539
Traction 404 Tumors 544
Epiretinal Membrane and Macular Chiasmal Syndromes 548
Pucker 404 Congenital Glaucoma 551
Myelinated Nerve Fibers 407 Primary Open-Angle Glaucoma 552
viii Contents
Secondary Open-Angle Glaucoma 561 APPENDIX 595

Normal (Low)-Tension Glaucoma 564
Ophthalmic History and
Examination 595
CHAPTER 12
American Academy of Ophthalmology
Visual Acuity, Refractive Suggested Routine Eye Examination
Procedures, and Sudden Guidelines 622
Vision Loss 567 Differential Diagnosis of Common Ocular
Refractive Error 567 Symptoms 622
Refractive Surgery Complications 570 Common Ophthalmic Medications 625
Refractive Surgery Complications: Color Codes for Topical Ocular
Evaluation and Management 579 Medication Caps 632
Vertebrobasilar Insufficiency Ocular Toxicology 633
(Vertebrobasilar Atherothrombotic List of Important Ocular
Disease) 581 Measurements 634
Migraine 582 List of Eponyms 635
Convergence Insufficiency 586 Common Ophthalmic Abbreviations
Accommodative Excess (Accommodative (How to Read an Ophthalmology
Spasm) 586 Chart) 638
Functional Visual Loss 586 Common Spanish Phrases 640
Transient Visual Loss (Amaurosis
Fugax) 587
Index 645
Amblyopia 588
Cortical Blindness (Cortical Visual
Impairment) 590
Visual Pathway Lesions 591
Video Contents
Video 2.1 Torsional nystagmus.

Video 2.2 Acquired pendular nystagmus.
Video 2.3 Down-beating nystagmus.
Video 2.4 Up-beating nystagmus.
Video 2.5 Fixation instability.
Video 2.6 Fixation instability, episodic.
Video 2.7 Ataxia of saccades.
Video 2.8 Saccadic pursuit.
Video 2.9 Cranial nerve 3 paresis, left.
Video 2.10 Cranial nerve 4 paresis, right.
Video 2.11 Cranial nerve 6 paresis, left.
Video 2.12 Internuclear ophthalmoparesis, right.
Video 2.13 Bilateral ophthalmoparesis (one-and-a-half syndrome, left,
and vertical gaze paresis in both eyes).
Video 2.14 Spasm of near reflex.
Video 2.15 Ocular myasthenia.
Video 3.1 Blepharospasm.
Video A.1 Ocular motility testing (cranial nerve 4 paresis, right).
Videos are courtesy of Y. Joyce Liao, MD, PhD, with special thanks to Dr. Thomas Hwang,
Angela Oh, and Ali Shariati for their assistance.
Available on www.expertconsult.com
Preface
We started this process more than two decades ago when the first edition was published,
and now we are excited to share the fifth edition of this book with you. Our goal remains
the same: to produce a concise manual that covers a broad variety of ophthalmic disorders
and present it in a user-friendly diagnostic atlas. With each update, we strive to improve on
the previous version. We believe that this edition continues to set the bar higher.
We have expanded many chapters by adding new sections and figures, we have com-
pletely revised various sections, and we have updated numerous evaluation and manage-
ment algorithms to incorporate the most up-to-date diagnostic and treatment options.
Current residents, fellows, and attending physicians have reviewed and contributed to the
book to ensure that the text is relevant to all ophthalmologists. The new figures include
more clinical photos and images of various tests (i.e., fluorescein angiography, spectral
domain optical coherence tomography, fundus autofluorescence, and visual fields) as well
as updating some of the older images.
In addition, the fifth edition contains newer classification systems for various entities
and updated epidemiology information. In the companion online material, we have added
more videos of motility disturbances.
We believe that the new and improved fifth edition retains its previous attributes and
incorporates important updates to keep pace with all the recent changes in our specialty.
We hope you enjoy it.
Neil J. Friedman, MD
Peter K. Kaiser, MD
Roberto Pineda II, MD
Contributors
We are most appreciative of the contribution of the following colleagues who helped review
and edit various chapters of this text:
Daniel Youngjun Choi, MD

Partner, Central Valley Eye Medical Group
Stockton, CA, USA
Yaping Joyce Liao, MD, PhD

Associate Professor
Director, Neuro-Ophthalmology
Department of Ophthalmology and Department of Neurology
Stanford University School of Medicine
Palo Alto, CA, USA
Acknowledgments
This book would not be possible without the help of numerous people to whom we are
grateful. We thank the faculty, staff, fellows, residents, colleagues, and peers at our training
programs, including the Bascom Palmer Eye Institute, the Cole Eye Institute, the Cullen
Eye Institute, the Massachusetts Eye and Ear Infirmary, the New York Eye and Ear
Infirmary, and Stanford University, for their teaching, guidance, and support of this project.
We are indebted to the individuals who contributed valuable suggestions and revisions to
the text.
We especially acknowledge our editorial and publishing staff at Elsevier—Russell
Gabbedy, Kayla Wolfe, Nani Clansey, Radjan Selvanadin, and the members of their
department—for their expertise and assistance in once again producing a work that we are
excited to share with you.
In addition, we owe a debt of gratitude to Tami Fecko, Nicole Brugnoni, Anne Pinter,
Shawn Perry, Louise Carr-Holden, Ditte Hesse, Kit Johnson, Bob Masini, Audrey
Melacan, Jim Shigley, Huynh Van, and their photography departments for the wonderful
images that truly set this book apart from other texts. We also appreciate the contributions
of the numerous physicians whose photographs complete the vast array of ophthalmic
disorders represented herein.
Finally, we acknowledge our families, including Mae, Jake, Alan, Diane, Peter (PJ),
Stephanie, Dawn, Peter, Anafu, Christine, Roberto, Anne, Gabriela, and Nicole, for all their
love and support.
Neil J. Friedman, MD
Peter K. Kaiser, MD
Roberto Pineda II, MD
Figure Courtesy Lines
The following figures are reproduced from Essentials of Ophthalmology, Friedman and
Kaiser, 2007, Saunders: 2.3, 2.15, 2.22, 4.1, 4.2, 4.31, 4.45, 7.9, 7.20, 7.21, 10.144, 11.30,
12.19, Figure A.7, A.10, A.19, A.20, A.23, A.27, A.28, A.30, A.31, A.32, A.43, Table A.2,
and Table A.3.
The following figures are reproduced from Review of Ophthalmology, Friedman, Kaiser, and
Trattler, 2007, Saunders: 2.25, 2.26, 7.1, 7.6, A.14, A.16, A.17, A.21, and A.29.
The following figures are courtesy of the Bascom Palmer Eye Institute: 3.10, 4.3, 4.43, 4.53,
4.66, 5.8, 5.13, 5.26, 5.34, 5.40, 5.47, 5.64, 5.65, 5.71, 5.76, 5.78, 5.87, 6.10, 6.11, 6.12, 7.8,
7.14, 7.22, 7.23, 8.6, 8.37, 8.39, 8.41, 9.7, 10.1, 10.7, 10.8, 10.13, 10.32, 10.34, 10.41, 10.42,
10.43, 10.47, 10.56, 10.57, 10.64, 10.66, 10.96, 10.99, 10.100, 10.110, 10.117, 10.134,
10.148, 10.149, 10.152, 10.153, 10.154, 10.155, 10.163, 10.169, 10.204, 10.205, 10.208,
10.210, 10.222, 10.223, 10.237, 10.239, 10.244, 10.246, 10.247, 10.248, 10.251, 10.260,
10.262, 10.263, 10.264, 10.265, 10.266, 10.267, 10.272, 10.273, 10.274, 10.276, 10.277,
11.15, 11.18, and 11.21.
The following figures are courtesy of the Cole Eye Institute: 1.3, 1.28, 1.32, 1.33, 1.34, 1.35,
3.3, 3.11, 3.14, 3.19, 3.22, 3.23, 3.37, 3.49, 3.52, 3.56, 3.65, 4.8, 4.20, 4.25, 4.29, 4.32, 4.40,
4.41, 4.44, 4.50, 4.55, 4.56, 4.58, 4.65, 4.68, 5.5, 5.6, 5.12, 5.25, 5.35, 5.38, 5.39, 5.42, 5.43,
5.51, 5.57, 5.61, 5.68, 5.92, 5.99, 5.100, 5.101, 5.102, 6.13, 6.14, 7.17, 7.31, 7.39, 7.46, 8.4,
8.8, 8.9, 8.10, 8.11, 8.21, 8.24, 9.2, 9.6, 10.2, 10.14, 10.18, 10.19, 10.20, 10.21, 10.22, 10.23,
10.25, 10.28, 10.30, 10.31, 10.35, 10.36, 10.37, 10.38, 10.44, 10.46, 10.48, 10.49, 10.50,
10.52, 10.58, 10.59, 10.61, 10.62, 10.67, 10.73, 10.76, 10.77, 10.78, 10.79, 10.93, 10.95,
10.97, 10.98, 10.102, 10.103, 10.105, 10.106, 10.108, 10.115, 10.121, 10.123, 10.124,
10.125, 10.131, 10.132, 10.135, 10.137, 10.138, 10.139, 10.140, 10.141, 10.145, 10.146,
10.147, 10.151, 10.157, 10.159, 10.160, 10.161, 10.162, 10.164, 10.165, 10.166, 10.167,
10.168, 10.171, 10.172, 10.174, 10.175, 10.179, 10.181, 10.182, 10.185, 10.188, 10.189,
10.190, 10.191, 10.192, 10.193, 10.194, 10.197, 10.198, 10.199, 10.200, 10.201, 10.202,
10.203, 10.207, 10.211, 10.214, 10.215, 10.217, 10.218, 10.219, 10.220, 10.221, 10.226,
10.227, 10.228, 10.230, 10.231, 10.232, 10.236, 10.241, 10.249, 10.254, 10.257, 10.258,
10.261, 10.269, 10.270, 10.271, 10.275, 11.1, 11.2, 11.3, 11.4, 11.12, 11.16, 11.17, 11.23,
11.24, 11.34, 11.37, 12.5, 12.9, 12.12, 12.13, and 12.14.
The following figures are courtesy of the Massachusetts Eye and Ear Infirmary: 1.2, 1.8,
1.10, 1.11, 1.12, 1.13, 1.14, 1.15, 1.16, 1.21, 1.29, 1.36, 2.1, 2.2, 2.4, 2.7, 2.10, 2.11, 2.12,
2.20, 2.23, 2.24, 3.5, 3.8, 3.12, 3.13, 3.17, 3.20, 3.21, 3.24, 3.29, 3.41, 3.47, 3.48, 3.57, 3.63,
3.64, 3.68, 4.4, 4.5, 4.6, 4.9, 4.12, 4.13, 4.15, 4.16, 4.17, 4.18, 4.19, 4.26, 4.27, 4.30, 4.33,
4.34, 4.37, 4.38, 4.39, 4.49, 4.51, 4.52, 4.57, 4.59, 4.61, 4.62, 4.63, 5.2, 5.7, 5.15, 5.16, 5.17,
5.18, 5.21, 5.22, 5.23, 5.29, 5.30, 5.36, 5.37, 5.41, 5.44, 5.45, 5.52, 5.55, 5.56, 5.60, 5.62,
5.72, 5.74, 5.75, 5.78, 5.88, 5.89, 5.93, 6.1, 6.2, 6.5, 6.8, 6.15, 7.2, 7.4, 7.7, 7.10, 7.12, 7.16,
7.24, 7.27, 7.29, 7.30, 7.33, 7.36, 7.37, 7.38, 7.40, 7.42, 7.43, 7.44, 7.45, 7.48, 8.1, 8.3, 8.5,
8.7, 8.12, 8.13, 8.15, 8.16, 8.17, 8.18, 8.22, 8.23, 8.27, 8.40, 8.42, 8.45, 9.1, 9.3, 10.29, 10.45,
10.65, 10.68, 10.69, 10.71, 10.116, 10.127, 10.128, 10.129, 10.130, 10.142, 10.150, 10.158,
10.170, 10.173, 10.178, 10.179, 10.180, 10.184, 10.196, 10.206, 10.209, 10.225, 10.229,
10.238, 10.240, 10.242, 10.243, 10.245, 10.250, 11.5, 11.6, 11.7, 11.10, 11.13, 11.26, 11.29,
and 11.35.
Figure Courtesy Lines xv
The following figures are courtesy of the New York Eye and Ear Infirmary: 3.7, 3.16, 3.34,
3.39, 3.59, 4.13, 4.21, 4.35, 4.37, 4.46, 4.47, 4.48, 4.54, 4.60, 4.64, 5.14, 5.46, 5.48, 5.49,
5.50, 5.53, 5.54, 5.59, 5.73, 5.95, 5.98, 7.3, 7.9, 7.11, 7.13, 7.26, 8.14, 8.28, 8.36, 8.38, 8.44,
9.5, 9.10, 10.3, 10.10, 10.11, 10.12, 10.17, 10.24, 10.30, 10.33, 10.51, 10.63, 10.92, 10.114,
10.156, 10. 186, 10.187, 10.195, 10.206, 10.212, 10.224, 10.233, 10.234, 10.235, 11.11,
and 11.20.
The following figure is courtesy of Shamik Barfna, MD: 12.16.
The following figures are courtesy of Michael Blair, MD: 10.279 and 10.280.
The following figure is courtesy of Robert Chang, MD: 5.97.
The following figures are courtesy of Warren Chang, MD: 2.8 and 2.9.
The following figure is courtesy of Netan Choudhry, MD: 10.133.
The following figures are courtesy of Cullen Eye Institute: 1.7, 5.82, and 11.14.
The following figure is courtesy of Eric D. Donnenfeld, MD: 3.6.
The following figures are courtesy of Jay Duker, MD: 10.176 and 10.177.
The following figure is courtesy of Chris Engelman, MD: 11.38.
The following figures are courtesy of Neil J. Friedman, MD: 1.6, 1.9, 4.10, 4.11, 4.69, 5.3,
5.4, 5.11, 5.19, 5.28, 5.31, 5.66, 5.67, 5.77, 5.86, 6.3, 7.5, 7.15, 7.47, 8.19, 8.25, 8.26, 8.30,
8.31, 10.9, 11.22, 11.27, 11.31, 11.32, 11.33, 11.36, 12.4, 12.6, 12.7, 12.8, 12.15, 12.20,
A.34, A.35, A.42, A.44, and A.45.
The following figures are courtesy of Ronald L. Gross, MD: 5.70, 6.4, 6.7, 6.9, 7.25, 7.28,
7.34, and 11.23.
The following figures are courtesy of M. Bowes Hamill, MD: 4.7, 4.25, 4.27, 4.41, 4.66, 5.9,
5.10, 5.81, 7.32, and 7.35.
The following figures are courtesy of Allen Ho, MD: 10.163, 10.183, and 10.255, 10.256.
The following figure is courtesy of Thomas N. Hwang, MD, PhD: 11.9.
The following figures are courtesy of J. Michael Jumper, MD: 10.128 and 10.129.
The following figures are courtesy of ATul Jain, MD: 6.6, 9.4, 10.15, and 10.16.
The following figures are courtesy of Peter K. Kaiser, MD: 2.13, 2.16, 2.19, 2.21, 9.8, 9.9,
10.4, 10.5, 10.6, 10.26, 10.27, 10.39, 10.40, 10.53, 10.54, 10.55, 10.70, 10.74, 10.75, 10.80,
10.81, 10.82, 10.83, 10.84, 10.85, 10.86, 10.87, 10.88, 10.94, 10.101, 10.104, 10.107,
10.109, 10.111, 10.112, 10.113, 10.116, 10.118, 10.119, 10.120, 10.136, 10.143, 10.212,
xvi Figure Courtesy Lines
10.216, 10.268, 11.16, 11.19, A.1, A.2, A.3, A.4, A.6, A.8, A.9, A.11, A.12, A.13, A.15,
A.18, A.22, A.24, A.25, A.26, A.38, A.39, A.40, and A.41.
The following figures are courtesy of Robert Kersten, MD: 3.51, 3.62, and 3.66.
The following figures are courtesy of Jonathan W. Kim, MD: 1.25, 1.26, and 3.43.
The following figure is courtesy of John Kitchens, MD: 10.60.
The following figures are courtesy of Douglas D. Koch, MD: 5.33, 5.69, 8.2, 8.20, 8.29,
8.32, 8.33, 8.34, 8.35, 8.43, 12.11, and 12.18.
The following figures are courtesy of Andrew G. Lee, MD: 2.14, 2.17, 2.27, 7.18, 11.1,
and 11.8.
The following figures are courtesy of Peter S. Levin, MD: 1.23, 3.9, 3.30, 3.38, 3.58, 3.60,
3.61, and 3.67.
The following figure is courtesy of Thomas Loarie: 12.17.
The following figure is courtesy of Edward E. Manche, MD: 12.10.
The following figure is courtesy of Samuel Masket, MD: 12.2.
The following figures are courtesy of Timothy J. McCulley, MD: 1.1, 1.5, 1.18, 1.20, 1.21,
1.22, 1.24, 1.30, 1.31, 3.2, 3.4, 3.25, 3.44, 3.45, and 11.25.
The following figure is courtesy of George J. Nakano, MD: 5.94.
The following figures are courtesy of James R. Patrinely, MD: 1.17, 1.27, 3.18, 3.28, 3.31,
3.32, 3.33, 3.35, 3.36, 3.40, 3.42, 3.50, 3.53, 3.54, and 3.55.
The following figures are courtesy of Julian Perry, MD: 3.1 and 3.46.
The following figures are courtesy of Roberto Pineda II, MD: 5.20, 5.27, 5.32, 5.90, 5.91,
5.96, A.33, A.36, and A.37.
The following figures are courtesy of David Sarraf, MD, and ATul Jain, MD: 10.122,
10.126, 10.260, 10.261, and 10.262.
The following figures are courtesy of Richard Spaide, MD: 10.89, 10.90, and 10.91.
The following figures are courtesy of Paul G. Steinkuller, MD: 1.19, 2.5, 2.6, and 12.1.
The following figures are courtesy of Christopher N. Ta, MD: 3.15, 3.26, 3.27, 4.21, 4.22,
4.23, 5.1, 5.24, 5.58, 5.63, 5.85, 7.41, and 12.3.
Introduction
Given the visual nature of ophthalmology, an illustrated manual is of utmost importance

to our specialty. Continuing in the tradition of excellence forged by Drs. Friedman, Kaiser,
and Pineda in the first four editions, the fifth edition of the MEEI Illustrated Manual of
Ophthalmology continues to provide us with an accessible and portable yet comprehensive
compendium that optimizes its availability for use by the practitioner.
Reflecting recent advances in ophthalmic care and understanding, the fifth edition
contains a number of new diagnoses, new photos, updated treatment regimens, and major
updates to many of the sections within the manual. New sections in this edition cover in-
fectious uveitis, limbal stem cell deficiency, graft-versus-host disease, neurotrophic keratitis,
hereditary color blindness, and refractive surgery procedures. The fifth edition continues
to highlight the importance of our most sophisticated imaging technologies with optical
coherence tomography angiography, wide-field angiography, and wide-field fundus pho-
tography. It serves as both a valuable teaching tool and a standard reference for practicing
ophthalmologists.
The authors—all of whom trained at Harvard Medical School as students, residents, or
fellows—continue to embody the best of the clinician–teacher paradigm. While advances
in research (basic, translational, and clinical) drive our practice forward, it is a critical to
share this knowledge to successive generations of ophthalmologists. We are especially
grateful for their commitment, wisdom, and diligence in updating this classic text.
Joan W. Miller, MD
Chief of Ophthalmology,
Massachusetts Eye and Ear and Massachusetts General Hospital
David Glendenning Cogan Professor of Ophthalmology and Chair,
Harvard Medical School
Boston, MA, USA
Orbit
1
Trauma 1 Congenital Anomalies 17
Globe Subluxation 7 Pediatric Orbital Tumors 19
Carotid–Cavernous and Dural Sinus Adult Orbital Tumors 24
Fistulas 8 Acquired Anophthalmia 29
Infections 10 Atrophia Bulbi and Phthisis Bulbi 30
Inflammation 13
Trauma
Blunt Trauma
Orbital Contusion
Periocular bruising caused by blunt trauma; often with injury to the globe, paranasal sinuses,
and bony socket; traumatic optic neuropathy or orbital hemorrhage may be present. Patients
report pain and may have decreased vision. Signs include eyelid edema and ecchymosis, as
well as ptosis. Isolated contusion is a preseptal (eyelid) injury and typically resolves without
sequelae. Traumatic ptosis secondary to levator muscle contusion may take up to
3 months to resolve; most oculoplastic surgeons observe for 6 months before surgical repair.
Fig 1.1 • Orbital contusion

demonstrating severe eyelid
ecchymosis and edema,
subconjunctival hemorrhage, and
conjunctival chemosis.
• In the absence of orbital signs (afferent pupillary defect, visual field defect, limited extra-
ocular motility, and proptosis), imaging studies are not necessarily required but should be
considered with more serious mechanisms of injury (e.g., motor vehicle accident [MVA],
massive trauma, or loss of consciousness) even in the absence of orbital signs. When
indicated, orbital computed tomography (CT) scan is the imaging study of choice.
2 CHAPTER 1 • Orbit
• When the globe is intact and vision is unaffected, ice compresses can be used every hour
for 20 minutes during the first 48 hours to decrease swelling.
• Concomitant injuries should be treated accordingly.
Orbital Hemorrhage and Orbital Compartment Syndrome
Accumulation of blood throughout the intraorbital tissues caused by surgery or trauma
(retrobulbar hemorrhage) may cause proptosis, distortion of the globe, and optic nerve
stretching and compression (orbital compartment syndrome). Patients may report pain and
decreased vision. Signs include bullous, subconjunctival hemorrhage, tense orbit, proptosis,
resistance to retropulsion of globe, limitation of ocular movements, lid ecchymosis, and
increased intraocular pressure (IOP). Immediate recognition and treatment are critical in
determining outcome. Urgent treatment measures may include canthotomy and cantholy-
sis. Evacuation of focal hematomas or bony decompression is reserved for the most severe
cases with an associated optic neuropathy.
Fig 1.2 • Retrobulbar

hemorrhage of the left eye
demonstrating proptosis, lid
swelling, chemosis, and restricted
extraocular motility on upgaze.
Conjunctival chemosis Lid edema
OPHTHALMIC EMERGENCY
• If orbital compartment syndrome is suspected, lateral canthotomy and cantholysis

should be performed emergently.
• Lateral canthotomy: This procedure is performed by compressing the lateral can-
thus with a hemostat, and Stevens scissors are then used to make a full-thickness
incision from the lateral commissure (lateral angle of the eyelids) posterolaterally to
the lateral orbital rim. Some advocate compression of the lateral canthal tendon
before incision. The inferior crus of the lateral canthal tendon is then transected by
elevating the lateral lower lid margin away from the face, placing the scissors between
the cut edges of lower lid conjunctiva and lower lid skin, palpating the tendon with
the tips of the scissors, and transecting it. If the inferior eyelid is not extremely mo-
bile, the inferior crus has not been transected adequately, and the procedure should
be repeated. If the IOP remains elevated and the orbit remains tense, the superior
Trauma 3
OPHTHALMIC EMERGENCY—cont’d
crus of the lateral canthal tendon may be cut. Septolysis, blunt dissection through the
orbital septum at the base of the cantholysis incision, may be performed when pres-
sure is not adequately relieved with lysis of the canthal tendon.
• Emergent inferior orbital floor fracture, although advocated by some, is fraught with
complications and is not advised for surgeons with little experience in orbital surgery;
however, it should be considered in emergent situations with risk of blindness.
• Canthoplasty can be scheduled electively 1 week after the hemorrhage.
• Orbital CT scan (without contrast, direct coronal and axial views, 3 mm slices) after
visual status has been determined and emergent treatment (if necessary) adminis-
tered (i.e., after canthotomy and cantholysis). Magnetic resonance imaging (MRI) is
contraindicated in acute trauma.
• If vision is stable and IOP is elevated (.25 mm Hg), topical hypotensive agents may
be administered (brimonidine 0.15% [Alphagan P] 1 gtt tid, timolol 0.5% 1 gtt bid,
and/or dorzolamide 2% [Trusopt] 1 gtt tid).
Orbital Fractures
Fracture of the orbital walls may occur in isolation (e.g., blow-out fracture) or with dis-
placed or nondisplaced orbital-rim fractures. There may be concomitant ocular, optic nerve,
maxillary, mandibular, or intracranial injuries.
Orbital floor (blow-out) fracture

This is the most common orbital fracture requiring repair and usually involves the maxillary
bone in the posterior medial floor (weakest point) and may extend laterally to the infraor-
bital canal. Orbital contents may prolapse or become entrapped in maxillary sinus. Signs
and symptoms include diplopia on upgaze (anterior fracture) or downgaze (posterior
fracture), enophthalmos, globe ptosis, and infraorbital nerve hypesthesia. Orbital and lid
emphysema is often present and may become extensive with nose blowing.
Subconjunctival Orbital floor fracture

hemorrhage with entrapment
Fig 1.3 • Orbital floor blow-out fracture with Fig 1.4 • Same patient as in Fig. 1.3
enophthalmos and globe dystopia and ptosis of demonstrating entrapment of the left inferior
the left eye. rectus and inability to look up.
Fig 1.5 • Orbital computed tomography

scan demonstrating large right orbital floor
fracture.
• For mild trauma, orbital CT scan need not be obtained in the absence of orbital
signs.
• Orbital surgery consultation should be considered, especially in the setting of diplo-
pia, large floor fractures (.50% of orbital floor surface area), trismus, facial asym-
metry, inferior rectus entrapment, and enophthalmos. Consider surgical repair after
1 week to allow for reduction of swelling except in cases of pediatric trapdoor-
type fractures with extraocular muscle entrapment, in which emergent repair is
advocated.
Pediatric floor fracture

This differs significantly from an adult fracture because the bones are pliable rather than
brittle. A “trapdoor” phenomenon is created in which the inferior rectus muscle or peri-
muscular tissue can be entrapped in the fracture site. In this case, enophthalmos is unlikely,
but ocular motility is limited dramatically. The globe halts abruptly with ductions opposite
the entrapped muscle (most often on upgaze with inferior rectus involvement) as if it is
“tethered.” Forced ductions are positive; nausea and bradycardia (oculocardiac reflex) are
common. Despite the severity of the underlying injury, the eye is typically quiet, hence the
nickname “white eyed blowout fracture.”
• Urgent surgery (,24 hours) is indicated in pediatric cases with entrapment.
Medial wall (nasoethmoidal) fracture

This involves the lacrimal and ethmoid (lamina papyracea) bones. It is occasionally as-
sociated with depressed nasal fracture, traumatic telecanthus (in severe cases), and orbital
floor fracture. Complications include nasolacrimal duct injury, severe epistaxis caused by
anterior ethmoidal artery damage, and orbit and lid emphysema. Medial rectus entrap-
ment is rare, and enophthalmos caused by isolated medial wall fractures is extremely
uncommon.
• Fractures extending through the nasolacrimal duct should be reduced with stenting of
the drainage system. If not repaired primarily, persistent obstruction requiring dacryocys-
torhinostomy may result.
• Otolaryngology consultation is indicated in the presence of nasal fractures.
Trauma 5
Orbital roof fracture

This is an uncommon fracture usually secondary to blunt or projectile injuries. It may in-
volve the frontal sinus, cribriform plate, and brain. It may be associated with cerebrospinal
fluid (CSF) rhinorrhea or pneumocephalus.
• Neurosurgery and otolaryngology consultations are advised, especially in the presence of
CSF rhinorrhea or pneumocephalus.
Orbital apex fracture

This may be associated with other facial fractures and involve optic canal and superior
orbital fissure. Direct traumatic optic neuropathy is likely. Complications include carotid–
cavernous fistula and fragments impinging on optic nerve. These are difficult to manage
because of proximity of multiple cranial nerves and vessels.
• Obvious impingement by a displaced fracture on the optic nerve may require immediate
surgical intervention by an oculoplastic surgeon or neurosurgeon. High-dose systemic
steroids may be given for traumatic optic neuropathy (see Chapter 11).
Tripod fracture
This involves three fracture sites: the inferior orbital rim (maxilla), lateral orbital rim (often
at the zygomaticofrontal suture), and zygomatic arch. The fracture invariably extends
through the orbit floor. Patients may report pain, tenderness, binocular diplopia, and
trismus (pain on opening mouth or chewing). Signs include orbital rim discontinuity or
palpable “step off,” malar flattening, enophthalmos, infraorbital nerve hypesthesia, emphy-
sema (orbital, conjunctival, or lid), limitation of ocular movements, epistaxis, rhinorrhea,
ecchymosis, and ptosis. Enophthalmos may not be appreciated on exophthalmometry
caused by a retrodisplaced lateral orbital rim.
Le Fort fractures
These are severe maxillary fractures with the common feature of extension through the
pterygoid plates:
Le Fort I: low transverse maxillary bone; no orbital involvement
Le Fort II: nasal, lacrimal, and maxillary bones (medial orbital wall), as well as bones of the
orbital floor and rim; may involve the nasolacrimal duct
Le Fort III: extends through the medial wall; traverses the orbital floor and through the
lateral wall (craniofacial dysjunction); may involve the optic canal
• Orbital CT scan (without contrast, direct axial and coronal views, 3 mm slices) is
indicated in the presence of orbital signs (afferent papillary defect, diplopia, limited
extraocular motility, proptosis, and enophthalmos) or ominous mechanism of injury (e.g.,
MVA, massive facial trauma). MRI is of limited usefulness in the evaluation of fractures
because bones appear dark.
• Otolaryngology consultation is indicated in the presence of mandibular fracture.
• Orbital surgery consultation is indicated in the presence of isolated orbital and trimalar
fractures.
• Instruct the patient to avoid blowing the nose. A “suck-and-spit” technique should be
used to clear nasal secretions.
• Nasal decongestant (oxymetazoline hydrochloride [Afrin nasal spray] bid as needed for
3 days. Note: This may cause urinary retention in men with prostatic hypertrophy).
• Ice compresses for the first 48 hours

• Systemic oral antibiotics (amoxicillin–clavulanate [Augmentin] 250–500 mg po tid for
10 days) are advocated by some.
• Nondisplaced zygomatic fractures may become displaced after initial evaluation because
of masseter and temporalis contraction. Orbital or otolaryngology consultation is indi-
cated for evaluation of such patients.
Penetrating Trauma
These may result from either a projectile (e.g., pellet gun) or stab (e.g., knife, tree branch)
injury. A foreign body should be suspected even in the absence of significant external wounds.
Intraorbital Foreign Body

Retained orbital foreign body with or without associated ocular and optic nerve involve-
ment. Inert foreign body (e.g., glass, lead, BB, plastics) may be well tolerated and should be
evaluated by an oculoplastic surgeon in a controlled setting. Organic matter carries signifi-
cant risk of infection and should be removed surgically. A long-standing iron foreign body
can produce iron toxicity (siderosis), including retinopathy.
Patients may be asymptomatic or may report pain or decreased vision. Critical signs include
eyelid or conjunctival laceration. Other signs may include ecchymosis, lid edema and ery-
thema, conjunctival hemorrhage or chemosis, proptosis, limitation of ocular movements, and
chorioretinitis sclopetaria (see Fig. 10.9). A relative afferent pupillary defect (RAPD) may be
present. The prognosis is generally good if the globe and optic nerve are not affected.
Fig 1.6 • Orbital computed tomography

scan demonstrating a foreign body at the
orbital apex.
Intraorbital foreign body
• Precise history (may be necessary to isolate a minor child from the parents while obtain-
ing history) is critical in determining the nature of any potential foreign body.
• Lab tests: Culture entry wound for bacteria and fungus. Serum lead levels should be
monitored in patients with a retained lead foreign body.
• Orbital CT scan (without contrast, direct coronal and axial views). The best protocol is
to obtain thin-section axial CT scans (0.625–1.25 mm, depending on the capabilities of
the scanner) and then to perform multiplanar reformation to determine character and
position of foreign body. MRI is contraindicated if the foreign body is metallic.
• If there is no ocular or optic nerve injury, small inert foreign bodies posterior to the
equator of the globe usually are not removed but observed.
• Patients are placed on systemic oral antibiotic (amoxicillin–clavulanate [Augmentin] 500
mg po tid for 10 days) and are followed up the next day.
Globe Subluxation 7
• Tetanus booster (tetanus toxoid 0.5 mL IM) if necessary for prophylaxis (.7 years since
last tetanus shot or if status is unknown).
• Indications for surgical removal include fistula formation, infection, optic nerve com-
pression, large foreign body, or easily removable foreign body (usually anterior to the
equator of the globe). Surgery should be performed by an oculoplastic surgeon. Organic
material should be removed more urgently.
Globe Subluxation
Definition Spontaneous forward displacement of the eye so that the equator of the globe
protrudes in front of the eyelids, which retract behind the eye.
Etiology Most often spontaneous in patients with proptosis (e.g., Graves’ disease) but may
be voluntary or traumatic.
Mechanism Pressure against the globe, typically from spreading the eyelids, causes the eye
to move forward, and then when a blink occurs, the eyelids contract behind the eye, locking
the globe in a subluxed position.
Epidemiology Occurs in individuals of any age (range, 11 months to 73 years) and has no
sex or race predilection. Risk factors include eyelid manipulation, exophthalmos, severe
eyelid retraction, floppy eyelid syndrome, thyroid eye disease (TED), and shallow orbits
(i.e., Crouzon’s or Apert’s syndrome).
Symptoms Asymptomatic; may have pain, blurred vision, and anxiety.
Signs Dramatic proptosis of the eye beyond the eyelids. Depending on the length of time the
globe has been subluxed, may have exposure keratopathy, corneal abrasions, blepharospasm,
and optic neuropathy.
Fig 1.7 • Globe subluxation

with equator of globe and lacrimal
gland in front of the eyelids.
Evaluation
• Complete ophthalmic history with attention to previous episodes and potential triggers.
• Complete eye exam (after the eye has been repositioned) with attention to visual acuity,
pupils, motility, exophthalmometry, lids, cornea, and ophthalmoscopy.
Management
• Immediately reposition the globe. Relax the patient, instill topical anesthetic, and
digitally reduce the subluxation by one of the following methods:
1. While the patient looks down, pull the upper eyelid up and depress the globe.
2. Place a retractor under the center of the upper eyelid, push the globe downward,
and advance the eyelid forward. When the eyelid is past the equator of the
globe, have the patient look up to pull the eyelid over the eye.
• May require a facial nerve block, sedation, or general anesthesia.
• Instruct the patient to avoid triggers and how to reduce a subluxation.
• Treat any underlying condition.
• Surgical options include partial tarsorrhaphy and orbital decompression.
Prognosis Good unless complications develop.
Carotid–Cavernous and Dural Sinus Fistulas

Definition
Arterial venous connection between the carotid artery and cavernous sinus; there are two types.
High-Flow Fistula
Between the cavernous sinus and internal carotid artery (carotid–cavernous fistula).
Low-Flow Fistula
Between small meningeal arterial branches and the dural walls of the cavernous sinus (dural
sinus fistula).
Etiology
High-Flow Fistula
Spontaneous; occurs in patients with atherosclerosis and hypertension with carotid
aneurysms that rupture within the sinus or secondary to closed-head trauma (basal skull
fracture).
Low-Flow Fistula
Slower onset compared with the carotid–cavernous variant; dural sinus fistula is more likely
to present spontaneously.
Symptoms May hear a “swishing” noise (venous souffle); may have a red “bulging” eye.
Signs
High-Flow Fistula
May have orbital bruit, pulsating proptosis, chemosis, epibulbar injection and vascular tor-
tuosity (conjunctival corkscrew vessels), congested retinal vessels, and increased IOP.
Carotid–Cavernous and Dural Sinus Fistulas 9
Low-Flow Fistula
Mild proptosis and orbital congestion. However, in more severe cases, findings are similar
to those described for carotid–cavernous fistula may occur.
Fig 1.8 • Carotid–cavernous fistula with Fig 1.9 • Carotid–cavernous fistula

conjunctival injection and chemosis. with dilated, corkscrew, episcleral, and
conjunctival vessels.
Differential Diagnosis Orbital varices that expand in a dependent position or during

Valsalva maneuvers and may produce hemorrhage with minimal trauma. Carotid–
cavernous fistula may also be mistaken for orbital inflammatory syndrome and occasionally
uveitis.
Evaluation
• Complete history with attention to onset and duration of symptoms and history of
trauma and systemic diseases (atherosclerosis, hypertension).
• Complete eye exam with attention to orbital auscultation, exophthalmometry, conjunc-
tiva, tonometry, and ophthalmoscopy.
• Orbital CT scan or MRI: Enlargement of the superior ophthalmic vein.
• Arteriography usually is required to identify the fistula; CT angiography and mag-
netic resonance angiography have largely replaced conventional angiography.
Management
• Consider treatment with selective embolization or ligation for severely symptomatic

patients (uncontrolled increase in IOP, severe proptosis, retinal ischemia, optic neu-
ropathy, severe bruit, involvement of the cortical veins).
• Treatment for all cases of carotid–cavernous fistula has been advocated but is
controversial.
Prognosis Up to 70% of dural sinus fistulas may resolve spontaneously.
Infections
Preseptal Cellulitis
Definition Infection of the eyelids not extending posterior to the orbital septum. The
globe and orbit are not involved.
Etiology Usually follows periorbital trauma or dermal infection. Suspect Staphylococ-
cus aureus in traumatic cases and Haemophilus influenzae (nontypeable) in children
5 years old.
Symptoms Eyelid swelling, redness, ptosis, and pain; low-grade fever.
Signs Eyelid erythema, edema, ptosis, and warmth (may be quite dramatic); visual
acuity is normal; full ocular motility without pain; no proptosis; the conjunctiva and
sclera appear uninflamed; an inconspicuous lid wound may be visible; an abscess may
be present.
Differential Diagnosis Orbital cellulitis, idiopathic orbital inflammation (IOI), dacryoad-
enitis, dacryocystitis, conjunctivitis, and trauma.
Lid erythema Lid edema Erythema
Fig 1.10 • Mild preseptal cellulitis with right Fig 1.11 • Moderate preseptal cellulitis
eyelid erythema in a young child. with left eyelid edema and erythema.
Evaluation
• Complete ophthalmic history with attention to trauma, sinus disease, recent dental work
or infections, history of diabetes or immunosuppression.
• Complete eye exam with attention to visual acuity, color vision, pupils, motility, exoph-
thalmometry, lids, conjunctiva, and sclera.
• Check vital signs, head and neck lymph nodes, meningeal signs (nuchal rigidity), and
sensorium.
• Lab tests: Complete blood count (CBC) with differential, blood cultures; wound culture
if present.
• Orbital and sinus CT scan in the absence of trauma or in the presence of orbital signs
to look for orbital extension and paranasal sinus opacification.
Infections 11
Management
MILD PRESEPTAL CELLULITIS

• Systemic oral antibiotic:
Amoxicillin-clavulanate (Augmentin) 250–500 mg po tid or
Second- or third-generation cephalosporin such as Cefaclor (Ceclor) 250–500 mg
po tid or
Trimethoprim–sulfamethoxazole (Bactrim) 1 double-strength tablet po bid in
penicillin-allergic patients.
• Topical antibiotic (bacitracin or erythromycin ointment qid) for concurrent
conjunctivitis.
• Eyelid abscess should be drained (avoid injury to the orbital septum and levator
aponeurosis).
MODERATE TO SEVERE PRESEPTAL CELLULITIS

• Systemic intravenous antibiotic:
Cefuroxime 1 g IV q8h or
Ampicillin–sulbactam (Unasyn) 1.5–3.0 g IV q6h.
• Systemic intravenous treatment also indicated for septic patients, outpatient
noncompliant patients, children 5 years old, and patients who fail oral antibiotic
treatment after 48 hours.
• Daily follow-up in all cases until improvement noted.
Prognosis Usually good when treated early.
Orbital Cellulitis
Definition
Infection extending posterior to the orbital septum. May occur in combination with prese-
ptal cellulitis.
Etiology Most commonly secondary to ethmoid sinusitis. May also result from frontal,
maxillary, or sphenoid infection. Other causes include dacryocystitis, dental caries, intracra-
nial infections, trauma, and orbital surgery. Streptococcus and Staphylococcus are most com-
mon isolates. H. influenzae (nontypeable) in children 5 years old. Fungi in the group
Phycomycetes (Absidia, Mucor, or Rhizopus) are the most common causes of fungal orbital
infection causing necrosis, vascular thrombosis, and orbital invasion. Fungal infections
usually occur in immunocompromised patients (e.g., those with diabetes mellitus, meta-
bolic acidosis, malignancy, or iatrogenic immunosuppression) and can be fatal because of
intracranial spread.
Symptoms Decreased vision, pain, red eye, headache, diplopia, “bulging” eye, lid swelling,
and fever.
Signs Decreased visual acuity, fever, lid edema, erythema, and tenderness, limitation of
or pain on extraocular movements, proptosis, relative afferent pupillary defect, conjunc-
tival injection and chemosis; may have optic disc swelling; fungal infection usually
manifests with proptosis and orbital apex syndrome (see Chapter 2). The involvement of
multiple cranial nerves suggests extension posteriorly to the orbital apex, or cavernous
sinus, or both.
Lid edema/erythema
Fig 1.13 • Mucormycosis of the left orbit

Conjunctival chemosis/injection with eyelid edema, conjunctival injection,
chemosis, and gaze restriction.
Fig 1.12 • Orbital cellulitis with right-sided
proptosis, lid edema and erythema,
conjunctival injection and chemosis, and right
exotropia (note decentered right corneal light
reflex at the limbus).
Differential Diagnosis Thyroid eye disease (adults), IOI, subperiosteal abscess, orbital
neoplasm (e.g., rhabdomyosarcoma, lymphoproliferative disease, ruptured dermoid
cyst), orbital vasculitis, trauma, carotid–cavernous fistula, and cavernous sinus throm-
bosis.
Evaluation
• Complete ophthalmic history with attention to trauma, sinus disease, recent dental work
or infections, history of diabetes or immunosuppression.
• Complete eye exam with attention to visual acuity, color vision, pupils, motility, exoph-
thalmometry, lids, conjunctiva, cornea (including corneal sensitivity), cranial nerve (CN)
V sensation, and ophthalmoscopy.
• Check vital signs, head and neck lymph nodes, meningeal signs (nuchal rigidity), and
sensorium. Look in the mouth for evidence of fungal involvement.
• Lab tests: CBC with differential, blood cultures (results usually negative in phycomyco-
sis); culture wound, if present.
• CT scan of orbits and paranasal sinuses (with contrast, direct coronal and axial views,
3 mm slices) to look for sinus opacification or abscess.
Inflammation 13
Management
• Systemic intravenous antibiotic (2-week course):

Nafcillin 1–2 g IV q4h and ceftriaxone 1–2 g IV q12–24h or
Ampicillin–sulbactam (Unasyn) 1.5–3.0 g IV q6h.
For methicillin-resistant S. aureus, IV vancomycin or cefotaxime.
For fungus, IV amphotericin B 0.25–1.0 mg/kg IV divided equally q6h.
• Topical antibiotic (bacitracin or erythromycin ointment qid) for conjunctivitis or
corneal exposure.
• Daily follow-up required to monitor visual acuity, color vision (red desaturation),
ocular movements, proptosis, IOP, cornea, and optic nerve.
• Systemic oral antibiotic (10-day course) after improvement on IV therapy:
Amoxicillin–clavulanate (Augmentin) 250–500 mg po tid or
Cefaclor (Ceclor) 250–500 mg po tid or
Trimethoprim–sulfamethoxazole (Bactrim) 1 double-strength tablet po bid in
penicillin-allergic patients.
• Subperiosteal abscess requires urgent referral to an oculoplastic surgeon for close
observation and possible surgical drainage.
• Otolaryngology consultation is indicated to obtain tissue diagnosis for opacified
sinuses and if phycomycosis is suspected.
• Patients who have diabetes or who are immunocompromised are at high risk for
phycomycosis (mucormycosis). Given the very high mortality rate, patients re-
quire emergent debridement and biopsy, systemic IV antifungal (amphotericin B
0.25–1.0 mg/kg IV divided equally q6h), and management of underlying medical
disorders.
Prognosis Depends on organism and extent of disease at the time of presentation. May
develop orbital apex syndrome, cavernous sinus thrombosis, meningitis, or permanent
neurologic deficits. Mucormycosis in particular may be fatal.
Inflammation
Thyroid Eye Disease
Definition An immune-mediated disorder usually occurring in conjunction with Graves’
disease that causes a spectrum of ocular abnormalities. Also called thyroid-related ophthal-
mopathy, dysthyroid ophthalmopathy, or Graves’ ophthalmopathy.
Epidemiology Most common cause of unilateral or bilateral proptosis in adults; female

predilection (8:1); 90% of patients have abnormal thyroid function test results; hyperthy-
roidism is most common (90%), although patients may be hypothyroid (4%) or euthyroid
(6%); 1% of patients have or will develop myasthenia gravis. Cigarette smoking is a risk
factor for thyroid disease and greatly increases the incidence of TED in patients with
Graves’ disease.
Symptoms
Note: Signs and symptoms reflect four clinical components of this disease process: eyelid
disorders, eye surface disorders, ocular motility disorders, and optic neuropathy.
May have red eye, foreign body sensation, tearing, decreased vision, dyschromatopsia,
binocular diplopia, or prominent (“bulging”) eyes.
Signs Eyelid retraction, edema, lagophthalmos, lid lag (von Graefe’s sign), reduced blink-
ing, superficial keratopathy, conjunctival injection, exophthalmos, limitation of extraocular
movements (supraduction most common reflecting inferior rectus involvement), positive
forced ductions, resistance to retropulsion of globe, decreased visual acuity and color vision,
relative afferent papillary defect, and visual field defect. A minority of cases may have acute
congestion of the socket and periocular tissues. The Werner Classification of Eye Findings
in Graves’ Disease (mnemonic NO SPECS) is:
No signs or symptoms
Only signs
Soft tissue involvement (signs and symptoms)
Proptosis
Extraocular muscle involvement
Corneal involvement
Sight loss (optic nerve compression)
Fig 1.14 • Thyroid ophthalmopathy with Fig 1.15 • Same patient as in Fig. 1.14,
proptosis, lid retraction, and superior and demonstrating lagophthalmos on the right side
inferior scleral show of the right eye. with eyelid closure (note the small incomplete
closure of the right eyelids).
Differential Diagnosis IOI, orbital and lacrimal gland tumors, orbital vasculitis, trauma,
cellulitis, arteriovenous fistula, cavernous sinus thrombosis, gaze palsy, cranial nerve palsy,
and physiologic exophthalmos.
Evaluation
• Complete ophthalmic history with attention to history of thyroid disease, autoimmune
disease, or cancer; history of hyperthyroid symptoms such as heat intolerance, weight
loss, palpitations, sweating, and irritability.
• Complete eye exam with attention to cranial nerves, visual acuity, color vision, pupils, mo-
tility, forced ductions, exophthalmometry, lids, cornea, tonometry, and ophthalmoscopy.
• Check visual fields as a baseline study in early cases and to rule out optic neuropathy in
advanced cases.
Inflammation 15
• Lab tests: Thyroid function tests (thyroid-stimulating hormone [TSH], thyroxine

[total and free T4], and triiodothyronine [T3], and thyroid-stimulating immunoglobu-
lin [TSI]).
• Orbital CT scan (with contrast, direct coronal and axial views, 3 mm slices) or MRI
with multiplanar reconstruction: Extraocular muscle enlargement with sparing of the
tendons; inferior rectus is most commonly involved followed by medial, superior, lateral,
and oblique (IMSLO). MRI provides better imaging of the optic nerve, orbital fat, and
extraocular muscle, but CT scan provides better views of bony architecture of the orbit.
• Endocrinology consultation.
Management
• Surgical interventions are deferred until a 9–12 month stable interval is recorded,
except in cases of optic neuropathy or extreme proptosis causing severe exposure
keratopathy.
• After an adequate quiescent interval, surgery proceeds in a stepwise fashion, moving
posteriorly to anteriorly: orbital bony decompression, strabismus surgery, and then
eyelid reconstruction as indicated.
• Underlying thyroid disease should be managed by an endocrinologist.
EXPOSURE
• Topical lubrication with artificial tears up to q1h while awake and ointment qhs.
• Consider lid taping or moisture chamber goggles at bedtime.
• Punctal occlusion for more severe dry eye symptoms.
• Permanent lateral tarsorrhaphy or canthorrhaphy is useful in cases of lateral chemo-
sis or widened lateral palpebral fissure.
EYELID RETRACTION
• Surgical eyelid recession (lengthening) after an adequate stable interval.
DIPLOPIA
• Oral steroids (prednisone 80–100 mg po qd for 1–2 weeks, then taper over 1 month)
are controversial.
• Fresnel (temporary) prisms.
• Strabismus surgery (rectus muscle recessions) considered after a 6-month stable in-
terval and after orbital surgery completed.
OPTIC NEUROPATHY
• Immediate treatment with oral steroids (prednisone 100 mg po qd for 2–14 days).
• The use of external beam irradiation (15–30 Gy) is controversial and falling out of favor.
• Orbital decompression for compressive optic neuropathy should be performed by an
oculoplastic surgeon. A balanced approach with decompression of the medial and
lateral orbital walls is most commonly used. Removal of the inferior wall is avoided
if possible caused by higher incidence of induced diplopia.
Prognosis Diplopia and ocular surface disease are common; 6% develop optic nerve dis-
ease. Despite surgical rehabilitation, which may require multiple procedures, patients are
often left with functional and cosmetic deficits.
Idiopathic Orbital Inflammatory Disease (Orbital Pseudotumor)

Definition Acute or chronic idiopathic inflammatory disorder of the orbital tissues, some-
times collectively termed orbital pseudotumor. Any of the orbital tissues may be involved:
lacrimal gland (dacryoadenitis), extraocular muscles (myositis), sclera (scleritis), optic nerve
sheath (optic perineuritis), and orbital fat.
Tolosa–Hunt syndrome is a form of IOI involving the orbital apex or anterior cavern-
ous sinus that produces painful external ophthalmoplegia.
Epidemiology Occurs in all age groups; usually unilateral, although bilateral disease is
more common in children; adults require evaluation for systemic vasculitis (e.g., Wegener’s
granulomatosis, polyarteritis nodosa) or lymphoproliferative disorders. Second most
common cause of exophthalmos after TED. Both infectious and immune-mediated theo-
ries have been proposed.
Symptoms Acute onset of orbital pain, decreased vision, binocular diplopia, red eye, head-
aches, and constitutional symptoms. (Constitutional symptoms including fever, nausea, and
vomiting are present in 50% of children.)
Signs Marked tenderness of involved region, lid edema and erythema, lacrimal gland en-
largement, limitation of and pain on extraocular movements (myositis), positive forced
ductions, proptosis, resistance to retropulsion of globe, induced hyperopia, conjunctival
chemosis, reduced corneal sensation (caused by CN V1 involvement), increased IOP;
papillitis or iritis may occur and are more common in children.
Conjunctival chemosis
Lid erythema Conjunctival chemosis

Lacrimal gland enlargement
Fig 1.16 • Idiopathic orbital inflammation
of the right orbit with lid edema, ptosis, and Fig 1.17 • Idiopathic orbital inflammation
chemosis. of the right orbit with lacrimal gland
involvement. Note the swollen, prolapsed
lacrimal gland superiorly.
Differential Diagnosis TED, orbital cellulitis, orbital tumors, lacrimal gland tumors,
orbital vasculitis, trauma, cavernous sinus thrombosis, cranial nerve palsy, and herpes zoster
ophthalmicus.
Congenital Anomalies 17
Evaluation
• Complete ophthalmic history with attention to previous episodes and history of cancer
or other systemic disease.
• Complete eye exam with attention to eyelid and orbital palpation, pupils, motility, forced
ductions, exophthalmometry, lids, cornea, tonometry, and ophthalmoscopy.
• Lab tests for bilateral or unusual cases (vasculitis suspected): CBC with differential,
erythrocyte sedimentation rate (ESR), antinuclear antibodies (ANA), blood urea nitro-
gen (BUN), creatinine, fasting blood glucose, antineutrophil cytoplasmic antibodies
(ANCA), angiotensin-converting enzyme (ACE), and urinalysis.
• Orbital CT scan or MRI: Thickened, enhancing sclera (ring sign); extraocular muscle
enlargement with involvement of the tendons; lacrimal gland involvement; or diffuse in-
flammation with streaking of orbital fat. However, recommended imaging for idiopathic
orbital inflammatory disease is contrast-enhanced thin section MRI with fat suppression.
• Consider orbital biopsy for steroid-unresponsive, recurrent, and unusual cases.
Management
• Oral steroids (prednisone 80–100 mg po qd for 1 week; then taper slowly over a few
months); check purified protein derivative (PPD) and controls, CBC, blood glucose,
lipid profile, and chest radiographs before starting systemic steroids and check
height, bone mineral density, and spinal radiograph at baseline and every 1–3 years
for patients on long-term steroids (5 mg qd for 3 months).
• Add an H2 blocker (ranitidine [Zantac] 150 mg po bid) or proton pump inhibitor
(omeprazole [Prilosec] 20 mg po qd); also add calcium, vitamin D, and possibly a
bisphosphonate or teriparatide when administering long-term systemic steroids.
• Topical steroid (prednisolone acetate 1% up to q2h initially; then taper over
3–4 weeks) if iritis present.
• Patients should respond dramatically to systemic corticosteroids within 24–48 hours.
Failure to do so strongly suggests another diagnosis.
Prognosis Generally good for acute disease, although recurrences are common. The scleros-
ing form of this disorder has a more insidious onset and is often less responsive to treatment.
Congenital Anomalies
Usually occur in developmental syndromes, rarely in isolation.
Congenital Anophthalmia
Absence of globe with normal-appearing eyelids caused by failure of optic vesicle forma-
tion; extraocular muscles are present and insert abnormally into orbital soft tissue. Ex-
tremely rare condition that produces a hypoplastic orbit that becomes accentuated with
contralateral hemifacial maturation. Usually bilateral and sporadic. Characteristic “purse
stringing” of the orbital rim. Orbital CT, ultrasonography, and examination under anesthe-
sia are required to make the diagnosis. In most cases, a rudimentary globe is present but not
identifiable short of postmortem sectioning of the orbital contents.
Fig 1.18 • Congenital

anophthalmia demonstrating
absence of globe with normal
eyelids and eyelashes.
Microphthalmos
Small, malformed eye caused by disruption of development after optic vesicle forms. More
common than anophthalmos and presents similar orbital challenges. Usually unilateral and
recessive. Associated with cataract, glaucoma, aniridia, coloboma, and systemic abnormali-
ties (including polydactyly, syndactyly, clubfoot, polycystic kidneys, cystic liver, cleft palate,
and meningoencephalocele). True anophthalmia and severe microphthalmia can be differ-
entiated only on histologic examination.
Microphthalmos with Cyst

Disorganized, cystic eye caused by failure of embryonic fissure to close. Appears as a blue
mass in lower eyelid. Associated with various conditions, including rubella, toxoplasmosis,
maternal vitamin A deficiency, maternal thalidomide ingestion, trisomy 13, trisomy 15, and
chromosome 18 deletion.
• Treatment is aimed at progressive orbital expansion for facial symmetry and includes
serial orbital implants requiring multiple orbitotomies over the first several years of life,
expandable orbital implants, and serial conjunctival conformers. Avoid enucleation in
cases of microphthalmos.
• Age of orbital maturation is not known, but elective enucleation should be deferred in
early childhood. Enucleation before the age of 9 years old may produce significant orbital
asymmetry (radiographically estimated deficiency up to 15%), but enucleation after
9 years old leads to no appreciable asymmetry.
• Reconstructive surgery can be undertaken after the first decade of life.
Nanophthalmos
Small eye (axial length ,20.5 mm) with normal structures; lens is normal in size, but sclera
and choroid are thickened. Associated with hyperopia and angle-closure glaucoma and
increased risk of choroidal effusion during intraocular surgery.
Craniofacial Disorders
Midfacial clefting syndromes can involve the medial superior or medial inferior orbit (some-
times with meningoencephalocele) and can produce hypertelorism (increased bony expanse
between the medial walls of the orbit). Hypertelorism also occurs in craniosynostoses such
Pediatric Orbital Tumors 19
as Crouzon’s syndrome (craniofacial dysostosis) and Apert’s syndrome (acrocephalosyndac-

tyly) in which there is premature closure of cranial sutures. Exorbitism and lateral canthal
dystopia are also found in these syndromes.
• Craniofacial surgery by an experienced oculoplastic surgeon.
Pediatric Orbital Tumors

Benign Pediatric Orbital Tumors
Orbital Dermoid (Dermoid Cyst)
Common, benign, palpable, smooth, painless choristoma (normal tissue, abnormal loca-
tion) composed of connective tissue and containing dermal adnexal structures including
sebaceous glands and hair follicles. Most common pediatric orbital tumor. Usually mani-
fests in childhood (90% in first decade) and may enlarge slowly. Most common location is
superotemporal at the zygomaticofrontal suture. Symptoms include ptosis, proptosis, and
diplopia. There may be components external or internal to the orbit or both (“dumb-bell”
dermoid).
Fig 1.19 • Dermoid cyst of the

right orbit appearing as a mass
at the lateral orbital rim. Also
note the epicanthus causing
pseudostrabismus.
Dermoid cyst Epicanthus
• Orbital CT scan (with contrast, direct coronal and axial views, 3 mm slices): Well
circumscribed; cystic mass with bony molding.
• Complete surgical excision; preserve capsule and avoid rupturing cyst to avoid recurrence
and prevent an acute inflammatory process should be performed by an oculoplastic
surgeon.
Lymphangioma
Low-flow malformations misnamed lymphangioma. Benign, nonpigmented choristoma
characterized by lymphatic fluid-filled spaces lined by flattened endothelial cells; vascular
channels do not contain red blood cells; patients do not produce true lymphatic vessels. May
appear blue through the skin. May be associated with head and neck components. Becomes
apparent in first decade with an infiltrative growth pattern or with abrupt onset caused by
hemorrhage within the tumor (“chocolate cyst”). May enlarge during upper respiratory tract
infections. Usually presents with sudden proptosis; may have pain, ptosis, and strabismus.
Complications include exposure keratopathy, compressive optic neuropathy, glaucoma, and
amblyopia. Slow, relentless progression is common; may regress spontaneously.
Fig 1.20 • Lymphangioma

with subcutaneous hemorrhage
of the left lower eyelid.
Fig 1.21 • Lymphangioma with anterior Fig 1.22 • T2-weighted magnetic

component visible as vascular subconjunctival resonance imaging scan of the same patient
mass at the medial canthus. as in Fig. 1.21 demonstrating the irregular
cystic appearance of the left orbital
lymphangioma.
• CT scan of orbit, paranasal sinuses, and pharynx with contrast: Nonencapsulated, ir-
regular mass with cystic spaces; infiltrative growth pattern.
• Orbital needle aspiration of hemorrhage (“chocolate cysts”) or surgical exploration for
acute orbital hemorrhage with compressive optic neuropathy.
• Complete surgical excision is usually not possible. Limited excision indicated for ocular
damage or severe cosmetic deformities; should be performed by an oculoplastic surgeon.
• Consider treatment with oral sildenafil (experimental).
• Children should undergo pediatric otolaryngologic examination to rule out airway compromise.
Juvenile Xanthogranuloma
Nevoxanthoendothelioma, composed of histiocytes and Touton giant cells that rarely in-
volve the orbit. Appears between birth and 1 year of age with mild proptosis. Associated
with yellow-orange cutaneous lesions and may cause destruction of bone. Spontaneous
resolution often occurs. Orbital ultrasound may be useful.
• Most cases can be observed with frequent spontaneous regression.
• Consider local steroid injection (controversial).

• Surgical excision in the rare case of visual compromise.
Histiocytic Tumors
Initially designated histiocytosis X, the Langerhans’ cell histiocytoses comprise a spectrum
of related granulomatous diseases that occur most frequently in children aged 1–4 years
old. Immunohistochemical staining and electron microscopy reveal atypical (Langerhans’)
histiocytes (1CD1a) with characteristic Birbeck’s (cytoplasmic) granules on electron
microscopy.
Hand–Schüller–Christian disease
Chronic, recurrent form. Classic triad of proptosis, lytic skull lesions, and diabetes
insipidus.
• Treatment is with systemic glucocorticoids and chemotherapy.
Letterer–Siwe disease
Acute, systemic form. Occurs during infancy with hepatosplenomegaly, thrombocytopenia,
and fever and with very poor prognosis for survival.
• Treatment is with systemic glucocorticoids and chemotherapy.
Eosinophilic granuloma
Localized form. Most likely to involve the orbit. Bony lesion with soft tissue involvement
that typically produces proptosis and more often is located in the superotemporal orbit as
a result of frontal bone disease.
• Treatment is with local incision and curettage, intralesional steroid injection, or
radiotherapy.
Malignant Pediatric Orbital Tumors

Rhabdomyosarcoma
Most common primary pediatric orbital malignancy and most common pediatric soft
tissue malignancy; mean age is 5–7 years old; 90% of cases occur in patients 16 years
old; male predilection (5:3). Presents with rapid onset, progressive, unilateral proptosis,
eyelid edema, and discoloration. Epistaxis, sinusitis, and headaches indicate sinus in-
volvement. History of trauma may be misleading. Predilection for superonasal orbit.
CT scan commonly demonstrates bony orbital destruction. Arises from primitive
mesenchyme, not extraocular muscles. Urgent biopsy necessary for diagnosis. Four
histologic forms:
Embryonal
Most common (70%); cross striations found in 50% of cells.
Alveolar
Most malignant, worst prognosis, inferior orbit, second most common (20%–30%); few
cross-striations.
Botryoid
Grape-like; originates within paranasal sinuses or conjunctiva; rare.
Pleomorphic
Rarest (,10%); most differentiated; occurs in older patients; best prognosis; 90%–95%
5-year survival rate if limited to orbit; cross-striations in most cells.
Fig 1.23 • Rhabdomyosarcoma

of the right orbit with marked
lower eyelid edema,
discoloration, and chemosis.
Eyelid edema/discoloration
• Emergent diagnostic biopsy with immunohistochemical staining in all cases. Staging of

rhabdomyosarcoma is essential to the treatment approach.
• Pediatric oncology consultation for systemic evaluation, including abdominal and tho-
racic CT, bone marrow biopsy, and lumbar puncture.
• Treatment involves combinations of surgery, systemic chemotherapy, and radiotherapy.
New protocols have improved outcomes (the Intergroup Rhabdomyosarcoma Study IV
[IRS-IV] showed a 3-year failure-free survival rate of 91%, 94%, and 80% for group I,
II, and III disease, respectively).
Neuroblastoma
Most common pediatric orbital metastatic tumor (second most common orbital malig-
nancy after rhabdomyosarcoma). Occurs in the first decade of life. Usually arises from a
primary tumor in the abdomen (adrenals in 50%), mediastinum, or neck from undifferenti-
ated embryonic cells of neural crest origin. Patients typically have sudden proptosis with
eyelid ecchymosis (“raccoon eyes”) that may be bilateral; may develop ipsilateral Horner’s
syndrome and opsoclonus (saccadomania). Prognosis is poor.
• Orbital CT scan: Poorly defined mass with bony erosion (most commonly the lateral wall).
• Pediatric oncology consultation for systemic evaluation.
• Treatment is with local radiotherapy and systemic chemotherapy.
Leukemia
Advanced leukemia, particularly the acute lymphocytic type, may appear with proptosis;
granulocytic sarcoma (chloroma), an uncommon subtype of myelogenous leukemia, may
also produce orbital proptosis, often before hematogenous or bone marrow signs. Both
forms usually occur during the first decade of life.
• Pediatric oncology consultation.
• Treatment is with systemic chemotherapy.
Fig 1.24 • (A) Neuroblastoma

presenting with bilateral eyelid
ecchymosis and right upper
eyelid swelling. (B) Computed
tomography scan demonstrating
orbital metastases.
Fig 1.25 • Orbital

neuroblastoma demonstrating
bilateral eyelid ecchymosis
(“raccoon eyes”).
“Raccoon eyes”
Adult Orbital Tumors

Benign Adult Orbital Tumors
Cavernous Hemangioma
This misnamed tumor is a vascular hamartoma and the most common adult orbital tumor.
Probably present from birth but typically appears in fourth to sixth decades. It is one of the
four periocular tumors that are more common in female patients (meningioma, sebaceous
carcinoma, and choroidal osteoma). Patients usually have painless, decreased visual acuity,
or diplopia. Signs include slowly progressive proptosis and compressive optic neuropathy.
May have induced hyperopia and choroidal folds caused by posterior pressure on the globe.
May enlarge during pregnancy.
• Orbital CT scan (in cases of suspected tumor, CT scans are ordered with contrast):
Well-circumscribed intraconal or extraconal lesion; no bony erosion (remodeling is
possible); adjacent structures may be displaced but are not invaded or destroyed.
• Orbital MRI: Tumor appears hypointense on T1-weighted images and hyperintense on
T2-weighted images with heterogeneous internal signal density.
• A-scan ultrasonography: High internal reflectivity.
• Complete surgical excision (usually requires lateral orbitotomy with bone removal) indi-
cated for severe corneal exposure, compressive optic neuropathy, intractable diplopia, or
exophthalmos; should be performed by an oculoplastic surgeon.
Fig 1.26 • T2-weighted magnetic

resonance imaging scan demonstrating
cavernous hemangioma of the left orbit as a
hyperintense mass displacing the globe and
optic nerve.
Mucocele
Cystic sinus mass caused by the combination of an orbital wall fracture and obstructed si-
nus excretory ducts, lined by pseudostratified ciliated columnar epithelium and filled with
mucoid material. Patients usually have a history of chronic sinusitis (frontal and ethmoidal
sinuses). Associated with cystic fibrosis; usually occurs in the superonasal orbit; must be
differentiated from encephalocele and meningocele.
Adult Orbital Tumors 25
Globe dystopia Mucocele
Fig 1.27 • Mucocele of the orbit with left Fig 1.28 • Mucocele of the left eye.
globe dystopia.
• Head and orbital CT scan: Orbital lesion and orbital wall defect with sinus opacification.
• Complete surgical excision should be performed by an oculoplastic or otolaryngology
plastic surgeon. May require obliteration of frontal sinus; preoperative and postoperative
systemic antibiotics (ampicillin–sulbactam [Unasyn] 1.5–3.0 g IV q6h).
Neurilemoma (Schwannoma)
Rare, benign tumor (1% of all orbital tumors) that occurs in young to middle-aged indi-
viduals. Patients have gradual, painless proptosis and globe displacement. May be associated
with neurofibromatosis type 1. One of two truly encapsulated orbital tumors. Histologic
examination demonstrates two patterns of Schwann cell proliferation enveloped by peri-
neurium: Antoni A (solid, nuclear palisading, Verocay bodies) and Antoni B (loose, myxoid
areas). Recurrence and malignant transformation are rare.
Fig 1.29 • Neurilemoma

(schwannoma) producing
proptosis of the left eye.
Proptosis
• Orbital CT scan: Well-circumscribed lesion; virtually indistinguishable from “cavernous

hemangioma”; may have cystic areas.
• A-scan ultrasonography: Low internal reflectivity.
• Complete surgical excision should be performed by an oculoplastic surgeon.
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This island did not tempt us to stay long, so we steered for
Cagayan Sulu, which is a gem in the ocean; it has three peaks,
wooded, but varied by grassy glades, groves of cocoa-nuts and fruit-
trees, partly concealing and partly revealing scattered houses and
villages. It is, indeed, a picturesque island from every view. Our first
intercourse appeared likely to be unfriendly. Steering round to the
south-west side, we landed at a place where we saw some houses
close to the beach, and as we pulled ashore, we could see the
inhabitants gathering in armed groups; however, we were received
with great civility, and explained the object of our visit, which was to
inquire what fresh provisions could be procured there. We did not
stay long, as they promised to bring us down next day a good
supply.
When we landed on the following morning, we found a very large
party assembled with several fine bullocks for sale; while the
bargaining was going on I wandered inland with a companion to
have a look at the country. Wherever we went we found plantations
of cocoa-nuts and plantains, and round the houses were small
vegetable gardens, while between the dwellings were occasionally
extensive tracks of long coarse grass, on which were herds of
bullocks feeding.
At length we came to a spot which tempted us to rest. It was a
rock overhanging a tiny bay, thrown into deep shade by the tall
graceful palms which bent over it; while looking inland across the
gently sloping fields of long high grass interspersed with groves, we
could see parties of natives marching in Indian file, with their bright
spear-heads flashing in the sun, winding their way down to the
extemporized market. We sat under the shade of some areca palms;
which, though young, and not twenty feet in height, were yet covered
with fruit and freshly expanded blossoms, which shed a delicious
perfume through the whole grove.
Our bargaining prospered, as fine cattle were secured at thirty
shillings a piece, ducks for two wine bottles, fine cocks and hens for
one; as well as a couple of pretty ponies, cocoa-nut oil and nuts,
plantains, limes, ginger, onions, and fruits. This island, though
formerly a dependency of Sulu, is now independent, and is governed
by some of those half-bred Arabs who corrupt and weigh heavily on
these countries. It is finely situated in the Sulu seas, and it is both
healthy and fertile. The inhabitants appear much the same as those I
had seen about Maludu Bay, and, with the exception of some
strangers, were civil. The latter were traders who had visited
Samboañgan, Manilla, and other Spanish ports, and were there
corrupted, by intercourse with the low Europeans and dissipated
classes who usually frequent such places; and at one time these
men were so insolent that I thought their conduct would become
unbearable, till they were quieted by my shooting down a cocoa-nut,
as mentioned in my Limbang journal.
The most singular spot in this island is near the old crater-looking
harbour, mentioned by Sir Edward Belcher, which we entered over a
reef. It is almost circular, and is surrounded by lofty rocks clothed
with trees, bushes, and hanging creepers, presenting a magnificent
wall of evergreen. Rowing to the west side of the bay, and climbing
to the top of a lofty bank, we had a splendid view of a remarkable
almost circular, lake. The place where we stood was a gap between
the lofty cliffs that rose on either hand, and appeared to have been
formed by the inner waters bursting their boundary, and overthrowing
the upper defences of this natural dam. The wooded cliff’s continue
all round, forming a perfect barrier, now rising to a great height, then
sinking to some fifty or sixty feet. The waters, elevated more than
forty feet above the sea, lay in undisturbed repose, and presented
for upwards of half a mile a clear mirror, reflecting back the rays of
the sun and the deep shadow of the tall trees.
I mounted with some difficulty the top of the left-hand cliff, and had
an extensive view through the tangled bushes. On one side were the
waters of the crater, on the other the serene lake with the sea
appearing beyond. We heard from the natives that alligators swarm
in this secluded water, so that fish must be plentiful also, as few pigs
could descend here. In the interior they say there is another more
extensive lake of the same formation; this one was found to be eight
fathoms deep at the edges, and forty in the centre.
Started from Cagayan Sulu, and after encountering rougher
weather than we expected to find in this usually calm sea, lay to, as
we thought we were not far from the island we were intending to
visit.
At daylight the two peaks of Sulu were visible; and as we
approached, the summits of the other hills appeared, while all the
rest of the island lay enveloped in mist; but the sun soon dispelled
this, and showed us the west coast of the lovely island of Sulu. The
slopes of the hills presented alternate patches of cleared grassy
land, with clumps of trees scattered over its face, reminding one of a
noble English park; while a long dense line of cocoa-nut palms
skirted the beach, among which were seen many houses and groups
of inhabitants, who were no doubt watching our approach with much
anxiety, as they had already suffered from the attacks of the Dutch
and Spaniards; but the sight of the English flag no doubt restored
their confidence.
Anchored off Sugh, the capital of Sulu, which is situated at the
bottom of a bay, and appears small; but among the existing
dwellings we could distinguish blackened piles, the remains of
portions of the city burnt by the Dutch. On the right of the town is a
high hill, curiously peaked and well wooded. Farther off to the left,
and at the back, are many high mountains, some peaked, others
rounded; but, as a whole, forming a beautiful view. A white flag, with
a castle represented on it, waved over the fort, and a pilot jack
marked the residence of Mr. Wyndham, an Englishman, settled here
for the purposes of trade.
Very few natives came off, until at length a messenger arrived
from the sultan to know who we were; we returned a suitable and, no
doubt, a satisfactory reply, as the Sulus were in a state of great
excitement, having suffered considerably from the recent shots of
the Dutch ships. Having communicated with Mr. Wyndham, we went
to see the watering-place about a mile to the west of the town,
situated near the great tree to which I have alluded in my second
account of Kina Balu, where we found the water bursting out of the
sand, clear as crystal, and pleasant to the taste.
The tree is very fine, being at least thirteen feet in diameter, with a
very sinewy stem. Mr. Wyndham walked with us a little way into the
country, and showed us some of the houses, having much the same
appearance as those of the Malays. These people are better-looking
than most other inhabitants of the archipelago; but appeared to be
suspicious, watching us at every point; in fact, we afterwards heard
the fugitives from Balignini were scattered among them, and they
had had no time to forget what they had suffered from the well-
deserved attacks of the Spaniards. We then pulled to Mr.
Wyndham’s house, a mere rough building, raised near the site of his
former one, burnt by the Dutch—why or wherefore is inconceivable.
The whole night after our arrival the country was in an uproar,
reports spreading of the advent of innumerable ships, which made
the inhabitants hurry their women, children, and goods up to the
mountain. In the evening we took a friendly letter to the sultan.
28th.—Went with the watering-party, but were unable to penetrate
far, on account of heavy rain and the incivility of the natives, who
waved us back. No answer, as yet, from the sultan.
30th.—Landed at the watering-place, where the mountaineers
were assembled at a sort of market, bartering, buying, and selling.
We walked about a little, and then returned to the beach, where we
were surrounded by some scores of men, women, and children from
the mountains and neighbourhood; the former are said to be of a
different race, but we saw little signs of it. The women, on the whole,
are better-looking than the Malays, and some of the little girls were
quite pretty; they are civil enough, but anxious to know our business.
In the afternoon we went to an audience with the sultan. Having
landed at Mr. Wyndham’s, who led us by a long shaky platform to the
shore, where we found numbers of armed natives assembled, an
officer from the sultan led the way along a broad rough road with a
high stockade on the left, and houses on the right. We passed in,
through ever-increasing crowds, to a market-place, where the
women were selling fowls, fish, and vegetables, till we came to a
creek, over which a rude bridge took us to the palace. Before
crossing, we observed a large brass 24-pounder showing through an
embrasure. The stockade continued on the left, until we passed a
large gate, where on a green were assembled some hundreds of
men, armed with muskets, spears, heavy Lanun swords, and krises,
and defended by shields, and some brass armour, and old Spanish-
looking helmets.
The audience hall was on the right, and the house of prayer on
the left. The crowd opening, we mounted some steps, and crossing a
verandah thronged with armed men, found ourselves in the presence
of the sultan. The audience hall is large, but perfectly bare of
ornament, as all their valuable silks and hangings were packed up,
and mostly sent to the hills, on account of an absurd report spread
by the mate of the Spanish brig we found anchored near, which,
when we came in sight, began to get under weigh, and stand out to
sea.
On being questioned by the Chinese passengers, he said that we
had given him notice to get out of the way, as we were about to
bombard the town. The rumour having spread, the natives packed
up their valuables, and spent the night in carrying their goods off to
the hills, and in removing their women and children. This caused the
suspicious behaviour of the people, and what tends to keep up their
apprehensions a little is that the Spanish brig has not yet returned to
her proper anchorage.
But to return to the hall. In the centre stood a round table; on the
opposite side sat the sultan surrounded by his datus, and around
were a number of empty chairs, on which we took our seats. After
shaking hands, a few questions were asked, as, “What was the
news? Was France quiet?” The sultan was very like the picture in Sir
Edward Belcher’s book, and was dressed in light-flowered silk, with a
very broad gold belt round his waist, a handsome kris, and gold
bracelets, sparkling with jewels. Some of the datus were splendidly
dressed in silks, gold brocades, handsome turbans and head-
dresses, like golden tiaras; the young men were, as usual, the most
gaudily decorated, while the old were in plain white jackets, and
crowds of the better class sat behind and around us.
Observing that Sir James Brooke, who had lately suffered much
from fever, looked hot and tired, the sultan politely broke up the
audience, and we returned by the same path we came, and after
sitting a short time with Mr. Wyndham, went on board to dine with
Captain Keppel, where our Sulu acquaintance amused us with
stories about the natives.
Went on shore to Mr. Wyndham’s to meet datu Daniel; very little
conversation passed. He appears to be a quiet, good-natured man;
his brothers are very fine fellows, and very fair; with them we went to
see the race-course. Passing through a portion of the town, we came
to an open grassy field, where a few men were trying their horses by
trotting them over the sward. None of the chiefs being present, there
were no trials of speed.
2nd.—On shore early with our guide, but the people not appearing
to like our penetrating into the country, we returned to Mr.
Wyndham’s house, and as we passed the stockades, the Sulus
laughingly pointed to some indentations in the wood where the shot
from the Dutch ships had struck, but had done little damage.
3rd.—Weighed anchor and stood along the coast for Tulyan Bay;
but wind and tide being against us, we let go our anchor; sailing
again at three, we found ourselves towards seven in Tulyan Bay,
much to the discomfort of the villagers, whose shouts and screams
could be distinctly heard on board. At last a couple of men came off
and returned on shore after a few reassuring words from Mr.
Wyndham, which appeared sufficient to pacify the inhabitants, as the
noises ceased. Tulyan Bay is rather deep, and appears to be well
protected, and takes its name from a pretty-looking island in the
offing, which was ceded to the English in Dalrymple’s time—in fact,
the inhabitants thought we were come to take possession.
4th.—I must now endeavour to give the little information I
collected concerning Sulu. The government is carried on by a sultan,
with his council of datus; at the present time the principal power is
held by datu Molok, an elder but illegitimate brother of the sultan—a
shrewd-looking man with quick, inquiring eyes. The sultan is said to
be well-intentioned; but, being weak in character, is totally unable to
subdue the turbulent aristocracy by whom he is surrounded. In
despair he is reported to give way to his fondness for opium-
smoking.
The laws are but little respected, and ancient customs are fast
falling into disuse, particularly one resembling a voluntary poor-rate.
Every Sulu trader used to present five per cent. of his yearly profits
to a fund, which was divided among the poor of the island. The
mountaineers acknowledge the supremacy of the sultan, but refuse
to pay tribute, and a government which cannot enforce that is not
likely to be able to suppress feuds, or effectually to put down
disturbances. Mr. Wyndham pointed out a man who was notorious
as a murderer, and one instance he had himself witnessed of his
bloodthirstiness.
Again, two mountaineers, bargaining for a slice of fish, quarrelled;
they mutually seized each other’s weapons; one held the handle of
his opponent’s kris, the other his spear shaft; they struggled, a fight
ensued, the crowd collected, some took one side, some the other,
and in a few minutes seven men lay gasping on the ground. It is not
to be expected that the dependencies of the island will obey, when
all is in such confusion. The sultan’s power is very limited, though
the datus still send parties to raise contributions from the
neighbouring towns, villages, and islands. In all decaying states we
find religion neglected, and here, I imagine, it is held but in slight
respect; their houses of prayer being like a tumble-down barn, and
the inhabitants indulging in the use of wine, and occasionally pork.
Mr. Wyndham told us an amusing story of an old datu, who, going
on business to a Chinese trader, began to find a delicious odour
insinuatingly creeping over his senses.
“Ah,” said he, “what is this? some cooking, what is it?”
“Pork.”
“Pork?” said he; “ah!”
“Would you like to taste some?”
“Why,” he answered in a low voice, but cautiously surveying the
room to see if he were watched, “yes, bring me a little.”
On tasting it, and finding it very good, he began to eat some more.
Mr. Wyndham living next door, and hearing the old fellow’s noise,
had removed some of the partition, and was watching him. He now
coughed.
“Oh, I am ruined,” cried the datu; “who lives in the next house?”
“Signor Wyndham.”
“Then he has me in his power.”
Our informant then went in, and, laughing, shook the Mahomedan
chief by the hand, and congratulated him on his freedom from
prejudice. He ever after had much influence with the old man, who
feared being exposed. The inland inhabitants call themselves
Islamites, but are very lax and ignorant.
The Sulu language is soft; it contains, I believe, many Malay
words and expressions, but it is essentially different; though the
upper classes understand Malay, and also many of the lower, there
being here numerous slaves from Borneo. The population, they say,
is 200,000; it is probably 100,000; not less, from the numerous towns
and villages along the coast, and the number of houses detached in
twos and threes. On an extraordinary occasion, they say they could
bring some 15,000 or 20,000 men into the field; but, in general,
5,000 would be as many as they could assemble. In fact, when the
day of trouble came, they had not, perhaps, 2,000 to defend the
town; and this may be readily accounted for, as a large proportion of
the population is in servitude, which is, however, generally an easy
state of existence.
The slaves are collected from all parts of the archipelago, from
Acheen Head to New Guinea, and from the south of Siam to the
most northern parts of the Philippines: it is a regular slave market.
The Sulus themselves are a better-looking people than any I have
yet seen; they are daring and independent, and the mountaineers,
particularly, are a wild but polite people. Their young women and
little girls are dark-eyed and good-featured, with easy figures; free,
though not obtrusive, in their ways.
Bold and daring as the datus appear, they have much politeness
in their manners, particularly datu Daniel and his brother; and on
proper occasions their carriage is dignified and commanding. The
lower orders are outwardly rough, violent, and fierce, yet have an
inherent politeness, which, when inclined to show confidence, they
display to much advantage. On state occasions the young men
appear in splendid dresses, while the elder content themselves with
plain clothes. The dress is the same as the rest of the archipelago—
a jacket, trousers, sarong, and occasionally a shirt or under-vest.
They all wear krises, and most of them also carry either muskets or
spears.
The Balignini near the watering-places were the worst we met—
insolent and inclined to pilfer; indeed, there was nearly a quarrel
about some of the seamen’s clothes they tried to appropriate. To
show their dislike, they planted sharp fish-bones round the watering-
place, in the hope that our men, landing in the dark, might cut their
feet. The Dutch burnt about two hundred houses, but did little injury
to the stockades, which are, however, sadly out of repair. In proper
order, well mounted with guns, they could make a good defence, as
the walls facing the sea are about fifteen feet thick of mud and stone,
encased with teak stockades. The rampart around the sultan’s
palace is in the best repair, but not so thick as the others; and datu
Daniel’s is by no means contemptible. The men, too, would fight
bravely, as they did against the Dutch; but their guns, except the
brass ones, are mostly dismounted, and they have no carriages
ready; the iron ones are said to be those taken at Balambañgan,
when they surprised and captured our settlement.
The appearance of the country from the sea is very beautiful,
many of the hills rising to a peak some 2,000 feet above the level of
the sea; while others are lower and wooded, and form an agreeable
contrast. Several of these eminences are forest-covered to the
summit, while many present alternate patches of rice cultivation,
pasture land, groves of cocoa-nut, palms, gardens, and detached
clumps of forest trees. It is by far the most beautiful island I have
seen. Sulu, in good hands, might be made to produce every tropical
production, and become the centre of the commerce in these seas.
Ships, by staying a little time, may obtain bullocks, fowls, ducks,
vegetables, fruits, cocoa-nuts, and very fine water at a very good
watering-place. The duties on goods are high; nevertheless, Mr.
Wyndham and the Spaniards carry on a profitable commerce.
Tulyan is rather a small island, with hills to the north, but low land
on the south: the former with a few trees and some bananas, with
cocoa-nut palms at the foot; the latter a little woody. Dalrymple gives
some account of it. In his time the Spaniards had driven the natives
away, burnt their houses, and cut down their fruit-trees; but there is
now a large village along the beach, with many cocoa-nut groves.
The inhabitants are pearl fishers.
Next day anchored off two woody islets; the captain, as usual,
shelling and dredging. Islands are to be seen in the distance all
around us.
6th.—Anchored off Basilan. High hills and lowlands covered with
woods, showing but few clearings. We counted eighteen islands at
one time; among which were the late pirate haunts of Balignini and
Tonquil. Beat about, and anchored off Samboañgan after dark.
We remained seven days at Samboañgan, walking and exploring
in every direction, and enjoyed our stay there very much.
Magindanau, as far as we have seen it, is very hilly and woody, with
the exception of the neighbourhood of the Spanish settlement of
Samboañgan, which has been cleared for some miles; though, for an
old colony, not so much as might have been expected.
The town is situated on the west point of Lanun Bay, and from the
sea appears much smaller than it is in reality. It presents no very
striking features; the long, low, dark fort and whitewashed houses,
intermixed with a few groves of cocoa-nuts, with forest on either
side, and the hills, some cleared and some wooded, rising about
seven miles inland, suggest a rough idea of this pleasant little town.
The plain around is very well cultivated; as you walk along the roads
—very much like English country ones—you have a continual series
of large rice fields, cocoa-nut groves, now swelling into extensive
plantations, then a few round a detached cottage, and intermixed
with these are great quantities of bananas. Many small streams
intersect the plain, adding much to its fertility, and are spanned by
covered bridges.
The fort is to the right of the town, and has rather low walls,
mounted with a good many guns; against a native force it must be
impregnable, but a little shelling would soon subdue it. It is
garrisoned by about two hundred and fifty native soldiers. Leaving its
gate, you cross a large green, beyond which lies the principal portion
of the town, laid out in a rectangular shape, with streets intersecting
each other at equal distances. The houses are in general mere
native ones; others a little superior; and perhaps a couple of dozen
of a better class, in which reside the Governor, Lieutenant-Governor,
Commandant, and other officers. Almost every other house has a
shop, in which cigars, spirits, chocolate, sugar, and various other
articles are sold. The most respectable class keep retail shops, as
well as the little traders.
Beyond this portion of the town is a little green, with the church—a
long barn-like building. Seen within by the imperfect light of evening,
it appeared destitute of ornaments, except round the altar, and
beyond this are some more streets. The houses I entered had very
little furniture; a small table, some chairs, a bedstead, and a kind of
drawers, with a few shelves, complete the whole.
The people themselves are well worthy of notice. They are a
mixture of Spaniards and natives; a few of pure blood, in the
Government offices; the rest half-castes, mestiches, and natives.
The men exhibit no remarkable features, except the Governor,
Colonel Cayelano de Feguaroa, who was an agreeable man, and
spoke French. We were much pleased with his liberal ideas and
gentlemanly manners, and the other officers were equally polite and
attentive. The generality of the native men are kind and civil, but with
fat, unmeaning faces. The women are much better. The Lieutenant-
Governor’s wife, the only pure Castilian in the place, was a very
pretty woman, with fine eyes and regular features. The mestiches
have in general good eyes and dark hair; but, with the exception of a
few, their faces are too broad.
There was a famous corner shop opposite the church, which
contained good specimens of the race:—Gabriella, likewise called
Romantica, one of the handsomest women in the town, with pleasing
features, and her sister, with the usual flat face. Every one visiting
Samboañgan made that shop their place of call, as the staid old
mother and the girls were very civil and hospitable.
In the country one could always obtain cocoa-nuts, and many of
us were invited in to eat fruit and drink chocolate and gin by the
obliging residents, whose pretty houses, embowered in fruit-trees,
were an ornament to the road side.
The officers of the Meander gave a ball. The quarter-deck was
cleared of guns and surrounded with flags on all sides, and
ornamented with green boughs. All the Spanish officers came, and
about fifty of the townswomen, some young, others old. We danced
quadrilles, waltzes, and polkas: the first caused much confusion, the
second was well danced, while the third was quite new to most of
them. The commandant gave one in return, which was kept up with
greater spirit. Many of the girls were fairer and better-looking than
those we saw on board, and a few were in European costumes, with
shoes and stockings, while the rest had Malay petticoats, and little
jackets with scarfs. Dancing the polka with them was found to be
very difficult, as, few having chemises on, the hand constantly
coming in contact with the skin, it was impossible to obtain a hold;
and their little slippers were flying in every direction.
Their own band played waltzes very well by ear; but nothing else.
Indeed, it is almost the only dance they care for, as the girls find it
difficult to try any other, on account of their wearing slippers without
heels, some of which are very prettily ornamented with gold and
silver embroidery.
Supplies were scarce, though I saw a great many oxen and cows,
some goats, fowls, and ducks; but its being a penal settlement, trade
is obstructed and carefully watched to prevent the escape of
convicts, and none could come to the ship without a pass. The
ponies are very good, except the hacks; the water buffaloes are
large, and employed to draw a peculiar sledge along the smooth
roads. The chief amusement of the men on Sundays is cock-fighting:
crowds assemble to witness this cruel sport; and then they show
some money, which at other times appears so scarce that few shops
could give change for a dollar. We observed that the rice was
trodden out by the buffaloes, on hard beaten ground. Washing was
dear, being eleven dollars a hundred.
16th.—Started on our return voyage. Lay-to off a sand-bank not
marked in the chart. A grave was found there with four bamboos
stuck round, one at each corner, in the midst of thousands of birds,
with immense numbers of eggs, some of which were brought off, and
proved good eating. I will omit the ground we went over on our
return, and give an account of a second visit we paid this
archipelago.
CHAPTER IX.
THE SULU ISLANDS.
SECOND VISIT.
Reach Sugh—Mr. Wyndham comes on board—His News—

Commercial Rivalry—The Stockades—Visit the Audience Hall—
Appearance of the Sultan—Visit Datu Daniel’s Stockaded House
—Guns—Datu Daniel—Appearance of the principal Chamber—
The Bed—Boxes—Property—General look of Discomfort—
Spittoons—Dismounted Iron Guns—Taken from the English—
Excitement in the Town—Hereditary Hatred of the Sulus to the
Spaniards—Their Treaty with Spain—Sandakan Bay—Supplies—
Variegated Wood—Salute—English popular—An Exception—
Death of a Sulu Lady from Grief—The Rumah Bechara—A Ship
taken—Interview with the Sultan—Hope—Character of Datus—
The Balignini—Capture an English Ship—Captives brought to
Sulu—Result of the Action of the Nemesis—The Lanuns—At
Magindanau and Cape Unsang—A narrow Escape—Mate to Lord
Cochrane—Capture of the Maria Frederica—Cold-blooded
Murder of the Captain—Jilolo Prahus—Their Rencontre with Sir
Edward Belcher—Pirates off the Arru Group—Sulu Justice—
Appearance of the People—Attack on the Spanish Gunboats—
Public Audience with the Sultan—Private Visit to the House of his
Bride—The Women—Opium-smoking—Invitation to revisit Sulu—
The Spanish Gunboats—Samboañgan—The Corner Shop—
Sunday’s Amusements—Appearance of the Neighbourhood—A
Breakfast in the Country—Long Walks—People comfortable—
Story of the Loss and Re-capture of the Dolphin—The Dolphin
sails for Maludu Bay—Quarrels—Surprised—Death of Mr. Burns
and the Captain—Murder of a Woman—Injury to Trade—Datu
Badrudin’s Monopolies—The Tungku Pirates—Visit the chief
Town of Maludu—Sherif Husin’s Account of the Surprise of the
Dolphin—The Re-capture of the Vessel by Sherif Yasin—Arrival
at Benggaya—Dolphin delivered up—Visit the Village of Sherif
Yasin—His Appearance—His Account of the Re-capture—His
Position—Smoking over Powder—Delivery of the Cargo—Return
to the Ship—Argus Pheasants—Meet with Baju Boats—Pearl
Fishers—Retaliation—Fishing for Pearls—Mr. Edwardes’s Pearl
—Story of the Datu, and his great good Fortune—The Mermaid
Pearl—Present State of Piracy on the North-West Coast—Cruise
of the Balignini in 1861—Ransom of Inchi Ngah—Names of
present Haunts of the Balignini—A Mangrove Swamp—Present
System of Balignini—Escape of a Native—The Lanuns—A
Dayak’s Experience—A Slave Mart—Spanish Attack on Sugh—
Severe Fight—Bravery of the Sulus—Capture of the Town—The
Sulu Government retire to the Hills, and refuse to submit—A Teak
Forest burnt—No Teak in Borneo—Elephants extinct in Sulu.
Started from Labuan in the steamer Nemesis; and passing over
our old ground soon found ourselves in the Sulu seas. It is difficult
navigation, but we passed safely among the shoals, steering south
of Cagayan Sulu, and between the islands of Ubian and Peñgaturan,
where there is a deep channel. The latter is a long and low island, of
great extent, with a few small villages, palm groves, and near it we
observed many fishermen’s canoes. The sea is studded with shoals
and little islands, and I counted eleven at one time from the deck. It
was misty weather when the island first appeared; but as we
approached Sugh the weather cleared, and by the time we had
anchored it was tolerably fine. Since our last visit many houses have
been built, and the town is gradually assuming its ancient
appearance.
A quarter of an hour after our arrival Mr. Wyndham, whom we had
met on our previous visit, came on board, and brought us the little
news he possessed, that Sulu was perfectly tranquil, and that the
Dutch, with two small vessels, were gradually extending their claims
along the east coasts of Borneo, that the Governor of Manilla had
protested against the Dutch interference in Sulu, and that the pirates
of Balignini were utterly rooted out of their old haunts on the islands
of Tonquil and Balignini. But it was a mistake to imagine that the
Spaniards had killed or taken prisoners the whole number, for very
many escaped and retired to Sulu. Mr. Wyndham was startled on
hearing of the expected arrival of an European enemy, and uttered
many exclamations as to the injustice and barbarity of attacking an
inoffensive people, and asked many questions as to the profit of
making this aggression, though he was scarcely surprised, as he
had known they had long desired the eastern coast of Borneo, and
that they are endeavouring to obtain a show of right for its seizure,
as by them our ancient claim is no longer remembered.
At four, we left the Nemesis with Mr. Wyndham, to visit datu
Molok, the prime minister. We pulled in for the little creek in the
centre of the town, passing many new houses lately built by the
Chinese. Mr. Wyndham told us that he found them very troublesome
competitors; as, spreading themselves over all the neighbouring
islands, they offered apparently higher prices for produce than he
could possibly do; so he obtained from the sultan an order for their
recall to the capital. I say apparently higher prices, for by means of
false weights and the tricks usually practised by the Chinese, they
were enabled to outbid the honest European. Yet I fear that in this
there is much commercial jealousy, and that the injury done to the
general trade by the restriction is much greater than the profit to the
individual.
As we passed before the fort I could see numerous guns
displaying their adamantine lips through the embrasures; and I
learned from our companion that the Sulus possess about 150 brass
guns, besides innumerable iron ones. In the market-place, crowds of
armed men were assembled, looking eagerly and anxiously at us.
We landed at the little bridge, and learning that Molok was at the
sultan’s palace, we proceeded thither, escorted by about half a
dozen men armed with long spears, and followed by a crowd of men,
women, and children. We soon arrived at the fort, and then entering
the old audience hall, found it in much the same condition as before,
quite as bare of ornament, with the old round table and white cloth,
and the chairs arranged around. Datu Molok was present, with a few
others; and we had nearly arranged about the salute when the sultan
entered, and it was settled that it should be given the next day.
The news of the Dutch having taken Bali made them all look at
each other with marks of great disquietude, and when they heard of
the amount of the Dutch force which was expected to visit Sulu, their
uneasiness was clearly to be seen under their assumed quietude.
The sultan appeared in better health, but the heaviness of the lower
part of his face gives him a stupid look, and his long jacket of white
silk did not suit his pale appearance. Having taken our leave, we
retired, and returned to the ship; but Sir James Brooke, being
anxious to see some of the datus that evening, sent us on shore
again to arrange a meeting with Mr. Wyndham: but Molok, being
then with the sultan, smoking opium, we went to datu Daniel’s.
For a couple of hundred yards from the shore the water was so
shallow, that we were compelled to be dragged along over the sand
in Mr. Wyndham’s flat-bottomed boat. Walking a few hundred yards
inland to the left of the town, on the road to the race-course, we
came to the house. It is surrounded by a stockade some thirty feet
high; there were two long iron eighteen-pounder guns to defend the
approaches, but only one was mounted, though there were two
brass ones ready for service in his verandah. A wretched-looking
pony, and a man with a chain round his neck pounding rice, were the
most remarkable features of the place.
Having mounted some high steps, we entered the house, where
we found datu Daniel lying down on his bed, suffering from an attack
of intermittent fever. He sat up, however, and talked a little,
expressed his regret that he was unable to come on board and see
the Rajah, but sent one of his people to Molok to arrange a meeting.
The room we entered was large, some fifty feet long by twenty
broad, with a raised recess on one side fifteen feet square. A native
bed, thirty feet long and twelve broad, occupied the greater portion of
the room; it was divided in two by a curtain, and resembled more a
large raised room than a bed. At the end were long shelves filled
with packets of goods, small boxes, and innumerable articles which I
could not distinguish, while around were hung the datu’s handsome
jackets, sarongs, trousers, krises, and other finery for state
occasions. Four gun-cases were piled at the side of the bed, while in
the recess above mentioned, and about the room, were forty or fifty
boxes, containing his valuable property; there was a ladder, also,
which led to the loft.
Chairs were provided for us; but, with the exception of the bed
covered with beautiful mats and the handsomely-ornamented
pillows, the whole place had an air of discomfort, a sort of musty
look. The bed itself is no doubt the datu’s chief residence; we could
only just see the head of the farther half, as a blue curtain was drawn
across, concealing its beauties and its treasures. Around the room
were arranged several dozen brass spittoons, as if the chief were
accustomed to give large parties. Some of the women and young
girls came to the doors to look at us; a few were tolerably good-
looking, with their dark eyes and black hair, but the generality were
like the Malays.
Returning, we were, as usual, very much stared at, but little
followed. We walked behind some of the stockades, but saw that
nothing had been done either to repair them, or to mount the guns,
which lay grass-covered in every direction. As they were those
captured from the English when Balambañgan was taken, it is
probable they were too honeycombed to be of any use. We
remained at Mr. Wyndham’s house waiting for Molok’s answer, which
came at length, mentioning nine as the hour.
The news of the intended visit of their last European enemy must
have spread very rapidly; boats were plying to and fro from the
palace and outside houses, bringing all the valuables on shore. As
Molok sent a message that he could not come, we had a long talk
with Mr. Wyndham, who frankly confessed he was a Spaniard in
heart, as he thought they were more likely to settle the affairs of
these countries than the English, but added, for some reason he
could not fathom, there was an unconquerable prejudice among the
Sulus against the Spaniards. It is no doubt an hereditary feeling, for
these islanders and the Castilians have been constantly at war for
the last three hundred years; the latter endeavouring to subject
them, and the former supporting their independence with great
determination.
By the treaty of September 23rd, 1836, the Spaniards offered their
protection and the assistance of their army and navy to support the
sultan and repel any enemies who might attack him, and the sultan
of Sulu accepted their friendship and protection. This article the
Sulus considered the Spaniards had failed to carry into effect, as the
spirit and letter of the treaty bound Spain and Sulu to consider their
respective enemies as perpetual foes, except that the Sulus were
not required to support Spain in an European war.
Mr. Wyndham said that Sandakan Bay is exceedingly unhealthy,
and that the whole eastern coast bears the same character during
the south-west monsoon; but nearly every tropical place is
insalubrious until cleared and drained. Sandakan is reported to be
one of the noblest harbours in the world, perfectly sheltered, with
eight fathoms of water. Innumerable boats came around the steamer
with vegetables, cocoa-nuts, eggs, fowls, fruit, krises, Sulu knives,
Dutch 32-pounder shot, cattle, and excellent fish, particularly the red
mullet; eggs on the whole very good; mangoes and plantains; but
krises of indifferent quality; the Sulu knives, of very peculiar shape,
are mostly made in China for this market; a tolerable one, with a
sheath of clouded wood, and a handle with an Arabic inscription, I
tried to buy, but they asked too much for it. The upper portion of the
sheath was of the Kayu Kamuning, a beautiful wood from the island
of Magindanau, which, if it could be obtained of large size, would be
invaluable for furniture; but the natives said it was only the knots of
the trees which were beautifully marked.
At one, we saluted the sultan with twenty-one guns. The echo
seemed to commence at the first hill, and gradually, now with a
deeper, then with a lighter sound, rolled round over the whole circle
of hills and valleys. The sultan returned the salute from his various
stockades.
The English appear very popular in Sulu, their only enemy being
datu Boyak, the rajah Mudu, who was away. He felt aggrieved with
the English on account of Sir Thomas Cochrane’s attack on Maludu
Bay. His sister had married sherif Usman, its chief, who, during the
fight, was shot in the stomach with grape, as he, being one of those
whom they deem invulnerable, exposed himself to every fire, and
fought to the last. His wife was inconsolable for his loss, refused to
return to Sulu, retired into the country, fell ill, and died. Her brother
keeps this as a sort of canker in his bosom. The way these men
prepare themselves to be invulnerable is different from that practised
in Sarawak: here they rub their whole bodies with some preparation
of mercury.
I asked Mr. Wyndham about the Rumah Bechara, or House of
Discussion, mentioned by the American navigator Wilkes, but he

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THE MASSACHUSETTS EYE AND EAR INFIRMARY ISBN: 978-0-323-61332-3

Previous editions copyrighted 2014, 2009, 2004, and 1998.

International Standard Book Number: 978-0-323-61332-3

Content Strategist: Kayla Wolfe

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Video Table of Contents ix Vertical Motility Disorders 63

CHAPTER 1 Eyelid Trauma 69

Graft-versus-Host Disease 160 Peripheral Anterior Synechiae 273

CHAPTER 10 Solar and Photic Retinopathy 407

Secondary Open-Angle Glaucoma 561 APPENDIX 595

Video 2.1 Torsional nystagmus.

Daniel Youngjun Choi, MD

Yaping Joyce Liao, MD, PhD

The following figure is courtesy of Shamik Barfna, MD: 12.16.

The following figure is courtesy of Robert Chang, MD: 5.97.

The following figure is courtesy of Netan Choudhry, MD: 10.133.

The following figure is courtesy of Eric D. Donnenfeld, MD: 3.6.

The following figure is courtesy of Chris Engelman, MD: 11.38.

The following figure is courtesy of Thomas N. Hwang, MD, PhD: 11.9.

The following figure is courtesy of John Kitchens, MD: 10.60.

The following figure is courtesy of Thomas Loarie: 12.17.

The following figure is courtesy of Edward E. Manche, MD: 12.10.

The following figure is courtesy of Samuel Masket, MD: 12.2.

The following figure is courtesy of George J. Nakano, MD: 5.94.

Given the visual nature of ophthalmology, an illustrated manual is of utmost importance

Fig 1.1 ​• ​Orbital contusion

Fig 1.2 ​• ​Retrobulbar

Conjunctival chemosis Lid edema

• If orbital compartment syndrome is suspected, lateral canthotomy and cantholysis

Orbital floor (blow-out) fracture

Subconjunctival Orbital floor fracture

Fig 1.5 ​• ​Orbital computed tomography

Pediatric floor fracture

Medial wall (nasoethmoidal) fracture

Orbital roof fracture

Orbital apex fracture

• Ice compresses for the first 48 hours

Intraorbital Foreign Body

Fig 1.6 ​• ​Orbital computed tomography

Intraorbital foreign body

Fig 1.7 ​• ​Globe subluxation

Prognosis ​Good unless complications develop.

Carotid–Cavernous and Dural Sinus Fistulas

Fig 1.8 ​• ​Carotid–cavernous fistula with Fig 1.9 ​• ​Carotid–cavernous fistula

Differential Diagnosis ​Orbital varices that expand in a dependent position or during

• Consider treatment with selective embolization or ligation for severely symptomatic

Prognosis ​Up to 70% of dural sinus fistulas may resolve spontaneously.

Lid erythema Lid edema Erythema

MILD PRESEPTAL CELLULITIS

MODERATE TO SEVERE PRESEPTAL CELLULITIS

Prognosis ​Usually good when treated early.

Fig 1.13 ​• ​Mucormycosis of the left orbit

• Systemic intravenous antibiotic (2-week course):

Epidemiology ​Most common cause of unilateral or bilateral proptosis in adults; female

• Lab tests: Thyroid function tests (thyroid-stimulating hormone [TSH], thyroxine

Idiopathic Orbital Inflammatory Disease (Orbital Pseudotumor)

Fig 1.1 • Orbital contusion

Fig 1.2 • Retrobulbar

Fig 1.5 • Orbital computed tomography

Fig 1.6 • Orbital computed tomography

Fig 1.7 • Globe subluxation

Prognosis Good unless complications develop.

Fig 1.8 • Carotid–cavernous fistula with Fig 1.9 • Carotid–cavernous fistula

Differential Diagnosis Orbital varices that expand in a dependent position or during

Prognosis Up to 70% of dural sinus fistulas may resolve spontaneously.

Prognosis Usually good when treated early.

Fig 1.13 • Mucormycosis of the left orbit

Epidemiology Most common cause of unilateral or bilateral proptosis in adults; female

Fig 1.18 • Congenital

Fig 1.19 • Dermoid cyst of the

Fig 1.20 • Lymphangioma

Fig 1.21 • Lymphangioma with anterior Fig 1.22 • T2-weighted magnetic

Fig 1.23 • Rhabdomyosarcoma

Fig 1.24 • (A) Neuroblastoma

Fig 1.25 • Orbital

Fig 1.26 • T2-weighted magnetic

Fig 1.29 • Neurilemoma