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John F. Salmon
MD, FRCS, FRCOphth
Consultant Ophthalmic Surgeon
Oxford Eye Hospital
Oxford
United Kingdom
KANSKI’S
Clinical
Ophthalmology
A Systematic Approach
Ninth Edition
© 2020, Elsevier Limited. All rights reserved.
First edition 1984

Second edition 1989
Third edition 1994
Fourth edition 1999
Fifth edition 2003
Sixth edition 2007
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Eighth edition 2016
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v
Contents
Dedication.......................................................................viii Cystic lesions.................................................................131

In Memoriam.....................................................................ix Vascular tumours...........................................................134
Preface to the Ninth Edition................................................x Lacrimal gland tumours.................................................140
Abbreviations.....................................................................xi Neural tumours..............................................................142
Lymphoma.....................................................................144
1 Examination Techniques....................... 1 Rhabdomyosarcoma......................................................147
Introduction.......................................................................2 Metastatic tumours........................................................148
Psychophysical tests..........................................................2 The anophthalmic socket...............................................150
Perimetry...........................................................................9 Craniosynostoses...........................................................153
Slit lamp biomicroscopy of the anterior segment..............20
Fundus examination.........................................................21 5 Dry Eye........................................... 155
Tonometry........................................................................27 Introduction...................................................................156
Gonioscopy......................................................................30 Sjögren syndrome..........................................................158
Central corneal thickness.................................................36 Clinical features.............................................................158
Investigation..................................................................159
2 Eyelids.............................................. 37 Treatment.......................................................................162
Introduction.....................................................................38
Non-neoplastic lesions....................................................39 6 Conjunctiva..................................... 167
Benign epidermal tumours...............................................43 Introduction...................................................................168
Benign pigmented lesions................................................44 Bacterial conjunctivitis...................................................171
Benign adnexal tumours..................................................47 Viral conjunctivitis..........................................................177
Miscellaneous benign tumours.........................................47 Allergic conjunctivitis.....................................................180
Malignant tumours...........................................................50 Conjunctivitis in blistering mucocutaneous disease........188
Disorders of the eyelashes...............................................60 Miscellaneous disorders of the conjunctiva....................194
Allergic disorders.............................................................66 Degenerations...............................................................197
Immune-related inflammation..........................................66 Subconjunctival haemorrhage........................................200
Bacterial infections..........................................................67
Viral infections.................................................................68 7 Cornea............................................ 203
Blepharitis.......................................................................70 Introduction...................................................................204
Ptosis..............................................................................74 Bacterial keratitis...........................................................209
Ectropion.........................................................................80 Fungal keratitis..............................................................216
Entropion.........................................................................85 Herpes simplex keratitis.................................................218
Miscellaneous acquired disorders....................................87 Herpes zoster ophthalmicus...........................................224
Cosmetic eyelid and periocular surgery............................91 Interstitial keratitis.........................................................229
Congenital malformations................................................93 Protozoan keratitis.........................................................232
Helminthic keratitis........................................................234
3 Lacrimal Drainage System.................. 99 Bacterial hypersensitivity-mediated
Introduction...................................................................100 corneal disease..........................................................234
Acquired obstruction......................................................105 Rosacea........................................................................236
Congenital obstruction...................................................108 Peripheral corneal ulceration/thinning...........................238
Chronic canaliculitis.......................................................109 Neurotrophic keratopathy...............................................241
Dacryocystitis................................................................110 Exposure keratopathy.....................................................242
Miscellaneous keratopathies..........................................243
4 Orbit................................................ 113 Corneal ectasia..............................................................248
Introduction...................................................................114 Corneal dystrophy..........................................................252
Thyroid eye disease........................................................118 Corneal degeneration.....................................................261
Infections.......................................................................124 Metabolic keratopathy....................................................266
Non-infective inflammatory disease...............................126 Contact lenses...............................................................268
Non-neoplastic vascular abnormalities...........................129 Congenital anomalies of the cornea and globe...............270
vi Contents
8 Corneal and Refractive Surgery........ 275 Investigation..................................................................429

Keratoplasty..................................................................276 Treatment.......................................................................432
Keratoprostheses...........................................................283 Immunomodulatory therapy for
Refractive procedures....................................................283 non-infectious uveitis.................................................433
Uveitis in spondyloarthropathies....................................435
9 Episclera and Sclera........................ 291 Fuchs uveitis syndrome..................................................437
Anatomy........................................................................292 Uveitis in juvenile idiopathic arthritis (JIA)......................439
Episcleritis.....................................................................292 Uveitis in bowel disease.................................................441
Immune-mediated scleritis.............................................293 Uveitis in renal disease..................................................442
Porphyria.......................................................................300 Intermediate uveitis.......................................................443
Infectious scleritis..........................................................300 Vogt–Koyanagi–Harada (VKH) syndrome.........................445
Scleral discolouration....................................................301 Sympathetic ophthalmitis..............................................448
Blue sclera....................................................................301 Lens-induced uveitis......................................................449
Miscellaneous conditions...............................................302 Sarcoidosis....................................................................450
10 Lens................................................ 307 Behçet disease..............................................................454
Acquired cataract..........................................................308 Parasitic uveitis..............................................................456
Management of age-related cataract..............................311 Viral uveitis....................................................................465
Congenital cataract........................................................335 Fungal uveitis.................................................................473
Ectopia lentis.................................................................338 Bacterial uveitis.............................................................477
Abnormalities of lens shape...........................................342 Miscellaneous idiopathic chorioretinopathies.................484
11 Glaucoma........................................ 345 13 Retinal Vascular Disease.................. 495

Introduction...................................................................346 Retinal circulation..........................................................496
Ocular hypertension.......................................................347 Diabetic retinopathy.......................................................496
Overview of glaucoma....................................................349 Non-diabetic retinopathy................................................513
Primary open-angle glaucoma.......................................349 Retinal venous occlusive disease...................................514
Normal-tension glaucoma..............................................367 Retinal arterial occlusive disease...................................525
Primary angle-closure glaucoma....................................370 Ocular ischaemic syndrome...........................................531
Classification of secondary glaucoma............................378 Hypertensive eye disease...............................................532
Pseudoexfoliation..........................................................379 Sickle-cell retinopathy....................................................533
Pigment dispersion syndrome and Thalassaemia retinopathy..............................................536
pigmentary glaucoma.................................................381 Retinopathy of prematurity.............................................536
Neovascular glaucoma...................................................383 Retinal artery macroaneurysm.......................................540
Inflammatory glaucoma.................................................385 Primary retinal telangiectasia.........................................543
Steroid-induced glaucoma.............................................388 Eales disease................................................................546
Lens-related glaucoma..................................................389 Radiation retinopathy.....................................................546
Traumatic glaucoma.......................................................390 Purtscher retinopathy.....................................................547
Ghost cell ‘glaucoma’.....................................................392 Valsalva retinopathy.......................................................549
Iridocorneal endothelial syndrome.................................392 Lipaemia retinalis..........................................................549
Glaucoma associated with intraocular tumours..............394 Retinopathy in blood disorders.......................................550
Glaucoma secondary to epithelial ingrowth....................394
14 Acquired Macular Disorders............. 555
Iridoschisis....................................................................395
Primary congenital glaucoma.........................................395 Introduction...................................................................556
Iridocorneal dysgenesis..................................................399 Clinical evaluation of macular disease...........................557
Glaucoma in phacomatoses...........................................403 Investigation of macular disease....................................558
Medical treatment of glaucoma......................................404 Age-related macular degeneration..................................572
Laser treatment of glaucoma.........................................407 Retinal angiomatous proliferation...................................589
Trabeculectomy..............................................................412 Polypoidal choroidal vasculopathy..................................589
Non-penetrating glaucoma surgery.................................419 Peripheral exudative haemorrhagic
chorioretinopathy.......................................................591
Minimally invasive glaucoma surgery (MIGS)..................420
Idiopathic choroidal neovascularization..........................591
Drainage shunts.............................................................421
Vitreomacular interface disorders...................................592
12 Uveitis............................................. 423 Central serous chorioretinopathy....................................598
Classification.................................................................424 Idiopathic macular telangiectasia...................................601
Clinical features.............................................................424 Cystoid macular oedema...............................................602
Contents
vii
Microcystic macular oedema..........................................604 19 Neuro-ophthalmology....................... 745

Degenerative myopia......................................................604 Neuroimaging................................................................746
Angioid streaks..............................................................607 Optic nerve....................................................................751
Choroidal folds..............................................................609 Pupils............................................................................779
Hypotony maculopathy...................................................610 Chiasm..........................................................................786
Solar retinopathy...........................................................610 Retrochiasmal pathways................................................792
Focal choroidal excavation.............................................611 Ocular motor nerves.......................................................795
Dome-shaped macula...................................................612 Supranuclear disorders of ocular motility.......................806
Low visual aids..............................................................613 Nystagmus.....................................................................809
Ocular myopathies.........................................................814
15 Hereditary Fundus Dystrophies......... 615
Miller Fisher syndrome...................................................819
Introduction...................................................................616 Neurofibromatosis.........................................................819
Investigation..................................................................616 Migraine........................................................................820
Generalized photoreceptor dystrophies...........................619 Neuralgias.....................................................................823
Macular dystrophies.......................................................631 Facial spasm.................................................................824
Generalized choroidal dystrophies..................................640 Disorders of circadian rhythm.........................................825
Hereditary vitreoretinopathies........................................641 Neuro-ophthalmology of space flight..............................825
Albinism........................................................................649
Cherry-red spot at the macula.......................................652 20 Ocular Tumours................................ 827
Benign epibulbar tumours..............................................828
16 Retinal Detachment......................... 653 Malignant and premalignant epibulbar tumours.............833
Introduction...................................................................654 Iris tumours...................................................................839
Peripheral lesions predisposing to Iris cysts........................................................................841
retinal detachment.....................................................657 Ciliary body tumours......................................................843
Posterior vitreous detachment........................................663 Tumours of the choroid..................................................846
Retinal breaks................................................................666 Neural retinal tumours...................................................860
Rhegmatogenous retinal detachment.............................668 Retinal vascular tumours................................................868
Tractional retinal detachment.........................................681 Primary intraocular lymphoma.......................................872
Exudative retinal detachment.........................................681 Tumours of the retinal pigment epithelium......................875
Pars plana vitrectomy.....................................................683 Paraneoplastic syndromes.............................................878
17 Vitreous Opacities........................... 691 21 Ophthalmic Side Effects of
Systemic Medication....................... 881
18 Strabismus...................................... 697 Eyelids...........................................................................882
Introduction...................................................................698 Cornea..........................................................................882
Amblyopia.....................................................................707 Ciliary effusion...............................................................882
Clinical evaluation..........................................................708 Lens..............................................................................883
Pseudostrabismus.........................................................726 Uveitis...........................................................................884
Heterophoria..................................................................727 Retina............................................................................884
Vergence abnormalities..................................................727 Optic nerve....................................................................889
Esotropia.......................................................................728 Visual cortex..................................................................890
Exotropia.......................................................................733
Congenital cranial dysinnervation disorders....................735
22 Trauma............................................ 891
Monocular elevation deficiency......................................737 Eyelid trauma.................................................................892
Brown syndrome............................................................737 Orbital trauma...............................................................894
Alphabet patterns..........................................................738 Trauma to the globe.......................................................898
Surgery..........................................................................739 Chemical injuries...........................................................912
Complications of strabismus surgery..............................742 Thermal burns................................................................916
Botulinum toxin chemodenervation................................743 Index.............................................................................917
In Memoriam
Jack J. Kanski MD, MS, FRCS, FRCOphth, Consultant Ophthalmic Surgeon (1939–2019)
Jack Kanski wrote more than 30 books, but is best known for Clinical Ophthalmology, which was first published in 1984. The
book has been studied by ophthalmology and optometry students throughout the world since that time. It has justifiably
become a classic because of its highly organized format, succinct but comprehensive text and superb clinical photographs. His
encyclopaedic knowledge of ophthalmology, meticulous attention to detail and unique ability to sort the wheat from the chaff
will be sorely missed. His legacy will live on in the minds of those who benefitted from his teaching.
x
Preface to the Ninth Edition
In presenting this new edition of Kanski’s Clinical Ophthalmology, South Africa, Tony Murray (strabismus) and Trevor Carmichael
I am reminded of a quotation from Lewis Carroll’s Alice’s Adven- (cornea), provided help with the text and images of pathology
tures in Wonderland: “What is the use of a book”, thought Alice, that are not easily found in developed countries. I received many
“without pictures or conversations?”. The ninth edition of this pictures from Jonathan Norris and Elizabeth Insull (oculoplas-
classic textbook is filled with beautiful illustrations and consider- tics), Darius Hildebrand and Manoj Parulekar (paediatrics),
able information and is intended to be a useful and comprehensive Peter Issa and Christine Kiire (medical retina), Bertil Damato
basis for general ophthalmic practice. It has been a privilege to (ocular oncology), Martin Leyland (corneal surgery), C.K. Patel
work on this remarkable book and I am grateful to Jack Kanski (vitreoretinal surgery), Patsy Terry (ultrasound) and Pieter Pre-
and the staff of Elsevier for entrusting me with the task. torius (neuroradiology). Mitch Ménage provided good pictures of
The challenge has been to cover the entire field of ophthalmol- common conditions. Aude Ambresin and Carl Herbort (Switzer-
ogy for a worldwide audience without depending on subspecialists land) supplied state-of-the-art retinal images. I have kept many
to prepare each chapter. In order to do this, I have maintained Jack of the outstanding pictures that Chris Barry and Simon Cheng
Kanski’s unique approach of presenting core clinical knowledge (Australia) provided for the eighth edition. Single examples of
in a systemic and succinct form. Brad Bowling has had a sig- rare conditions have been kindly provided by a number of col-
nificant influence on the two previous editions and his accuracy leagues throughout the United Kingdom and elsewhere and their
and meticulous attention to detail has been extremely helpful. I contribution has been recognized next to the images provided.
have reverted to the format that was used in the sixth edition by Other individuals have helped substantially with previous editions
starting with an initial chapter on examination techniques. Special of Clinical Ophthalmology, including Terry Tarrant, the artist who
investigations remain in the chapters where they are most relevant. produced the meticulous ocular paintings. I also wish to thank
Each chapter has been updated and the latest evidence-based Kim Benson, Sharon Nash, Kayla Wolfe, Julie Taylor, Anne Collett
diagnostic and therapeutic approaches have been covered, includ- and the production team at Elsevier.
ing genetics, immunotherapy and imaging techniques. Many The ninth edition of Kanski’s Clinical Ophthalmology could not
new illustrations have been added and better examples of a range have been produced in the time available without the help of my
of conditions have been used. Jack Kanski’s idea of including assistant, Carolyn Bouter, whose resilience, diligence, intelligence
important ‘tips’ has been reintroduced. I have included sufficient and skill were evident throughout the 6 months that she worked
practical information for trainees to manage common ophthalmic with me. I have also had the good fortune to work with Jonathan
conditions in the clinic and enough detail on rare conditions to Brett, a world-class photographer and artist, whose genius is
enable them to prepare for their examinations without resorting present in hundreds of the images included in this edition. My
to the internet. wife, Susie, has been extremely supportive throughout this project
I have been extremely fortunate to have received help from and her happy and helpful nature has made the task a pleasant and
colleagues past and present, to whom I wish to express my grate- enjoyable experience.
ful thanks. The photographers and research staff at the Oxford
Eye Hospital have been wonderfully supportive. Jack Kanski John F. Salmon
generously gave me his huge collection of images. My friends in 2019
xi
Abbreviations
AAION arteritic anterior ischaemic optic neuropathy C-MIN conjunctival melanocytic intraepithelial
AAU acute anterior uveitis neoplasia
AC anterior chamber CMO cystoid macular oedema (US = CME)
AC/A ratio accommodative convergence/accommodation CNS central nervous system
ratio CNV choroidal neovascularization
ACE angiotensin converting enzyme CNVM choroidal neovascular membrane
AD autosomal dominant COX-2 cyclo-oxygenase-2
AF autofluorescence CPEO chronic progressive external ophthalmoplegia
AGIS Advanced Glaucoma Treatment Study CRAO central retinal artery occlusion
AHP abnormal head posture CRP C-reactive protein
AI accommodative insufficiency CRVO central retinal vein occlusion
AIBSE acute idiopathic blind spot enlargement CSC central serous chorioretinopathy
syndrome CSC/CSCR central serous chorioretinopathy
AIDS acquired immune deficiency syndrome CSMO clinically significant macular oedema (US =
AIM (unilateral) acute idiopathic maculopathy CSME)
AION anterior ischaemic optic neuropathy CSR central serous chorioretinopathy
AIR autoimmune retinopathies CSS central suppression scotoma
AKC atopic keratoconjunctivitis CT computed tomography
ALT argon laser trabeculoplasty CXL corneal collagen cross-linking
AMD age-related macular degeneration DALK deep anterior lamellar keratoplasty
AMN acute macular neuroretinopathy DCCT Diabetes Control and Complication Trial
ANA antinuclear antibody DCR dacryocystorhinostomy
ANCA antineutrophil cytoplasmic antibodies DCT dynamic contour tonometry
APD afferent pupillary defect DMEK Descemet membrane endothelial keratoplasty
APMPPE acute posterior multifocal placoid pigment DMO diabetic macular oedema (US = DME)
epitheliopathy DR diabetic retinopathy
AR autosomal recessive DRCR.net Diabetic Retinopathy Clinical Research Network
AREDS Age-Related Eye Disease Study DRPPT dark room prone provocative test
ARN acute retinal necrosis DRS Diabetic Retinopathy Study
ARPE acute retinal pigment epitheliitis DSAEK Descemet stripping automated endothelial
AZOOR acute zonal occult outer retinopathy keratoplasty
AZOR acute zonal outer retinopathy DVD dissociated vertical deviation
BADI bilateral acute depigmentation of the iris ECG electrocardiogram
BCC basal cell carcinoma EDTA ethylenediaminetetraacetic acid
BCVA best-corrected visual acuity EGFR epidermal growth factor inhibitors
BIO binocular indirect ophthalmoscopy EKC epidemic keratoconjunctivitis
BP blood pressure EMGT Early Manifest Glaucoma Trial
BRAO branch retinal artery occlusion EOG electro-oculography/gram
BRVO branch retinal vein occlusion ERG electroretinography/gram
BSV binocular single vision ERM epiretinal membrane
BUT breakup time ESR erythrocyte sedimentation rate
CAI carbonic anhydrase inhibitor ETDRS Early Treatment Diabetic Retinopathy Study
CCDD congenital cranial dysinnervation disorders ETROP Early Treatment of Retinopathy of Prematurity
CCT central corneal thickness FA fluorescein angiography (also FFA)
C/D cup/disc FAF fundus autofluorescence
CDCR canaliculodacryocystorhinostomy FAP familial adenomatous polyposis
CF counts (or counting) fingers FAZ foveal avascular zone
CHED congenital hereditary endothelial dystrophy FBA frosted branch angiitis
CHP compensatory head posture FBC full blood count
CHRPE congenital hypertrophy of the retinal pigment FDT frequency doubling test
epithelium FFM fundus flavimaculatus
CI convergence insufficiency FTMH full-thickness macular hole
xii Abbreviations
5-FU 5-fluorouracil MMC mitomycin C

GA geographic atrophy MPS mucopolysaccharidosis
GAT Goldmann applanation tonometry MRI magnetic resonance imaging
GCA giant cell arteritis MS multiple sclerosis
GDD glaucoma drainage device NF1 neurofibromatosis type I
GHT glaucoma hemifield test NF2 neurofibromatosis type II
GPA guided progression analysis NPDR non-proliferative diabetic retinopathy
GPC giant papillary conjunctivitis NRR neuroretinal rim
G-TOP glaucoma tendency orientated perimetry NSAID non-steroidal anti-inflammatory drug
HAART highly active antiretroviral therapy NSR neurosensory retina
HFA Humphrey field analyser NTG normal-tension glaucoma
HIV human immunodeficiency virus NVD new vessels on the disc
HM hand movements NVE new vessels elsewhere
HRT Heidelberg retinal tomography NVG neovascular glaucoma
HSV-1 herpes simplex virus type 1 NVI new vessels iris
HSV-2 herpes simplex virus type 2 OCT optical coherence tomography/gram
HZO herpes zoster ophthalmicus OHT ocular hypertension
ICE iridocorneal endothelial OHTS Ocular Hypertension Treatment Study
ICG indocyanine green OIS ocular ischaemia syndrome
ICGA indocyanine green angiography OKN optokinetic nystagmus
ICROP International Classification of Retinopathy of OVD ophthalmic viscosurgical devices
Prematurity PAC primary angle closure
IFIS intraoperative floppy iris syndrome PACG primary angle-closure glaucoma
Ig immunoglobulin PACS primary angle-closure suspect
IK interstitial keratitis PAM primary acquired melanosis
ILM internal limiting membrane PAN polyarteritis nodosa
IMT idiopathic macular telangiectasia PAS peripheral anterior synechiae
INO internuclear ophthalmoplegia PC posterior chamber
INR international normalized ratio PCO posterior capsular opacification
IOFB intraocular foreign body PCR polymerase chain reaction
IOID idiopathic orbital inflammatory disease PCV polypoidal choroidal vasculopathy
IOL intraocular lens PDR proliferative diabetic retinopathy
IOP intraocular pressure PDS pigment dispersion syndrome
IRMA intraretinal microvascular abnormality PDT photodynamic therapy
IRVAN idiopathic retinal vasculitis, aneurysms and PED pigment epithelial detachment
neuroretinitis syndrome
PEE punctate epithelial erosions
ITC iridotrabecular contact
PEK punctate epithelial keratitis
IU intermediate uveitis
PEHCR peripheral exudative haemorrhagic
IVTS International Vitreomacular Traction Study chorioretinopathy
JIA juvenile idiopathic arthritis PH pinhole
KC keratoconus PHM posterior hyaloid membrane
KCS keratoconjunctivitis sicca PIC punctate inner choroidopathy
KP keratic precipitate PIOL primary intraocular lymphoma
LA local anaesthetic PION posterior ischaemic optic neuropathy
LASEK laser (also laser-assisted) epithelial keratomileusis PKP penetrating keratoplasty
LASIK laser-assisted in situ keratomileusis PMMA polymethyl methacrylate
LN latent nystagmus POAG primary open-angle glaucoma
LSCD limbal stem cell deficiency POHS presumed ocular histoplasmosis syndrome
LV loss variance PP pars planitis
MALT mucosa-associated lymphoid tissue PPCD posterior polymorphous corneal dystrophy
MCP multifocal choroiditis and panuveitis PPDR preproliferative diabetic retinopathy
MEWDS multiple evanescent white dot syndrome PPM persistent placoid maculopathy
MFC multifocal choroiditis and panuveitis PPRF paramedian pontine reticular formation
MIGS minimally invasive glaucoma surgery PPV pars plana vitrectomy
MLF medial longitudinal fasciculus PRK photorefractive keratectomy
MLT micropulse laser technology PRP panretinal photocoagulation
Abbreviations
xiii
PS posterior synechiae SJS Stevens–Johnson syndrome

PSD pattern standard deviation SLK superior limbic keratoconjunctivitis
PSS Posner-Schlossman syndrome SLT selective laser trabeculoplasty
PUK peripheral ulcerative keratitis SMILE small incision lenticule extraction
PVD posterior vitreous detachment SPARCS Spaeth Richman contrast sensitivity test
PVR proliferative vitreoretinopathy SPK superficial punctate keratitis
PVRL primary vitreoretinal lymphoma SRF subretinal fluid
PXE pseudoxanthoma elasticum SS Sjögren syndrome
PXF pseudoexfoliation STIR short T1 inversion recovery
RA rheumatoid arthritis SWAP short-wave automated perimetry
RAO retinal artery occlusion TAL total axial length
RAPD relative afferent pupillary defect TB tuberculosis
RD retinal detachment TEN toxic epidermal necrolysis
RNFL retinal nerve fibre layer TGF transforming growth factor
ROCK Rho-kinase TIA transient ischaemic attack
ROP retinopathy of prematurity TM trabecular meshwork
RP retinitis pigmentosa TRD tractional retinal detachment
RPC relentless placoid chorioretinitis TRP targeted retinal photocoagulation
RPE retinal pigment epithelium TTT transpupillary thermotherapy
RRD rhegmatogenous retinal detachment UBM ultrasonic biomicroscopy
RS retinoschisis US ultrasonography
RVO retinal vein occlusion VA visual acuity
SANS space flight-associated neuro-ocular syndrome VEGF vascular endothelial growth factor
SAP standard automated perimetry VEP visual(ly) evoked potential(s)
SCC squamous cell carcinoma VFI visual field index
SCN suprachiasmic nucleus VHL von Hippel–Lindau syndrome
SD-OCT spectral domain optical coherence tomography VKC vernal keratoconjunctivitis
SF short-term fluctuation VKH Vogt–Koyanagi–Harada syndrome
SFU progressive subretinal fibrosis and uveitis VMA vitreomacular adhesion
syndrome VMT vitreomacular traction
SIC solitary idiopathic choroiditis VZV varicella zoster virus
SITA Swedish Interactive Thresholding Algorithm XL X-linked
Chapter
Examination Techniques 1
INTRODUCTION 2 Sources of error 18 TONOMETRY 27
Microperimetry 18 Goldmann tonometry 27
PSYCHOPHYSICAL TESTS 2
SLIT LAMP BIOMICROSCOPY OF THE Other forms of tonometry 29
Visual acuity 2
ANTERIOR SEGMENT 20 Ocular response analyser and corneal
Near visual acuity 4 hysteresis 30
Contrast sensitivity 4 Direct illumination 20
Amsler grid 5 Scleral scatter 20 GONIOSCOPY 30
Light brightness comparison test 6 Retroillumination 20 Introduction 30
Photostress test 6 Specular reflection 21 Indirect gonioscopy 32
Colour vision testing 7 Direct gonioscopy 33
FUNDUS EXAMINATION 21
Plus lens test 9 Identification of angle structures 34
Direct ophthalmoscopy 21
Pathological findings 35
PERIMETRY 9 Slit lamp biomicroscopy 22
Definitions 9 Goldmann three-mirror examination 23 CENTRAL CORNEAL THICKNESS 36
Testing algorithms 11 Head-mounted binocular indirect
Testing patterns 14 ophthalmoscopy 25
Analysis 14 Fundus drawing 27
High-sensitivity field modalities 17
2 Psychophysical Tests
• Pinhole VA: a pinhole (PH) aperture compensates for the

INTRODUCTION effect of refractive error, and consists of an opaque occluder
Patients with ophthalmic disease must have their vision accurately perforated by one or more holes of about 1 mm diameter (Fig.
measured and their eyes need to be examined using specialized 1.2). However, PH acuity in patients with macular disease and
techniques. Special investigations should be used to supplement posterior lens opacities may be worse than with spectacle cor-
the findings of clinical examination. Electrophysical tests, fluores- rection. If the VA is less than 6/6 Snellen equivalent, testing is
cein angiography and optical coherence tomography are discussed repeated using a pinhole aperture.
in later chapters. • Binocular VA is usually superior to the better monocular VA
of each eye, at least where both eyes have roughly equal vision.
Very poor visual acuity

PSYCHOPHYSICAL TESTS
• Counting (or counts) fingers (CF) denotes that the patient is
Visual acuity able to tell how many fingers the examiner is holding up at a
specified distance (Fig. 1.3), usually 1 metre.
Snellen visual acuity • Hand movements (HM) is the ability to distinguish whether
Distance visual acuity (VA) is directly related to the minimum the examiner’s hand is moving when held just in front of the
angle of separation (subtended at the nodal point of the eye) patient.
between two objects that allow them to be perceived as distinct. • Perception of light (PL): the patient can discern only light
In practice, it is most commonly carried out using a Snellen chart, (e.g. pen torch), but no shapes or movement. Careful occlu-
which utilizes black letters or symbols (optotypes) of a range of sion of the other eye is necessary. If poor vision is due solely
sizes set on a white chart (Fig. 1.1), with the subject reading the to a dense media opacity such as cataract, the patient should
chart from a standard distance. Distance VA is usually first meas-
ured using a patient’s refractive correction, generally their own
glasses or contact lenses. For completeness, an unaided acuity may
also be recorded. The eye reported as having worse vision should
be tested first, with the other eye occluded. It is important to push
the patient to read every letter possible on the optotypes being
tested.
• Normal monocular VA equates to 6/6 (metric notation; 20/20
in non-metric ‘English’ notation) on Snellen testing. Normal
corrected VA in young adults is often superior to 6/6.
• Best-corrected VA (BCVA) denotes the level achieved with
optimal refractive correction.
Fig. 1.2 Pinhole
Fig. 1.1 Snellen visual acuity chart Fig. 1.3 Testing of ‘counts fingers’ visual acuity
1
CHAPTER
Fig. 1.4 Notation for the projection of light test (right eye); the
patient cannot detect light directed from the superior and
temporal quadrants
Fig. 1.5 Bailey–Lovie chart
readily be able to determine the direction from which the light

is being projected (Fig. 1.4).
LogMAR acuity Table 1.1 Comparison of Snellen and logMAR Visual Acuity
Testing
LogMAR charts address many of the deficiencies of the Snellen
chart (Table 1.1), and are the standard means of VA measurement Snellen LogMAR
in research and, increasingly, in clinical practice. Shorter test time Longer test time
• LogMAR is an acronym for the base-10 logarithm of the More letters on the Equal numbers of letters
minimum angle of resolution (MAR) and refers to the ability lower lines introduces an on different lines controls
unbalanced ‘crowding’ for ‘crowding’ effect
to resolve the elements of an optotype. Thus, if a letter on the
effect
6/6 (20/20) equivalent line subtends 5′ of arc, and each limb of
Fewer larger letters Equal numbers of letters
the letter has an angular width of 1′, a MAR of 1′ is needed for reduces accuracy at lower on low and higher acuity
resolution. For the 6/12 (20/40) line, the MAR is 2′, and for the levels of VA lines increases accuracy at
6/60 (20/200) line it is 10′. lower VA
• The logMAR score is simply the base-10 log of the MAR. Variable readability Similar readability between
Because the log of the MAR value of 1′ is zero, 6/6 is equivalent between individual letters letters
to logMAR 0.00. The log of the 6/60 MAR of 10′ is 1, so 6/60 Lines not balanced with Lines balanced for
is equivalent to logMAR 1.00. The log of the 6/12 MAR of 2′ is each other for consistency consistency of readability
0.301, giving a logMAR score of 0.30. Scores better than 6/6 of readability
have a negative value. 6 m testing distance: 4 m testing distance on
longer testing lane (or a many charts: smaller
• As letter size changes by 0.1 logMAR units per row and there mirror) required testing lane (or no mirror)
are five letters in each row, each letter can be assigned a score required
of 0.02. The final score can therefore take account of every Letter and row spacing not Letter and row spacing
letter that has been read correctly and the test should continue systematic set to optimize contour
until half of the letters on a line are read incorrectly. interaction
Lower accuracy and Higher accuracy and
LogMAR charts consistency so relatively consistency so appropriate
• The Bailey–Lovie chart (Fig. 1.5). unsuitable for research for research
○ Used at 6 m testing distance. Straightforward scoring More complex scoring
○ Each line of the chart comprises five letters and the spacing system
between each letter and each row is related to the width Easy to use Less user-friendly
and the height of the letters. The letter signs are rectan- A target must be sufficiently large to be seen, but must also
gular rather than square, as with the EDTRS chart. A 6/6 be of high enough contrast with its background. A light grey
letter is 5′ in height by 4′ in width. letter will be less well seen against a white background than a
○ The distance between two adjacent letters on the same row black letter. Contrast sensitivity represents a different aspect
is equal to the width of a letter from the same row, and of visual function to that tested by the spatial resolution tests
the distance between two adjacent rows is the same as the described above, which all use high-contrast optotypes.
height of a letter from the lower of the two rows. ○ Many conditions reduce both contrast sensitivity and
○ Snellen VA values and logMAR VA are listed to the right VA, but under some circumstances (e.g. amblyopia, optic
and left of the rows respectively. neuropathy, some cataracts, and higher-order aberra-
• The ETDRS (Early Treatment Diabetic Retinopathy Study) tions), visual function measured by contrast sensitivity can
chart is calibrated for 4 m. This chart utilizes balanced rows be reduced whilst VA is preserved.
comprising Sloan optotypes, developed to confer equivalent ○ Hence, if patients with good VA complain of visual
legibility between individual letters and rows. ETDRS letters symptoms (typically evident in low illumination), contrast
are square, based on a 5 × 5 grid, i.e. 5′ × 5′ for the 6/6 equiva- sensitivity testing may be a useful way of objectively dem-
lent letters at 6 m. onstrating a functional deficit. Despite its advantages, it
• Computer charts are available that present the various forms has not been widely adopted in clinical practice.
of test chart on display screens, including other means of • The Pelli–Robson contrast sensitivity letter chart is viewed
assessment such as contrast sensitivity (see below). at 1 metre and consists of rows of letters of equal size (spatial
frequency of 1 cycle per degree) but with decreasing contrast of
0.15 log units for groups of three letters (Fig. 1.7). The patient
TIP LogMAR charts are commonly used in clinical trials reads down the rows of letters until the lowest-resolvable
because they are the most accurate method of measuring VA. group of three is reached.
• Sinusoidal (sine wave) gratings require the test subject to
Near visual acuity view a sequence of increasingly lower contrast gratings.
• Spaeth Richman contrast sensitivity test (SPARCS) is per-
Near vision testing can be a sensitive indicator of the presence of formed on a personal computer with internet access. It can be
macular disease. A range of near vision charts (including logMAR accessed online. Each patient is supplied with an identification
and ETDRS versions) or a test-type book can be used. The book or number and instructions on how to do the test. The test takes
chart is held at a comfortable reading distance and this is measured 5–10 minutes per eye and measures both central and peripheral
and noted. The patient wears any necessary distance correction contrast sensitivity. Since the test is based on gratings it can be
together with a presbyopia correction if applicable (usually their used on illiterate patients.
own reading spectacles). The smallest type legible is recorded for
each eye individually and then using both eyes together (Fig. 1.6).
Contrast sensitivity
• Principles. Contrast sensitivity is a measure of the ability of the
visual system to distinguish an object against its background.
Fig. 1.6 Near visual acuity using a magnifying lens Fig. 1.7 Pelli–Robson contrast sensitivity letter chart
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CHAPTER
Amsler grid • Chart 5 consists of horizontal lines and is designed to detect

metamorphopsia along specific meridians. It is of particular
The Amsler grid evaluates the 20° of the visual field centred on use in the evaluation of patients describing difficulty reading.
fixation (Fig. 1.8). It is principally useful in screening for and mon- • Chart 6 is similar to chart 5 but has a white background and
itoring macular disease, but will also demonstrate central visual the central lines are closer together, enabling more detailed
field defects originating elsewhere. Patients with a substantial risk evaluation.
of choroidal neovascularization (CNV) should be provided with • Chart 7 includes a fine central grid, each square subtending an
an Amsler grid for regular use at home. angle of a half degree, and is more sensitive.
Technique
TIP An Amsler grid is a simple and easy method of monitoring The pupils should not be dilated, and in order to avoid a photo-
central visual field and is commonly abnormal in patients with stress effect, the eyes should not yet have been examined on the
macular disease.
slit lamp. A presbyopic refractive correction should be worn if
appropriate. The chart should be well illuminated and held at a
comfortable reading distance, optimally around 33 cm.
Charts
• One eye is covered.
There are seven charts, each consisting of a 10-cm outer square • The patient is asked to look directly at the central dot with
(Figs 1.9 and 1.10). the uncovered eye, to keep looking at this, and to report any
• Chart 1 consists of a white grid on a black background, the distortion or waviness of the lines on the grid.
outer grid enclosing 400 smaller 5-mm squares. When viewed • Reminding the patient to maintain fixation on the central dot,
at about one-third of a metre, each small square subtends an he or she is asked if there are blurred areas or blank spots any-
angle of 1°. where on the grid. Patients with macular disease often report
• Chart 2 is similar to chart 1 but has diagonal lines that aid fixa- that the lines are wavy whereas those with optic neuropathy
tion for patients with a central scotoma. tend to remark that some of the lines are missing or faint but
• Chart 3 is identical to chart 1 but has red squares. The red-on- not distorted.
black design aims to stimulate long wavelength foveal cones. • The patient is asked if he or she can see all four corners and all
It is used to detect subtle colour scotomas and desaturation in four sides of the square – a missing corner or border should
toxic maculopathy, optic neuropathy and chiasmal lesions. raise the possibility of causes other than macular disease, such
• Chart 4 consists only of random dots and is used mainly to as glaucomatous field defects or retinitis pigmentosa.
distinguish scotomas from metamorphopsia, as there is no The patient may be provided with a recording sheet and pen
form to be distorted. and asked to draw any anomalies (Fig. 1.11).
Fig. 1.8 Amsler grid superimposed on the macula. The central

fixation dot of the grid does not coincide with the foveal Fig. 1.9 Amsler grid chart
anatomical centre in this image (Courtesy of A Franklin)
(Courtesy of A Franklin)
Fig. 1.10 Amsler charts 2–7

(Courtesy of A Franklin)
Light brightness comparison test

This is a test of optic nerve function, which is usually normal in
early and moderate retinal disease. It is performed as follows:
• A light from an indirect ophthalmoscope is shone first into the
normal eye and then the eye with suspected disease.
• The patient is asked whether the light is symmetrically bright
in both eyes.
• In optic neuropathy the patient will report that the light is less
bright in the affected eye.
• The patient is asked to assign a relevant value from 1 to 5 to the
brightness of the light in the diseased eye, in comparison to the
normal eye.
Photostress test
• Principles. Photostress testing is a gross test of dark adapta-
tion in which the visual pigments are bleached by light. This
causes a temporary state of retinal insensitivity perceived by
the patient as a scotoma. The recovery of vision is dependent
Fig. 1.11 Stylized Amsler recording sheet shows wavy lines on the ability of the photoreceptors to re-synthesize visual
indicating metamorphopsia, and a dense scotoma pigment. The test may be useful in detecting maculopathy
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when ophthalmoscopy is equivocal, as in mild cystoid macular match those within the spectrum. Any given cone pigment may
oedema or central serous retinopathy. It may also differentiate be deficient (e.g. protanomaly – red weakness) or entirely absent
visual loss caused by macular disease from that caused by an (e.g. protanopia – red blindness). Trichromats possess all three
optic nerve lesion. types of cones (although not necessarily functioning perfectly),
• Techniques while absence of one or two types of cones renders an individual
○ The best-corrected distance VA is determined. a dichromat or monochromat, respectively. Most individuals with
○ The patient fixates on the light of a pen torch or an indi- congenital colour defects are anomalous trichromats and use
rect ophthalmoscope held about 3 cm away for about 10 abnormal proportions of the three primary colours to match those
seconds (Fig. 1.12A). in the light spectrum. Those with red–green deficiency caused by
○ The photostress recovery time (PSRT) is the time taken abnormality of red-sensitive cones are protanomalous, those with
to read any three letters of the pre-test acuity line and is abnormality of green-sensitive cones are deuteranomalous and
normally between 15 and 30 seconds (Fig. 1.12B). those with blue–green deficiency caused by abnormality of blue-
○ The test is performed on the other, presumably normal, sensitive cones are tritanomalous. Acquired macular disease tends
eye and the results are compared. to produce blue–yellow defects, and optic nerve lesions red–green
○ The PSRT is prolonged relative to the normal eye in defects.
macular disease (sometimes 50 seconds or more) but not
in an optic neuropathy. Colour vision tests
• The Ishihara test is designed to screen for congenital protan
and deuteran defects. It is simple, widely available and fre-
Colour vision testing quently used to screen for a red–green colour vision deficit.
The test can be used to assess optic nerve function. It consists
Introduction of a test plate followed by 16 plates, each with a matrix of dots
Assessment of colour vision is useful in the evaluation of optic arranged to show a central shape or number that the subject
nerve disease and in determining the presence of a congenitally is asked to identify (Fig. 1.13A). A colour-deficient person will
anomalous colour defect. Dyschromatopsia may develop in retinal only be able to identify some of the figures. Inability to identify
dystrophies prior to the impairment of other visual parameters. the test plate (provided VA is sufficient) indicates non-organic
Colour vision depends on three populations of retinal cones, visual loss.
each with a specific peak sensitivity: blue (tritan) at 414–424 nm, • The City University test consists of 10 plates, each containing
green (deuteran) at 522–539 nm and red (protan) at 549–570 nm. a central colour and four peripheral colours (Fig. 1.13B) from
Normal colour perception requires all these primary colours to which the subject is asked to choose the closest match.
A B
Fig. 1.12 Photostress test. (A) The patient looks at a light held about 3 cm away from the eye,
for about 10 seconds; (B) the photostress recovery time is the time taken to read any three
letters of the pre-test acuity line and is normally between 15 and 30 seconds
A B
Fig. 1.13 Colour vision tests. (A) Ishihara; (B) City University; (C) Hardy–Rand–Rittler; (D)
Farnsworth–Munsell 100-hue test
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• The Hardy–Rand–Rittler test is similar to the Ishihara, but

can detect all three congenital colour defects (Fig. 1.13C).
• The Farnsworth–Munsell 100-hue test is a sensitive but longer
test for both congenital and acquired colour defects. Despite
the name, it consists of 85 caps of different hues in four racks
(Fig. 1.13D). The subject is asked to rearrange randomized caps
in order of colour progression, and the findings are recorded
on a circular chart. Each of the three forms of dichromatism
is characterized by failure in a specific meridian of the chart
(Fig. 1.14).
Plus lens test

A temporary hypermetropic shift may occur in some conditions
due to an elevation of the sensory retina – the classic example is
central serous chorioretinopathy (CSR). A +1.00-dioptre lens will A
demonstrate the phenomenon.
PERIMETRY
Definitions
• The visual field can be represented as a three-dimensional
structure akin to a hill of increasing sensitivity (Fig. 1.15A). The
outer aspect extends approximately 50° superiorly, 60° nasally,
70° inferiorly and 90° temporally. VA is sharpest at the very
top of the hill (i.e. the fovea) and then declines progressively
towards the periphery, the nasal slope being steeper than the
temporal. The ‘bottomless pit’ of the blind spot is located
temporally between 10° and 20°, slightly below the horizontal.
• An isopter is a line connecting points of the same sensitivity, B
and on a two-dimensional isopter plot encloses an area within
which a stimulus of a given strength is visible. When the field
is represented as a hill, isopters resemble the contour lines on
a map (Fig. 1.15B).
• A scotoma is an area of reduced (‘relative’) or total (‘absolute’)
loss of vision surrounded by a seeing area.
• Luminance is the intensity or ‘brightness’ of a light stimulus,
measured in apostilbs (asb). A higher intensity stimulus has a
higher asb value; this is related inversely to sensitivity.
• A logarithmic rather than a linear scale is used for stimulus
intensity and sensitivity, so that for each log unit intensity
changes by a factor of 10. With a log scale, greater significance
is given to the lower end of the intensity range. The normal eye
has a very large sensitivity range, and assessment of the lower
end of the scale is of critical significance so that early damage
can be detected. With a linear scale, the lower end would be C
reduced to a very small portion of a graphical chart axis. The
visual system itself operates on close to a logarithmic scale,
so using this method more closely matches the physiological Fig. 1.14 Farnsworth–Munsell test results of colour deficien-
situation. cies. (A) Protan; (B) deuteron; (C) tritan
• Decibels. Simple log units are not used in clinical perimetry,
but rather ‘decibels’ (dB), where 10 dB = 1 log unit. Decibels
are not true units of luminance but a representation, and vary
between visual field machines. Perimetry usually concentrates
on the eye’s sensitivity rather than the stimulus intensity.
10 Perimetry
Fig. 1.15 (A) Hill of vision; (B) isopter plot
Therefore, the decibel reading goes up as retinal sensitivity three-dimensional representation of differential light sensitiv-
increases, which obviously corresponds to reducing intensity ity at different points.
of the perceived stimulus. This makes the assessment of visual • Threshold at a given location in the visual field is the bright-
fields more intuitive, as a higher number corresponds with ness of a stimulus at which it can be detected by the subject. It
higher retinal sensitivity. If the sensitivity of a test location is defined as ‘the luminance of a given fixed-location stimulus
is 20 dB (= 2 log units), a point with a sensitivity of 30 dB at which it is seen on 50% of the occasions it is presented’.
would be the more sensitive. The blind spot has a sensitivity In practice we usually talk about an eye’s sensitivity at a given
of 0 dB. If, on a given machine, seeing a stimulus of 1000 point in the field rather than the stimulus intensity. The
asb gives a value of 10 dB, a stimulus of 100 asb will give threshold sensitivity is highest at the fovea and decreases
20 dB. progressively towards the periphery. After the age of 20 years
• Differential light sensitivity represents the degree by which the sensitivity decreases by about 1 dB per 10 years.
the luminance of a target must exceed background lumi- • Background luminance. The retinal sensitivity at any
nance in order to be perceived. The visual field is therefore a location varies depending on background luminance. Rod
1
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photoreceptors are more sensitive in dim light than cones, perimeter if the latter is equipped with an appropriate software
and so owing to their preponderance in the peripheral retina, program.
at lower (scotopic) light levels the peripheral retina becomes • Manual perimetry involves presentation of a stimulus by the
more sensitive in proportion to the central retina. The hill of perimetrist, with manual recording of the response. It was
vision flattens, with a central crater rather than a peak at the formerly the standard method of field testing but has now
fovea due to the high concentration of cones, which have low largely been superseded by automated methods. It is still
sensitivity in scotopic conditions. Some diseases give mark- used occasionally, particularly in cognitively limited patients
edly different field results at different background luminance unable to interact adequately with an automated system, and
levels, e.g. in retinitis pigmentosa the field is usually much for dynamic testing of peripheral fields.
worse with low background luminance. It should be noted • Standard automated perimetry (SAP) is the method used
that it takes about 5 minutes to adapt from darkness to bright routinely in most clinical situations. Automated perimeters in
sunlight and 20–30 minutes from bright sunlight to darkness. common use include the Humphrey Field Analyser (HFA), the
The HFA (see below) uses a photopic (preferentially cone) Octopus, Medmont, Henson and Dicon (Figs 1.17 and 1.18).
level of background luminance at 31.5 asb. These predominantly utilize static testing, though software is
• Static perimetry. A method of assessing fields, usually auto- available on some machines to perform dynamic assessment.
mated, in which the location of a stimulus remains fixed, with
intensity increased until it is seen by the subject (threshold is
reached – Fig. 1.16A) or decreased until it is no longer detected. TIP Visual field results should always be used in conjunction
with the clinical findings.
• Kinetic (dynamic) perimetry is now much less commonly
performed than static perimetry. A stimulus of constant
intensity is moved from a non-seeing area to a seeing area
(Fig. 1.16B) at a standardized speed until it is perceived, and
Testing algorithms
the point of perception is recorded on a chart. Points from dif-
ferent meridians are joined to plot an isopter for that stimulus Threshold
intensity. Stimuli of different intensities are used to produce a Threshold perimetry is used for detailed assessment of the hill
contour map of the visual field. Kinetic perimetry can be per- of vision by plotting the threshold luminance value at various
formed by means of a manual (Goldmann) or an automated locations in the visual field and comparing the results with age-
matched ‘normal’ values. A typical automated strategy is to present
a stimulus of higher than expected intensity. If seen, the intensity
is decreased in steps (e.g. 4 dB) until it is no longer seen (‘staircas-
ing’). The stimulus is then increased again (e.g. 2 dB steps) until
seen once more (Fig. 1.19). If the stimulus is not seen initially, its
intensity is increased in steps until seen. Essentially, the threshold
is crossed in one direction with large increments, then crossed
again to ‘fine-tune’ the result with smaller increments. Threshold
testing is commonly used for monitoring glaucoma.
Suprathreshold
Suprathreshold perimetry involves testing with stimuli of
A
luminance above the expected normal threshold levels for an age-
matched population to assess whether these are detected. In other
words, testing to check that a subject can see stimuli that would be
seen by a normal person of the same age. It enables testing to be
carried out rapidly to indicate whether function is grossly normal
or not and is usually reserved for screening.
Fast algorithms
In recent years strategies have been introduced with shorter
testing times, providing efficiency benefits with little or no detri-
B ment to testing accuracy. The HFA offers the SITA (Swedish
Interactive Thresholding Algorithm), which uses a database of
Fig. 1.16 Principles of perimetry. (A) Static – stimulus normal and glaucomatous fields to estimate threshold values and
intensity (red arrow) at a single location is increased until takes responses during the test into account to arrive at adjusted
perceived – areas of lower sensitivity perceive only stimuli of
greater intensity (longer red arrows); (B) kinetic – stimulus estimates throughout the test. Full-threshold values are obtained
of constant intensity is moved from a non-seeing area until at the start of the test for four points. SITA-Standard and SITA-
perceived Fast (Fig. 1.20) versions are available. The Octopus Perimeter
12 Perimetry
Fig. 1.17 Humphrey perimeter and printout

1
CHAPTER
Fig. 1.18 Octopus perimeter and printout

14 Perimetry
over 33%. In patients who consistently fail to achieve good reli-

ability it may be useful to switch to a suprathreshold strategy or
kinetic perimetry.
• Fixation losses indicate steadiness of gaze during the test.
Methods of assessment include presentation of stimuli to the
blind spot to ensure no response is recorded, and the use of a
‘gaze monitor’.
• False positives are usually assessed by decoupling a stimulus
from its accompanying sound. If the sound alone is presented
Fig. 1.19 Determination of threshold and the patient still responds, a false positive is recorded. With
a high false-positive score the grey scale printout appears
abnormally pale (Fig. 1.21). In SITA testing, false positives are
uses G-TOP (Glaucoma Tendency Oriented Perimetry), which estimated based on the response time.
estimates thresholds based on information gathered from more • False negatives are registered by presenting a stimulus much
detailed assessment of adjacent points. TOP presents each stimu- brighter than threshold at a location where the threshold has
lus once at each location, instead of 4–6 times per location with a already been determined. If the patient fails to respond, a false
standard technique. negative is recorded. A high false-negative score indicates
inattention, tiredness or malingering, but is occasionally an
Testing patterns indication of disease severity rather than unreliability. The

grey scale printout in individuals with high false-negative
• Glaucoma responses tends to have a clover leaf shape (Fig. 1.22).
○ Importance of central area. Most important defects in
glaucoma occur centrally – within a 30° radius from the
fixation point – so this is the area most commonly tested. TIP If the reliability indices are poor, be careful when
○ 24-2 is a routinely used glaucoma-orientated pattern. ‘24’ interpreting the results of a visual field test.
denotes the extent in degrees to which the field is tested on
the temporal side (to 30° on the nasal side). The number
after the hyphen (2) describes the pattern of the points
Sensitivity values
tested. 30-2 is an alternative. • A numerical display (see Fig. 1.20, upper left display) gives the
○ 10-2 is used to assess a central area of radius 10°. Glauco- measured or estimated (depending on strategy) threshold in
matous defects here may threaten central vision. The 10-2 dB at each point. In a full-threshold strategy, where the thresh-
pattern facilitates more detailed monitoring of the extent old is rechecked either as routine or because of an unexpected
of damage, especially in advanced glaucoma where there is (>5 dB) result, the second result is shown in brackets next to
‘split’ fixation. the first.
• Peripheral field. Patterns that include central and peripheral • A grey scale represents the numerical display in graphical form
points (e.g. FF-120) are typically limited to the assessment of (see Fig. 1.20, upper right display) and is the simplest display
neurological defects. modality to interpret: decreasing sensitivity is represented by
• Binocular field testing (e.g. Esterman strategy) is used to darker tones – the physiological blind spot is a darker area
assess statutory driving entitlement in many jurisdictions. in the temporal field typically just below the horizontal axis.
Each change in grey scale tone is equivalent to a 5 dB change in
Analysis •
sensitivity at that location.
Total deviation (see Fig. 1.20, middle left display) shows the
SAP provides the clinician with an array of clinically relevant difference between a test-derived threshold at a given point
information via monitor display or printout. The patient’s name and the normal sensitivity at that point for the general popula-
and age are confirmed and a check made that any appropriate tion, correcting for age. Negative values indicate lower than
refractive error compensation was used. General information normal sensitivity, positive values higher than normal.
should be reviewed, such as the type of algorithm performed, the • Pattern deviation (see Fig. 1.20, middle right display) is
time taken for the test and the order in which the eyes were tested. derived from total deviation values adjusted for any gen-
eralized decrease in sensitivity in the overall field (e.g. lens
Reliability indices opacity), and demonstrates localized defects.
Reliability indices (see Fig. 1.20, top left corner) reflect the extent • Probability value plots of the total and pattern deviation (see
to which the patient’s results are reliable. If significantly unreliable, Fig. 1.20, left and right lower displays) are a representation of
further evaluation of the visual field printout is pointless. With the percentage (<5% to <0.5%) of the normal population in
SITA strategies, false negatives or false positives over about 15% whom the measured defect at each point would be expected.
should probably be regarded as significant and with full-threshold Darker symbols represent a greater likelihood that a defect is
strategies, fixation losses over 20% and false positives or negatives significant.
1
CHAPTER
Single Field Analysis Eye: Right

Name: DOB:
ID:
Central 24-2 Threshold Test
Fixation Monitor: Gaze/Blind Spot Stimulus: III, White Pupil Diameter: 4.7 mm Date: 16-08-2013
Fixation Target: Central Background: 31.5 ASB Visual Acuity: Time: 2:12 PM
Fixation Losses: 0/10 Strategy: SITA-Fast RX: +3.25 DS DC × Age: 68
False POS Errors: 0%
False NEG Errors: 0%
Test Duration: 02:42
Fover: OFF
26 23 28 28
30 30 30 29 29 29
29 29 31 31 29 30 31 31
29 30 32 33 33 32 29 26 33
30 30
29 31 33 34 33 34 33 0 31
30 30 33 33 33 31 32 28
30 30 30 32 32 30
31 30 29 31
0 –4 1 2 –2 –6 –1 0
2 1 1 1 1 1 0 –1 –1 –2 –1 –1
1 –1 0 0 –1 0 2 3 –1 –3 –2 –2 –3 –2 –1 1
GHT
2 1 1 1 1 1 –2 3 0 –1 –1 –1 –1 –2 –4 1
Within Normal Limits
2 1 2 2 1 2 2 1 0 –1 0 0 –1 0 0 –1
1 0 2 1 2 0 1 –2 –1 –2 0 –1 0 –2 –1 –4
VFI 100%
0 –1 –1 1 1 0 –2 –3 –3 –1 –1 –2
3 1 –1 1 1 –1 –3 –1 MD +0.75 dB
PSD 1.25 dB
Total Deviation Pattern Deviation
<5%
<2%
<1%
<0.5%
© 2010 Carl Zeiss Meditec

HFA II 750-41202-5.1.2/5.1.2
Fig. 1.20 Humphrey perimeter – SITA-Fast printout (see text)

(Copyright 2010 Carl Zeiss Meditec)
16 Perimetry

Name: 1587884 ID: DOB: 13-11-1824
Fixation Monitor: Gaze/Blind Spot Stimulus: III, White Pupil Diameter: Date: 14-02-2002
Fixation Losses: 9/14 Strategy: SITA-Standard RX: DS DC × Age: 77
Fover: OFF
32 25 30 29
27 30 28 29 27 26
33 33 32 32 30 29 30 29
36 322 33 34 32 31 31 39 49
30 30
35 29 33 32 33 34 32 32 32
28 34 36 35 32 32 32 31
32 34 34 33 32 39
32 34 29 33
Fig. 1.21 High false-positive score (arrow) with an abnormally pale grey scale display

Name: ID: DOB:
Fixation Monitor: Gaze/Blind Spot Stimulus: III, White Pupil Diameter: DATE:
Fixation Losses: 0/17 Strategy: SITA-Standard RX: +0.50 DS +1.00 DC × 30 Age: 85
Fover: OFF
〈0 〈0 〈0 〈0
13 〈0 7 9 17 〈0
〈0 20 23 17 11 25 12 4
〈0 〈0 13 18 28 24 22 13 6
30 30
0 8 15 26 28 28 22 〈0 24
2 27 26 15 19 28 26 21
18 26 21 16 18 24
10 18 17 15
Fig. 1.22 High false-negative score (arrow) with a clover leaf-shaped grey scale display
1
CHAPTER
RIGHT EYE
Summary values
Test Duration: 02:09 min
Summary values (‘global indices’ on the HFA – see Fig. 1.20, right
of middle row) represent distilled statistical information, which
Total Deviation
considers age-matched normal data. These values are principally
used to monitor progression of glaucomatous damage rather than
for initial diagnosis.
30°
• Visual field index (VFI) in the HFA is a measure of the
patient’s overall visual field function expressed as a percentage,
the normal age-adjusted value being 100%.
• Mean deviation (MD) on the HFA (mean defect on the
Octopus) gives an indication of the overall sensitivity of the
field. It is derived from averaging the total deviation values.
FIXATION ERRS: 0/3
• Pattern standard deviation (PSD) is a measure of focal loss FALSE POS ERRS: 0/5
or variability within the field and considers any general-
ized depression in the hill of vision. An increased PSD is
therefore a more specific indicator of glaucomatous damage LEFT EYE
than MD. Test Duration: 01:28 min
• Loss variance (LV) is a summary measure on the Octopus
Perimeter similar to PSD. Total Deviation
• Probability values. Abnormal summary values are followed
by a probability value, representing the percentage likelihood
that an abnormal value of this level will occur in a normal 30°
subject. The lower the P value, the more likely the result is
abnormal.
• The glaucoma hemifield test (GHT) compares corresponding
areas in the superior and inferior hemifields and relates only to
glaucoma.
FIXATION ERRS: 0/3
Computer analysis of serial fields FALSE POS ERRS: 0/5
Computed analysis of serial visual fields for progression is in wide-
spread use. A disadvantage is the requirement for several reliable
fields to be carried out before analysis is effective. The quality of Probability Symbols
available software has been improving steadily, with integrated P ≥ 5%
P < 5%
programs such as GPA (Guided Progression Analysis) on the HFA P < 2%
and several trend analysis options on the Octopus. P < 1%
High-sensitivity field modalities

SAP tends to detect field damage only after substantial ganglion
cell loss is established. Attempts at detecting change at an earlier
stage include the adoption of stimuli intended to target specific
ganglion cell types.
• Short-wave automated perimetry (SWAP) uses a blue stimu-
lus on a yellow background. Sensitivity to blue light (mediated
by blue cone photoreceptors) is adversely affected relatively
early in glaucoma. SWAP is more sensitive to early glaucoma-
tous defects but has not been widely adopted because cataract
decreases sensitivity to blue light (the brunescent lens acts as a
yellow filter) and patients frequently dislike the lengthy test. It Fig. 1.23 Screening frequency-doubling perimeter with display
is available on newer HFA models.
• Frequency-doubling test (FDT). Large diameter axon (mag- rapid alternation in which the light bars become dark and
nocellular) ganglion cells appear to be preferentially lost in vice versa produces the illusion of the grating having doubled
early glaucoma. The frequency-doubling illusion is produced its frequency; magnocellular ganglion cells are believed to
when a low spatial frequency sinusoidal grating undergoes mediate the pathways used. Screening (Fig. 1.23) and extended
high temporal frequency counter phase flicker (>15 Hz). The testing (Humphrey Matrix) perimeter versions are available,
18 Perimetry
the latter being suitable for detailed assessment and monitor-

ing of glaucoma.
Sources of error
• Inexperienced or unskilled technician. Though less impor-
tant with SAP than manual perimetry, correctly setting up the
test, explaining the procedure to and reassuring the patient
and monitoring performance are fundamental to obtaining an
accurate field.
• Incorrect patient details. The patient’s date of birth must be
entered correctly to facilitate appropriate normative database
matching.
• Poor patient performance.
• Uncorrected refractive error can cause a significant decrease
in central sensitivity. If a patient with hypermetropia who
usually wears contact lenses is tested wearing spectacles, this
will have the effect of magnifying and enlarging any scotomas
as compared with contact lenses. Most perimetry is performed
with a stimulus at approximately reading distance, so a near
correction should be used for individuals who are presbyopic.
• Spectacle rim artefact. Spectacles can cause rim scotomas if
small aperture lenses are used or if incorrectly dispensed (Fig.
Fig. 1.24 Grey scale display of spectacle rim artefact
1.24). Narrow-aperture trial frame lenses are unsuitable for
perimetry.
• Miosis decreases sensitivity in the peripheral field and
increases variability in the central field in both normal and It allows an exact correlation between pathology involving
glaucomatous eyes. Pupils less than 3 mm in diameter should the macula and the corresponding functional abnormality.
therefore be dilated prior to perimetry; a consistent mydriatic Microperimetry is more sensitive than SAP in detecting subtle
should be used for serial tests. abnormality of visual function.
• Media opacities (usually cataract) can have a profound effect, • The MAIA perimeter is a table top instrument (Fig. 1.25).
exaggerated by miosis. The test is usually undertaken after 20 minutes of adaptation
• Ptosis, even if mild, can suppress the superior visual field. in mesopic conditions. Fundus tracking occurs utilizing a
Similar effects result from dermatochalasis, prominent eye- line-scanning laser ophthalmoscope (SLO), with super-
lashes and deeply set eyes. luminescent diode illumination using a central wavelength of
• Inadequate retinal adaptation may lead to error if perimetry 850 nm.
is performed soon after ophthalmoscopy. • Goldmann size 3 stimuli are projected onto the central 9° of
the fundus. A 4-2 staircase thresholding technique is used,
with each stimulus applied for 200 milliseconds against a white
TIP Perimetry is a subjective examination and is not always background. Using this instrument normal retinal sensitivity
reliable. is 18 dB.
• Results are printed, together with reliability indices (fixation
loss), probabilities, and retinal sensitivity values, which are
Microperimetry colour-coded. Microperimetry is particularly useful in assess-
ing the effect of existing and future therapeutic interventions
• Microperimetry is a visual field test that measures retinal on the macula. It can also be helpful in patients with early
sensitivity and fixation behaviour in patients with macular glaucoma, particularly when there is subtle change close to
disease and focal glaucoma involving the central visual field. fixation (Fig. 1.26).
1
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Expert exam #7693 [4-2 strategy] / Duration: 8′ 38″

Fixation Losses: 13%
Generated by MAIA s/n 4003

SENSITIVITY MAP
Macular Integrity: [Not available, Custom grid]
26.6
Aver. Thresh.
(dB)
36 24 12 0
this exam
Histogram of Thresholds Frequencies reference database
25
19
15
7
FIXATION PLOT
2
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
<0
0
1
2
3
4
5
6
7
8
9
Pl=98%, P2=100%
Fixation Stability STABLE REL. UNSTABLE UNSTABLE
Fixation Graph
6
distance [°]
5
4
3
2
1
Bivariate Contour Ellipse Area:
63% BCEA: 0.8° × 0.6°, Area = 0.4°2, angle = –1.8° 1 2 3 4 5 6 7 8
95% BCEA: 1.4° × 1.0°, Area = 1.1°2, angle = –1.8° time [minutes]
Fig. 1.25 MAIA perimetry and printout

20 Slit Lamp Biomicroscopy of the Anterior Segment
Fig. 1.26 Abnormal microperimetry in a patient with geographic atrophy of the macula
SLIT LAMP BIOMICROSCOPY OF THE • The use of a red-free filter makes red objects appear black,
ANTERIOR SEGMENT thereby increasing contrast when observing vascular struc-
tures. A cobalt blue filter is normally used in conjunction with
The purpose of slit lamp examination of the cornea and anterior fluorescein.
segment is to determine the position, depth and size of any abnor-
mality (Fig. 1.27).
Scleral scatter
Direct illumination Scleral scatter involves decentring the slit beam laterally so that
the light is incident on the limbus with the microscope focused
Direct illumination with a diffuse light is used to detect gross centrally. Light is transmitted within the cornea by total internal
abnormalities: reflection. A corneal stromal lesion will become illuminated
• A narrow obliquely directed slit beam is used to visualize a because of forward light scatter. This technique is especially useful
cross-section of the cornea. to detect subtle stromal haze, or cellular or lipid infiltration.
• Further narrowing of the beam to a very thin optical section
moved across the cornea can determine the depth of a lesion.
• The height of the coaxial beam can be adjusted to measure the
Retroillumination
horizontal and vertical size of a lesion or associated epithelial Retroillumination uses reflected light from the iris or fundus after
defect. pupil dilation to illuminate the cornea. This allows the detection
1
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Direct illumination of 15–20 cm, lens and vitreous opacities can be detected
(Fig. 1.29).
• The light beam can be used to (a) illuminate the cornea,
allowing detection of a foreign body, (b) check the pupil for
irregularity, and (c) determine the light reflexes. Some oph-
thalmoscopes incorporate a cobalt blue filter, which allows
corneal abrasions and ulcers to be seen after the insertion of
fluorescein.
Scleral scatter TIP A direct ophthalmoscope can be used at the bedside

and provides a magnified view of the fundus, but there is no
stereopsis and the field of view is small.
Technique
• It is preferable to dilate the pupil if there is no contraindication.
However, a good view can be obtained through an undilated
pupil by darkening the examination room and by asking the
Retro-illumination patient to look into the distance.
• When examining the right eye, the clinician should stand at
the patient’s right side, holding the ophthalmoscope in the
right hand. When examining the left eye, the clinician should
stand at the left side, holding the ophthalmoscope in the left
hand and using the left eye (Fig. 1.30).
Fig. 1.27 Technique of slit lamp biomicroscopy of the anterior

segment
of fine epithelial and endothelial changes, such as epithelial cysts,

keratic precipitates and small blood vessels.
Specular reflection
Specular reflection shows abnormalities of the endothelium such
as reduced cell density and guttata. Pseudoguttata probably rep- Fig. 1.28 Magnified image obtained from direct ophthalmoscope
resent reversible endothelial cell oedema and inflammatory cells
beneath the endothelial layer.
FUNDUS EXAMINATION
Direct ophthalmoscopy
• Direct examination of the structures of the fundus using an
ophthalmoscope can reveal disease of the eye itself or may
reveal an abnormality indicative of disease elsewhere in the
body (for example: diabetes, systematic hypertension, raised
intracranial pressure). The major advantage of direct oph-
thalmoscopy is that it can be used at the bedside. The image
obtained is significantly magnified (15 times normal) (Fig.
1.28).
• The direct ophthalmoscope can be used to examine the
‘red’ reflex using retroillumination. By placing a +15.00
lens in position and looking at the fundus at a distance Fig. 1.29 Red reflex showing anterior capsular thickening
22 Fundus Examination
Fig. 1.30 Technique of direct ophthalmoscopy (see text)
• The ‘O’ on the illuminated lens dial of the ophthalmoscope

should be selected.
• To overcome corneal reflection, the small aperture can be used
and the light beam directed towards the edge of the pupil,
rather than through the centre. The linear polarizing filter may
be helpful.
• The examiner’s free hand should rest on the patient’s forehead.
• The patient is slowly approached at a slight angle, from the
temporal side.
• The light beam is directed at the pupil and the optic disc
should come into view at a distance of about 3.5 cm from the B
eye. If the disc is not in sharp focus, the ophthalmoscope lenses
should be rotated into the aperture using the index finger until Fig. 1.31 (A) Indirect slit lamp biomicroscopy; (B) fundus view
the disc becomes clearly visible.
• In hyperopic individuals use a plus lens (green) and in myopic
individuals a minus lens (red).
• Examine the disc for clarity of outline, colour, elevation and ○ 90 D. Wide-field lens with lower magnification and shorter
condition of vessels. Check for spontaneous venous pulsation. (7 mm) working distance. Can be used with smaller pupils.
Follow the vessels as far as possible into the retinal periphery. The correction factor is ×1.3 (Fig. 1.31 A and B).
• To locate the macula, focus the light on the disc then move the ○ 78 D. Intermediate properties; ideal for general-purpose
light about two-disc diameters temporally. Alternatively, ask examination. The correction factor is ×1.1.
the patient to look at the light. ○ Miscellaneous. Numerous other lenses are available, offer-
• The retinal periphery can be examined by asking the patient to ing qualities such as a very wide field of view and extremely
look up/down and to the sides. small pupil capability.
Technique
Slit lamp biomicroscopy Indirect ophthalmoscopy utilizes a high-power convex lens which
A range of diagnostic contact and non-contact lenses are available is designed to obtain a wide field of view of the fundus. The image
for use with the slit lamp. Contact lenses should not be used if is vertically inverted and laterally reversed. The technique is as
a penetrating injury is suspected or in the presence of corneal follows:
trauma, hyphaema or corneal infection. • The slit beam is adjusted to a width of about 1/4 of its full
• Non-contact lenses round diameter.
○ 60 D. High-magnification lens optimized for viewing the • The illumination is set at an angle coaxial with the slit lamp
posterior pole from a working distance of 13 mm. When viewing system.
estimating optic disc diameter use a correction factor of • The magnification and light intensity are adjusted to the lowest
×0.88–1.0 for the Volk lens and ×1.0 for the Nikon lens. settings.
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• The light beam should be centred to pass directly through the ○ When viewing the vertical meridian, the image is upside
patient’s pupil. down but not laterally reversed, in contrast to indirect
• The lens is held directly in front of the cornea just clearing the ophthalmoscopy. Lesions located to the left of 12 o’clock
lashes so that the light beam passes through its centre. in the retina will therefore also appear in the mirror on the
• The fundus is examined by moving the joystick and vertical left-hand side (Fig. 1.33).
adjustment mechanism of the slit lamp whilst keeping the lens ○ When viewing the horizontal meridian, the image is later-
still. ally reversed.
• Magnification is increased to show greater detail. • Technique:
• To view the peripheral retina the patient should be instructed ○ The pupils are dilated.
to direct their gaze accordingly. ○ The locking screw of the slit lamp is unlocked (Fig. 1.34A)
to allow the illumination column to be tilted (Fig. 1.34B).
○ Anaesthetic drops are instilled.
Goldmann three-mirror examination ○ Coupling fluid (high viscosity methylcellulose or equiva-
• Goldmann three-mirror lens consists of four parts: the lent) is inserted into the cup of the contact lens; it should
central lens and three mirrors set at different angles. Because be no more than half full.
the curvature of the contact surface of the lens is steeper than ○ The patient is asked to look up. The inferior rim of the lens
that of the cornea, a viscous coupling substance with the same is inserted into the lower fornix (Fig. 1.35A) and quickly
refractive index as the cornea is required to bridge the gap pressed against the cornea so that the coupling fluid is
between the cornea and the goniolens. It is important to be retained (Fig. 1.35B).
familiar with each part of the lens, as follows (Fig. 1.32): ○ The illumination column should always be tilted except
○ The central part provides a 30° upright view of the poste- when viewing the 12 o’clock position in the fundus (i.e.
rior pole. with the mirror at 6 o’clock).
○ The equatorial mirror (largest and oblong-shaped) enables ○ When viewing horizontal meridians (i.e. 3 and 9 o’clock
visualization from 30° to the equator. positions in the fundus) the column should remain central.
○ The peripheral mirror (intermediate in size and square- ○ When viewing the vertical meridians (i.e. 6 and 12 o’clock
shaped) enables visualization between the equator and the positions) the column can be positioned left or right of
ora serrata. centre.
○ The gonioscopy mirror (smallest and dome-shaped) may ○ When viewing oblique meridians (i.e. 1.30 and 7.30 o’clock)
be used for visualizing the extreme retinal periphery and the column is kept right of centre, and vice versa when
pars plana. viewing the 10.30 and 4.30 o’clock positions (Fig. 1.36).
○ It is therefore apparent that the smaller the mirror, the
more peripheral the view obtained.
• Mirror positioning:
○ The mirror should be positioned opposite the area of the
fundus to be examined. To examine the 12 o’clock position
the mirror should be positioned at 6 o’clock.
Fig. 1.33 (A) U-tear left of 12 o’clock and an island of lattice

degeneration right of 12 o’clock; (B) the same lesions seen
Fig. 1.32 The Goldmann three-mirror lens with the three-mirror lens positioned at 6 o’clock
Fig. 1.35 Insertion of contact lens (A) into the lower fornix
with the patient looking up; (B) in position for examination
of posterior pole.
Fig. 1.34 Preparation of the slit lamp for fundus examination.

(A) Unlocking the screw; (B) tilting the illumination column
○ When viewing different positions of the peripheral retina,

the axis of the beam is rotated so that it is always at right
angles to the mirror.
○ To visualize the entire fundus the lens is rotated for 360°
using first the equatorial mirror and then the peripheral
mirrors.
○ To obtain a more peripheral view of the retina the lens
is tilted to the opposite side asking the patient to move
the eyes to the same side. For example, to obtain a more
peripheral view of 12 o’clock (with mirrors at 6 o’clock) tilt
the lens down and ask the patient to look up.
○ The vitreous cavity is examined with the central lens using
both a horizontal and a vertical slit beam.
○ The posterior pole is examined.
• Scleral indentation at the slit lamp can be accomplished
using a three-mirror lens with a special attachment (Eisner Fig. 1.36 The illumination column is tilted and positioned
funnel) or a purpose-made ora serrata contact lens that com- right of centre to view the oblique meridian at 1.30 and 7.30
bines a mirror angled similarly to a gonioscopy lens with an o’clock
1
CHAPTER
incorporated attachment to facilitate scleral depression (e.g. Small pupil capability is available, and a flange is offered on
Goldmann 904® – Fig. 1.37). many lenses with the aim of improving stability of retention
• Miscellaneous contact lenses are divided principally into those and of lens position on the eye.
conferring high magnification for an optimal posterior pole
view, and those offering a wide field of view, allowing visuali-
zation extending to the ora serrata under optimal conditions. Head-mounted binocular indirect
ophthalmoscopy
The term binocular indirect ophthalmoscopy (BIO) is by conven-
tion used to refer to the head-mounted technique, though strictly
it also applies to slit lamp indirect ophthalmoscopy. BIO allows
retinal visualization through a greater degree of media opacity
than slit lamp biomicroscopy, and readily facilitates scleral inden-
tation. Light is transmitted from the headset to the fundus through
a condensing lens held at the focal point of the eye, providing an
inverted and laterally reversed image that is observed through a
stereoscopic viewing system (Fig. 1.38A).
• Lenses of various powers and diameters are available for
BIO (Fig. 1.38B). A lens of lower power confers increased
magnification, but a smaller field of view. The magnifica-
tion can be calculated by dividing the dioptric power of the
examining lens into 60. (For example, a 20 D lens would
have a magnification of 3.) Yellow filters may improve patient
comfort.
○ 20 D (magnifies ×3; field about 45°) is the most commonly
used for general examination of the fundus.
○ 28 D (magnification with the head-mounted set of ×2.27;
Fig. 1.37 Diagnostic contact Goldmann 904®lens with inden- field of 53°) has a shorter working distance and is useful
tation attachment when examining patients with small pupils.
Fig. 1.38 (A) Principles of indirect ophthalmoscopy; (B) condensing lenses

○ 40 D (magnification ×1.5; field 65°) is used mainly to ○ For the examination of small children (e.g. retinopathy of
examine small children. A broad fundus scan can be prematurity – see also Ch. 13) a speculum may be utilized
acquired rapidly and it can also be used at the slit lamp to to keep the eyelids apart, with an implement such as a
provide very high magnification. squint hook employed to direct the position of the eye.
○ Panretinal 2.2 combines magnification similar to the 20 D • Scleral indentation:
lens with a field of view similar to that of the 28 D, and can ○ The main function of scleral indentation (depression) is to
be used with small pupils. improve visualization of the retina anterior to the equator;
○ Ultra-high magnification lenses for macula and optic disc it also permits kinetic evaluation (Fig. 1.40).
examination (e.g. Macula Plus® 5.5) are available. ○ Indentation should be attempted only after the basic
• Technique: technique of BIO has been mastered. It requires practised
○ The patient should be supine on a bed or reclining chair coordination between the relative position of the indenter
rather than sitting upright (Fig. 1.39).
○ The pupils should be dilated. Reducing the ambient
illumination is often helpful as this improves contrast and
allows a lower incident light intensity to be used.
○ The eyepieces are set at the correct interpupillary distance
and the beam aligned so that it is located in the centre of
the viewing frame.
○ The patient is instructed to keep both eyes open at all times.
If necessary, the patient’s eyelids are gently separated with
the fingers.
○ The lens is taken into one hand with the flat surface facing
the patient.
○ The peripheral fundus should be examined first in order to
allow the patient to adapt to the light. The patient is asked
to move the eyes into optimal positions for examination,
e.g. looking away from the examiner to facilitate examina-
tion of the retinal periphery.
Fig. 1.40 Appearance of retinal breaks in detached retina. (A)

Fig. 1.39 Position of patient during indirect ophthalmoscopy Without scleral indentation; (B) with indentation
1
CHAPTER
and the viewing apparatus, as well as care to prevent but documentation generally takes the form of a manually drawn
patient discomfort. For example, to view the ora serrata at illustration that optimally is colour-coded (Fig. 1.42). If a retinal
12 o’clock, the patient is asked to look down and the scleral detachment is found, the boundaries are drawn by starting at the
indenter (a cotton-tipped applicator is preferred by some optic nerve and then extending to the periphery. Detached retina
practitioners) is applied to the outside of the upper eyelid is shaded in blue and flat retina in red. The course of retinal vessels
at the margin of the tarsal plate (Fig. 1.41A). (usually veins) is indicated with blue. Retinal breaks are drawn
○ With the indenter in place, the patient is asked to look up. in red with blue outlines; the flap of a retinal tear is also drawn in
At the same time the indenter is advanced into the anterior blue. Thin retina may be represented by red hatching outlined in
orbit parallel with the globe, and the examiner’s eyes are blue and lattice degeneration by blue hatching outlined in blue.
aligned with the condensing lens and indenter (Fig. 1.41B). Retinal pigment is indicated in black, retinal exudates in yellow
○ Gentle pressure is exerted so that a mound is created. and vitreous opacities in green.
After adequate viewing, the indenter is gently moved to an
adjacent part of the fundus.
○ The indenter should be kept tangential to the globe at all
times, as perpendicular indentation will cause pain and
TONOMETRY
even risk perforation if the sclera is very thin. Goldmann tonometry
○ For viewing the 3 and 9 o’clock positions, indentation
directly on the sclera is sometimes necessary, facilitated by Principles
topical anaesthesia. Indentation can also be performed at Goldmann applanation tonometry is based on the Imbert–Fick
the slit lamp using some fundus contact lenses. principle, which states that for an ideal, dry, thin-walled sphere,
the pressure inside the sphere (P) equals the force necessary to
Fundus drawing flatten its surface (F) divided by the area of flattening (A) (i.e.
P = F/A). The intraocular pressure (IOP) is proportional to the
When available, wide-field photographic imaging can be an pressure applied to the globe (in practice, the cornea) and the
excellent aid in recording the features of a retinal detachment, thickness of the wall of the globe (i.e. the thickness of the cornea,
which is variable). The human eye, however, is not an ideal sphere
– the cornea is rigid and resists flattening. Capillary attraction of
the tear meniscus, however, tends to pull the tonometer towards
the cornea. Corneal rigidity and capillary attraction cancel each
other out when the flattened area has a diameter of 3.06 mm, as in
Goldmann tonometry (Fig. 1.43A). The Goldmann tonometer is
an accurate variable-force tonometer consisting of a double prism
(Fig. 1.43B). The tonometer prism should be disinfected between
a
tin
re
d
Br
he
e
c
ak
A e ta
s
D
Vitre
ous
ning
opa
Thin
city
Ex
ud
at
e
e
B Reti ttic
nal p La
igme
nt
Fig. 1.41 Technique of scleral indentation. (A) Insertion of
indenter; (B) indentation Fig. 1.42 Colour coding for retinal illustration
28 Tonometry
A B
Fig. 1.43 Goldmann tonometry. (A) Physical principles; (B) tonometer
patients and replaced regularly in accordance with the manufac-

turer’s instructions. Two per cent Na-hypochlorite (dilute bleach)
offers effective disinfection against adenovirus and herpes simplex
virus. However, disinfectants can cause the tonometer tip to swell
and crack with time, which can lead to disinfectant entering the
tonometer tip resulting in a corneal abrasion when applied to
the cornea. Seventy per cent isopropyl alcohol wipes do not offer
protection against viral infections. Disposable tonometer prisms
and caps have been introduced to address concerns of infection
from reusable prisms.
Technique
A
• Topical anaesthetic (commonly proxymetacaine 0.5%) and a
small amount of fluorescein are instilled into the conjunctival
sac.
• The patient is positioned at the slit lamp with his or her fore-
head firmly against the headrest and instructed to look straight
ahead (often at the examiner’s opposite ear) and to breathe
normally.
• With the cobalt blue filter in place and illumination of maximal
intensity directed obliquely (approximately 60°) at the prism, B
the prism is centred in front of the apex of the cornea.
• The dial is preset at 1 (i.e. 10 mmHg). Fig. 1.44 Applanation tonometry. (A) Contact between the
• The prism is advanced until it just touches the apex of the tonometer prism and the cornea; (B) fluorescein-stained
cornea (Fig. 1.44A). semi-circular mires – the diagram at right showing the correct
end-point using mires of appropriate thickness
• Viewing is switched to the ocular of the slit lamp.
• A pattern of two green semi-circular mires will be seen, one
above and one below the horizontal midline, which represent TIP Inadvertent finger pressure applied to the globe when
undertaking applanation tonometry or squeezing of the eyelids
the fluorescein-stained tear film touching the upper and lower
can cause an anomalously high IOP reading.
outer halves of the prism. Mire thickness should be around
1
CHAPTER
10% of the diameter of its total arc (Fig. 1.44B). Care should
be taken to horizontally and vertically centre the mires so that
two centralized semi-circles are observed.
• The dial on the tonometer is rotated to vary the applied force.
The inner margins of the semi-circles align when a circular
area of diameter precisely 3.06 mm is flattened.
• The reading on the dial, multiplied by 10, gives the IOP in
mmHg.
Sources of error
• Inappropriate fluorescein pattern. Excessive fluorescein will
result in the mires being too thick, with consequent overes-
timation of IOP. Insufficient will make the semi-circles too
thin, with consequent underestimation (see Fig. 1.44B, left and
centre).
• Pressure on the globe from the examiner’s fingers, eyelid
squeezing or restricted extraocular muscles (e.g. thyroid myo-
pathy) may give an anomalously high reading.
• Central corneal thickness (CCT). Calculations of IOP by
Goldmann applanation tonometry (GAT) assume that CCT
is 520 µm, with minimal normal variation. If the cornea is
thinner, an underestimation of IOP is likely to result, and if
thicker, an overestimation. Corneas tend to be thicker than
average in individuals with ocular hypertension, and thinner
Fig. 1.45 Tonometer calibration bar in position
in normal-tension glaucoma (NTG). Following refractive
surgery procedures, the cornea is both thinner and structur-
ally altered, leading to an underestimation of the IOP. Some
methods of IOP measurement (e.g. DCT – see below) may
reduce the effect of structural confounding variables. Other
Other forms of tonometry
corneal mechanical factors may also be important but are less • Pneumotonometry (Fig. 1.46A) is based on the principle of
well defined. applanation, but the central part of the cornea is flattened by a
• Corneal oedema may result in artificial lowering of IOP, jet of air rather than a prism. The time required to sufficiently
hypothesized to be due to a boggy softening; the associated flatten the cornea relates directly to the level of IOP. Contact is
increased CCT seems to be more than offset. not made with the eye and topical anaesthesia is not required,
• Astigmatism, if significant, may give distorted mires as well as so it is particularly useful for screening in the community. The
leading to mechanically induced errors. If over 3 dioptres, the sudden jet of air can startle the patient. Accuracy is improved
average reading of two can be taken with the prism rotated 90° if an average of at least three readings is taken.
for the second, or optimally the prism is rotated so that the red • Portable applanation tonometry (Perkins) uses a Goldmann
line on the tonometer housing is aligned with the prescription prism in conjunction with a portable light source (Fig. 1.46B).
of the minus axis. It is hand-held and can therefore be used in bed-bound or
• Incorrect calibration of the tonometer can result in a false anaesthetized patients.
reading, and calibration should be checked before each clinical • Dynamic contour tonometry (DCT) (e.g. PASCAL®) uses a
session using the manufacturer’s calibration arm (Fig. 1.45). solid-state sensor and a corneal contour-matching surface,
• Wide pulse pressure. It is normal for there to be a small oscil- with the aim of measuring IOP relatively independently of
lation of IOP in concert with the rhythm of ocular perfusion. corneal mechanical factors such as rigidity. It is mounted on
If this ‘pulse pressure’ is substantial, either the midpoint or the a slit lamp in similar fashion to the Goldmann tonometer and
highest level observed may be taken. IOP is shown on a digital display. Studies comparing DCT and
• Repeated readings over a short period will often be associated GAT IOP readings with manometric intracameral IOP seem to
with a slight fall in IOP due to a massaging effect on the eye. confirm DCT as providing a more physiological measurement.
• Other factors include a tight collar and breath-holding, both • Electronic indentation/applanation tonometry (e.g. Tono-
of which obstruct venous return, can raise IOP. Pen® – Fig. 1.46C) is a hand-held electronic contact tonometer
(a modified version of the older Mackay–Marg tonometer).
The probe tip contains a transducer that measures applied
TIP The Goldmann tonometer loses accuracy with constant force. Besides portability, its main advantage is the facility to
use and should be checked for calibration error on a regular measure IOP reasonably accurately in eyes with distorted or
basis.
oedematous corneas and through a soft contact lens.
30 Gonioscopy
A B
C D
Fig. 1.46 Portable tonometers. (A) Keeler pneumotonometer; (B) Perkins applanation tonom-
eter; (C) Tono-Pen®; (D) iCare®
• Rebound tonometry (e.g. iCare® – Fig. 1.46D) involves a between the IOP measurements is called corneal hysteresis (Fig. 1.47).
1.8 mm plastic ball attached to a wire. Deceleration of the Corneal hysteresis is not a measure of the stiffness of the cornea,
probe upon contact with the cornea is proportional to IOP. but rather a measure of how corneal tissue absorbs and dissipates
Anaesthesia is not required. The instrument can be used for energy during deformation and return. Corneal hysteresis appears to
self-monitoring – a tailored personal version is available – and provide a measurement of IOP that is less affected by factors such as
for screening in the community. previous laser refractive surgery. It also offers information on which
• Indentation (impression) tonometry (e.g. Schiotz) is a patients with glaucoma are more likely to progress (patients with a
seldom-used portable device that measures the extent of low hysteresis value are at a greater risk of glaucoma progression)
corneal indentation by a plunger of known weight. and it may serve as a biomarker to aid glaucoma case detection.
• Implantable tonometers are under development and if a There is also a strong relationship between corneal hysteresis and
clinically workable device is realized should facilitate accurate the magnitude of IOP reduction with topical prostaglandin therapy.
lifelong 24-hour IOP measurement.
Ocular response analyser and GONIOSCOPY

corneal hysteresis
Introduction
The ocular response analyser (e.g. Reichert®) utilizes air-puff
technology to record two applanation measurements: one while Overview
the cornea is moving inward and one when the cornea returns to • Gonioscopy is a method of evaluating the anterior chamber
its normal position. The average of these two IOP measurements (AC) angle, and can be used therapeutically for procedures
provides a Goldmann-correlated IOP measurement. The difference such as laser trabeculoplasty and goniotomy.
1
CHAPTER
Applanation Signal Pressure (air pulse)

Optical principles
Pressure / Signal Amplitude
“In” Signal dslope1 “Out” Signal

Peak The angle of the AC cannot be visualized directly through the
Peak
intact cornea because light from angle structures undergoes ‘total
uslope1
internal reflection’ at the anterior surface of the precorneal tear
Applanation film (Fig. 1.48, top). When light travels from a medium of higher
Pressure 1 to one of lower refractive index (such as cornea to air) it will
Hysteresis Applanation
Pressure 2 be reflected at the interface between the two unless the angle of
incidence is less than a certain ‘critical angle’ dependent on their
Baseline w2
refractive index difference (46° for the tear film–air interface). The
0 10 15 20 25 phenomenon is utilized in optical fibre signal transmission, where
Time - msec it ensures that light is retained within the core of a cable. Because
the refractive index of a goniolens is similar to that of the cornea,
it eliminates total internal reflection by replacing the tear film–air
interface with a tear film–goniolens interface (Fig. 1.48, bottom).
Light rays can then be viewed as they exit the contact lens, directly
or indirectly (see below).
Fig. 1.47 Corneal hysteresis as measured by the Ocular

Response Analyzer. It is defined as the difference between
the pressure at which the cornea bends inward during air-jet
applanation and the pressure at which it bends out again
• Other means of angle assessment, such as anterior segment

optical coherence tomography (OCT) and high-frequency
ultrasound biomicroscopy (UBM), offer advantages in some
aspects of angle analysis, but current clinical opinion suggests
they should supplement rather than replace gonioscopic
evaluation (see Ch. 11).
TIP Gonioscopy is an indispensable technique that allows

the filtration angle to be examined in patients with ocular
Fig. 1.48 Optical principles of gonioscopy; n = refractive index;
hypertension or glaucoma.
i = angle of incidence
32 Gonioscopy
• Technique
Disinfection ○ It is essential that the examination takes place in a room in
Lenses must be cleaned between patients to remove any particulate which the ambient illumination is low.
matter and then sterilized. A suggested regimen is to soak the lens ○ The size and intensity of the slit beam should be reduced
in 2% hypochlorite solution for at least 5 minutes followed by to the absolute minimum compatible with an adequate
thorough rinsing in sterile saline, then air-drying. view. Do not direct the beam through the pupil.
○ The patient is seated at the slit lamp and advised that the
Indirect gonioscopy lens will touch the eye but will not usually cause discom-
fort. The forehead must be kept against the headband and
Indirect goniolenses use a mirror to reflect rays from the angle both eyes should remain open.
such that they exit the goniolens at much less than the critical ○ A drop of local anaesthetic is instilled.
angle. They provide a mirror image of the opposite angle and can ○ A drop or two of coupling fluid (e.g. hypromellose 0.3%)
be used only in conjunction with a slit lamp. is placed on the contact surface of the lens.
○ The patient is asked to look upwards and the lens is
Non-indentation gonioscopy inserted rapidly so as to avoid loss of the coupling fluid.
• Goniolenses The patient then looks straight ahead.
○ The classic Goldmann lens consists of three mirrors, one ○ Indirect gonioscopy gives an inverted view of the portion
of which is specifically for gonioscopy. Some goniolenses of the angle opposite the mirror.
have one (Fig. 1.49), two or four mirrors. ○ Once the initial examination has been performed and the
○ Lenses of similar basic structure but with modifications findings noted, increasing the level of illumination may
include the Magna View, Ritch trabeculoplasty and the help in defining the angle structures.
Khaw direct view. ○ When the view of the angle is obscured by a convex iris,
○ Because the curvature of the contact surface of the lens is it is possible to see ‘over the hill’ by asking the patient to
steeper than that of the cornea, a viscous coupling sub- look in the direction of the mirror. Only slight movement
stance of refractive index similar to the cornea is required is permissible, otherwise the structures will be distorted
to bridge the gap between cornea and lens. and a closed angle may appear open.
○ Excessive pressure with a non-indentation lens narrows
the angle appearance (in contrast to the effect of pressure
TIP Gonioscopy should be undertaken in a room where the during indentation gonioscopy – see below). Excessive
ambient illumination is low, as pupil size influences the grade pressure also causes folds in the cornea that compromise
of angle closure.
the clarity of the view.
○ In some eyes, suction on the cornea from the lens may
artificially open the angle. Awareness of the need to avoid
retrograde, as well as anterograde, pressure on the lens will
tend to prevent inadvertent distortion.
TIP Indentation gonioscopy is a useful technique to

determine the degree of peripheral anterior synechiae in a
patient with appositional angle closure.
Indentation (dynamic, compression) gonioscopy

• Goniolenses include the Zeiss (Fig. 1.50A and B), Posner
and Sussman (no handle), all of which are four-mirror
gonioprisms.
○ The contact surface of the lenses has a curvature flatter
than that of the cornea, negating the need for a coupling
substance.
○ The lenses do not stabilize the globe and are relatively
unsuitable for laser trabeculoplasty.
○ The lenses are useful for indentation gonioscopy.
• Technique
○ The first stages are as set out above for non-indentation
Fig. 1.49 Goldmann single mirror goniolens gonioscopy.
1
CHAPTER
A A
B B
Fig. 1.50 (A) Zeiss goniolens; (B) slit lamp view with lens in Fig. 1.51 Indentation gonioscopy in appositional angle
place on the cornea closure. (A) Total angle closure prior to indentation; (B) during
indentation the entire angle becomes visible (arrow) – the
corneal folds are typical
(Courtesy of W Alward, from Color Atlas of Gonioscopy, Wolfe
1994)
○ Indentation is performed by gently pressing the lens pos-

teriorly against the cornea. This forces aqueous into the
angle, pushing the peripheral iris posteriorly.
○ If the angle is closed only by apposition between the iris
Direct gonioscopy
and cornea it will be forced open, allowing visualization of Direct goniolenses work by constructing the viewing surface of the
the angle recess (Fig. 1.51A and B). lens in a domed or slanted configuration such that exiting light
○ If the angle is closed by adhesions between the peripheral rays strike the contact lens/air interface at a steeper than critical
iris and cornea – peripheral anterior synechiae (PAS) – it angle so that they will pass through to the observer. This approach
will remain closed. is called ‘direct’ because light rays from the angle are viewed
○ Dynamic gonioscopy can be invaluable in helping to define directly, without reflection inside the lens. They do not require
the structures in angles that are difficult to assess, such as a slit lamp and are used with the patient in the supine position,
in distinguishing an extensive or double highly pigmented typically under general anaesthesia in the evaluation and surgical
Schwalbe line from the pigmented meshwork. treatment of infantile glaucoma.
34 Gonioscopy
• Direct goniolenses include the Koeppe (Fig. 1.52A and B), ○ The technique cannot be used with a desktop slit lamp so
Medical Workshop, Barkan and Swan–Jacob (Fig. 1.52C). clarity, illumination and variable magnification are not
• Technique comparable with indirect lenses.
○ Gonioscopy is performed with the patient in the supine
position (note that this may deepen the angle) in con-
junction with an operating or hand-held microscope or
Identification of angle structures
magnifying loupes. Accurate identification of angle structures (Fig. 1.53A and B) is not
always straightforward, even for the experienced clinician.
• Schwalbe line. This is the most anterior structure, appearing
whitish to variably pigmented. Anatomically it demarcates the
peripheral termination of Descemet membrane and the ante-
rior limit of the trabeculum. It may be barely discernible in
younger patients. In contrast, there may be pigment deposits
on or anterior to the Schwalbe line – a Sampaolesi line –
especially in heavily pigmented angles (e.g. pseudoexfoliation
syndrome). It may have a double-line configuration, when
the posterior component may be mistaken for the pigmented
meshwork (see Ch. 11).
• The corneal wedge is useful in locating an inconspicuous
Schwalbe line. Using a narrow slit beam, two distinct linear
corneal reflections can be identified, one on the inner and
one on the outer corneal surface. The outer reflection will arc
A round across the corneoscleral interface – due to the sclera
being opaque – to meet the inner reflection at the apex of
the corneal wedge that coincides with the Schwalbe line (Fig.
1.53C).
• The trabeculum extends from the Schwalbe line to the scleral
spur, with an average width of 600 µm. In younger people
it has a ground-glass translucent appearance. The anterior
non-functional part lies adjacent to the Schwalbe line and has
B a whitish colour. The posterior pigmented functional part lies
adjacent to the scleral spur and has a greyish-blue translucent
appearance in the young. Trabecular pigmentation is rare
prior to puberty, but in older eyes involves the posterior tra-
beculum to a variable extent, most marked inferiorly. Patchy
trabecular pigmentation in a suspiciously narrow angle raises
the possibility of intermittent iris contact.
• The Schlemm canal may be identified in the angle, espe-
cially if non-pigmented, as a slightly darker line deep to the
posterior trabeculum. Blood can sometimes be seen in the
canal, either physiologically (sometimes due to excessive
pressure on the episcleral veins with a goniolens), or in
the presence of low intraocular or raised episcleral venous
pressure.
• The scleral spur is the most anterior projection of the sclera
and the site of attachment of the longitudinal muscle of the
ciliary body. Gonioscopically it is situated immediately poste-
rior to the trabeculum and appears as a narrow whitish band
that yellows with age.
• The ciliary body stands out just behind the scleral spur as
a pink, dull brown or slate grey band. Its width depends on
the position of iris insertion and it tends to be narrower in
C
hypermetropic eyes and wider in myopic eyes. The angle recess
Fig. 1.52 Goniolenses. (A) Diagrammatic representation of represents the posterior dipping of the iris as it inserts into
the mechanism of direct gonioscopy; (B) Koeppe; (C) Swan– the ciliary body. It may not be visible in some eyes due to a
Jacob physiological anterior iris insertion, though fixed pathological
1
CHAPTER
B C
Fig. 1.53 Normal angle structures. (A) Schematic representation – inset painting demon-
strates corneal wedge; (B) goniophotograph – a broad Schwalbe line is indicated by the white
arrow, below which is the non-pigmented meshwork, the pigmented meshwork, the scleral
spur and the ciliary body (black arrow) – the ciliary body is relatively lightly pigmented; (C)
corneal wedge on gonioscopy (arrow showing Schwalbe line)
(Courtesy of W Alward, from Color Atlas of Gonioscopy, Wolfe 1994 – fig. A; R Taylor – fig. C)
angle narrowing due to PAS – adhesions between the iris and meshwork is abnormal. Larger circumferential vessels may
angle structures – should be excluded. also be seen.
• Iris processes are small, usually tenuous extensions of the
anterior surface of the iris that insert at the level of the scleral
spur and cover the ciliary body to a varying extent (Fig. 1.54).
Pathological findings
They are present in about one-third of normal eyes and are • Peripheral anterior synechiae
most prominent during childhood and in brown eyes. The ○ Primary angle-closure glaucoma.
processes should not be confused with PAS, which typically ○ Anterior uveitis.
extend more anteriorly and are more substantial. ○ Iridocorneal endothelial (ICE) syndrome.
• Blood vessels. Radial vessels at the base of the angle recess • Neovascularization
are often seen in normal eyes. Pathological blood vessels run ○ Neovascular glaucoma.
randomly in various directions. As a general principle, any ○ Fuchs heterochromic cyclitis.
blood vessel that crosses the scleral spur onto the trabecular ○ Chronic anterior uveitis.
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tariff act have been proclaimed with Portugal, with Italy and
with Germany. Commercial conventions under the general
limitations of the fourth section of the same act have been
concluded with Nicaragua, with Ecuador, with the Dominican
Republic, with Great Britain on behalf of the island of
Trinidad and with Denmark on behalf of the island of St.
Croix. These will be early communicated to the Senate.
Negotiations with other governments are in progress for the
improvement and security of our commercial relations."
The question of the ratification of all these treaties was

pending in the Senate when the term of the 56th Congress
expired, March 4, 1901. Opposing interests in the United
States seemed likely then to defeat their ratification. On the
last day of the special session of the Senate, March 5-9, an
agreement extending the time for the ratification of the
French reciprocity treaty was received and referred to the
committee on foreign relations. On the 15th of March,
Secretary Hay and Lord Pauncefote signed protocols extending
for one year the time of ratification for four of the British
West Indian reciprocity treaties, namely, Jamaica, Bermuda,
Guiana and Turks and Caicos islands.
UNITED STATES OF AMERICA: A. D. 1900.

Naval strength.
See (in this volume)

NAVIES OF THE SEA POWERS.
UNITED STATES OF AMERICA: A. D. 1900.

State of Indian schools.
Recent Indian policy.
Indian population.

INDIANS, AMERICAN: A. D. 1899-1900.
UNITED STATES OF AMERICA: A. D. 1900 (January).
Report of the First Philippine Commission.

PHILIPPINE ISLANDS: A. D. 1900 (JANUARY).
UNITED STATES OF AMERICA: A. D. 1900 (January-March).

The outbreak of the "Boxers" in northern China.

CHINA: A. D. 1900 (JANUARY-MARCH).
UNITED STATES OF AMERICA: A. D. 1900 (February).

Negotiation of the Hay-Pauncefote Convention relative
to the Nicaragua Canal.

CANAL, INTEROCEANIC: A. D. 1900 (DECEMBER).
UNITED STATES OF AMERICA: A. D. 1900 (March-December).

Passage of the Financial Bill.
Settlement of the question of the monetary standard.
The working of the act.
Legislation in the direction sought by the advocates of the

gold standard and of a reformed monetary system for the
country, whose agitations are referred to above, was attained
in the spring of 1900, by the passage of an important
"Financial Bill" which became law on the 14th of March.

UNITED STATES OF AMERICA: A. D. 1896-1898
The provisions and the effect of the Act were summarized at

the time by the Secretary of the Treasury, Mr. Gage, in a
published statement, as follows:
"The financial bill has for its first object what its title
indicates, the fixing of the standard of value and the
maintaining at a parity with that standard of all forms of
money issued or coined by the United States. It reaffirms that
the unit of value is the dollar, consisting of 25.8 grains of
gold, nine tenths fine, but from that point it goes on to make
it the duty of the Secretary of the Treasury to maintain all
forms of money issued or coined at a parity with this
standard. It puts into the hands of the Secretary ample power
to do that.
{640}
For that purpose, the bill provides in the Treasury bureaus of
issue and redemption and transfers from the general fund of
the Treasury's cash $150,000,000 in gold coin and bullion to
redemption fund, that gold to be used for the redemption of
United States notes and Treasury notes. That fund is
henceforth absolutely cut out of and separated from the cash
balance in the Treasury and the available cash balance will
hereafter show a reduction of $150,000,000 from the figures
that have heretofore prevailed. This $150,000,000 redemption
fund is to be used for no other purpose than the redemption of
United States notes and Treasury notes and those notes so
redeemed may be exchanged for the gold in the general fund or
with the public, so that the reserve fund is kept full with
gold to the $150,000,000 limit. If redemptions go on so that
the gold in this reserve fund is reduced below $100,000,000,
and the Secretary is unable to build it up to the $150,000,000
mark by exchange for gold in the general fund or otherwise, he
is given power to sell bonds and it is made his duty to
replenish the gold to the $150,000,000 mark by such means.
"The 'endless chain' is broken by a provision which prohibits

the use of notes so redeemed to meet deficiencies in the
current revenues. The act provides for the ultimate retirement
of all the Treasury notes issued in payment for silver bullion
under the Sherman act. As fast as that bullion is coined into
silver dollars Treasury notes are to be retired and replaced
with an equal amount of silver certificates. The measure
authorizes the issue of gold certificates in exchange for
deposits of gold coin, the same as at present, but suspends
that authority whenever and so long as the gold in the
redemption fund is below $100,000,000 and gives to the
Secretary the option to suspend the issue of such certificates
whenever the silver certificates and United States notes in
the general fund of the Treasury exceed $40,000,000. The bill
provides for a larger issue of silver certificates, by
declaring that hereafter silver certificates shall be issued
only in denominations of $10 and under except as to 10 per
cent. of the total volume. Room is made for this larger use of
silver certificates in the way of small bills by another
provision which makes it necessary as fast as the present
silver certificates of high denominations are broken up into
small bills to cancel a similar volume of United States notes
of small denominations and replace them with notes of
denominations of $10 and upward. Further room is made for the
circulation of small silver certificates by a clause which
permits national banks to have only one third of their capital
in denomination under $10.
"One clause of the bill which the public will greatly

appreciate is the right it gives to the Secretary to coin any
of the 1890 bullion into subsidiary silver coins up to a limit
of $100,000,000. There has for years been a scarcity of
subsidiary silver during periods of active retail trade, but
this provision will give the Treasury ample opportunity to
supply all the subsidiary silver that is needed. Another
provision that the public will greatly appreciate is the
authority given to the Secretary to recoin worn and uncurrent
subsidiary silver now in the Treasury or hereafter received.
"A distinct feature of the bill is in reference to refunding

the 3 per cent. Spanish war loan, the 2 per cent. bonds
maturing in 1907 and the 5 per cent. bonds maturing in 1904, a
total of $839,000,000, into new 2 per cent. bonds. These new 2
per cent. bonds will not be offered for sale, but will only be
issued in exchange for an equal amount, face value, of old
bonds. This exchange will save the Government, after deducting
the premium paid, nearly $23,000,000, if all the holders of the
old bonds exchange them for the new ones. National banks that
take out circulation based on the new bonds are to be taxed
only one half of 1 per cent. on the average amount of
circulation outstanding, while those who have circulation
based on a deposit of old bonds will be taxed, as at present,
1 per cent. There are some other changes in the national
banking act. The law permits national banks with $25,000
capital to be organized in places of 3,000 inhabitants or
less, whereas heretofore the minimum capital has been $50,000.
It also permits banks to issue circulation on all classes of
bonds deposited up to the par value of the bonds, instead of
90 per cent. of their face, as heretofore. This ought to make
an immediate increase in national bank circulation of
something like $24,000,000, as the amount of bonds now
deposited to secure circulation is about $242,000,000. If the
price of the new 2s is not forced so high in the market that
there is no profit left to national banks in taking out
circulation, we may also look for a material increase in
national bank circulation based on additional deposits of
bonds. National banks are permitted under the law to issue
circulation up to an amount equal to their capital. The total
capital of all national banks is $616,000,000. The total
circulation outstanding is $253,000,000. There is, therefore,
a possibility of an increase in circulation of $363,000,000,
although the price of the 2 per cent. bonds, as already
foreshadowed by market quotations in advance of their issue,
promises to be so high that the profit to the banks in taking
out circulation will not be enough to make the increase
anything like such a possible total."
Upon the working of the Act, during the first nine months of
its operation, Secretary Gage remarked as follows, in his
annual report dated December 14, 1900:
"The operation of the act of March 14 last with respect to
these two important matters of our finances has well
exemplified its wisdom. Confidence in the purpose and power of
the Government to maintain the gold standard has been greatly
strengthened. The result is that gold flows toward the
Treasury instead of away from it. At the date of this report
the free gold in the Treasury is larger in amount than at any
former period in our history. Including the $150,000,000
reserve, the gold in the Treasury belonging to the Government
amounts to over $242,000,000, while the Treasury holds,
besides, more than $230,000,000, against which certificates
have been issued. That provision of the act which liberalized
the conditions of bank-note issue was also wise and timely.
Under it, … there has been an increase of some $77,000,000 in
bank-note issues. To this fact may be chiefly attributed the
freedom from stress for currency to handle the large harvests
of cotton, wheat, and corn. In this respect the year has been
an exception to the general rule of stringency which for
several years has so plainly marked the autumn season.
{641}
"Nevertheless, the measures referred to, prolific as they have

been in good results, will yet need re-enforcement in some
important particulars. Thus, as to the redemption fund
provided for in said act, while the powers conferred upon the
Secretary are probably ample to enable a zealous and watchful
officer to protect fully the gold reserve, there appears to be
lacking sufficient mandatory requirement to furnish complete
confidence in the continued parity, under all conditions,
between our two forms of metallic money, silver and gold. Upon
this point further legislation may become desirable. As to the
currency, while the liberalizing of conditions has, as previously
noted, found response in a necessary increase of bank-note
issues, there is under our present system no assurance
whatever that the volume of bank currency will be continuously
responsive to the country's needs, either by expanding as such
needs require or by contracting when superfluous in amount.
The truth is that safe and desirable as is our currency system
in many respects, it is not properly related. The supply of
currency is but remotely, if at all, influenced by the ever
changing requirements of trade and industry. It is related
most largely, if not entirely, to the price of Government
bonds in the market."
Annual Report of the Secretary of the Treasury, 1900,

pages 72-73.
UNITED STATES OF AMERICA: A. D. 1900 (April).

Speech of Senator Hoar in denial of the right of the
government of the United States, under the Constitution, to
hold the Philippine Islands as a subject state.
On the 17th of April, the following joint resolution was under

consideration in the Senate: "Be it resolved by the Senate and
House of Representatives of the United States of America in
Congress assembled, that the Philippine Islands are territory
belonging to the United States; that it is the intention of
the United States to retain them as such and to establish and
maintain such governmental control throughout the archipelago
as the situation may demand." Senator Hoar, of Massachusetts,
spoke in opposition to the resolution, and some passages from
his speech are quoted here, because they are notably
representative of the ground and spirit of an opposition which
existed within the party controlling the government to the war
of subjugation in the Philippine Islands, to which the party
and the government were finally committed by the adoption of
this Congressional declaration. The attitude and argument of
parties on the question are set forth below, in the platforms
and manifestos of the presidential election. This speech
exhibits a feeling on that question which was overridden in
the winning party, and it has an importance both forensic and
historical:
"The American people, so far as I know, were all agreed that
their victory [in the Spanish American war] brought with it
the responsibility of protecting the liberated peoples from
the cupidity of any other power until they could establish
their own independence in freedom and in honor. I stand here
to-day to plead with you not to abandon the principles that
have brought these things to pass. I implore you to keep to
the policy that has made the country great, that has made the
Republican party great, that has made the President great. I
have nothing new to say. But I ask you to keep in the old
channels, and to keep off the old rocks laid down in the old
charts, and to follow the old sailing orders that all the old
captains of other days have obeyed, to take your bearings, as
of old, from the north star,
Of whose true fixed and resting quality

There is no fellow in the firmament,
and not from this meteoric light of empire.
"Especially, if I could, would I persuade the great Republican

party to come back again to its old faith, to its old
religion, before it is too late. There is yet time. The
President has said again and again that his is only an ad
interim policy until Congress shall act. It is not yet too
late. Congress has rejected, unwisely, as I think, some
declarations for freedom. But the two Houses have not as yet
committed themselves to despotism. The old, safe path, the
path alike of justice and of freedom, is still easy. It is a
path familiar, of old, to the Republican party. If we have
diverged from it for the first time, everything in our
history, everything in our own nature calls us back. The great
preacher of the English church tells you how easy is the
return of a great and noble nature from the first departure
from rectitude:—
'For so a taper, when its crown of flame is newly blown off,
retains a nature so symbolical to light,
that it will with greediness reenkindle and snatch a ray
from the neighbor fire.'
"I, for one, believed, and still believe that the pathway to
prosperity and glory for the country was also the pathway to
success and glory for the Republican party. I thought the two
things inseparable. If, when we made the treaty of peace, we
had adhered to the purpose we declared when we declared war;
if we had dealt with the Philippine Islands as we promised to
deal, have dealt, and expect to deal with Cuba, the country
would have escaped the loss of 6,000 brave soldiers, other
thousands of wrecked and shattered lives, the sickness of many
more, the expenditure of hundreds of millions, and, what is
far worse than all, the trampling under foot of its cherished
ideals. There would have been to-day a noble republic in the
East, sitting docile at our feet, receiving from us
civilization, laws, manners, and giving in turn everything the
gratitude of a free people could give-love, obedience, trade.
The Philippine youth would throng our universities; our
Constitution, our Declaration, the lives of Washington and
Lincoln, the sayings of Jefferson and Franklin would have been
the textbooks of their schools. How our orators and poets
would have delighted to contrast America liberating and
raising up the republic of Asia, with England subduing and
trampling under foot the republic of Africa. Nothing at home
could have withstood the great party and the great President
who had done these things. We should have come from the next
election with a solid North and have carried half the South.
You would at least have been spared the spectacle of great
Republican States rising in revolt against Republican
policies. I do not expect to accomplish anything for liberty
in the Philippine Islands but through the Republican party.
Upon it the fate of these Islands for years to come is to
depend. If that party can not be persuaded, the case is in my
judgment for the present hopeless. …
{642}
"The practical question which divided the American people last

year, and which divides them to-day, is this: Whether in
protecting the people of the Philippine Islands from the
ambition and cupidity of other nations we are bound to protect
them from our own. … In dealing with this question, Mr.
President, I do not mean to enter upon any doubtful ground. I
shall advance no proposition ever seriously disputed in this
country till within twelve months. … If to think as I do in
regard to the interpretation of the Constitution; in regard to
the mandates of the moral law or the law of nations, to which
all men and all nations must render obedience; in regard to
the policies which are wisest for the conduct of the State, or
in regard to those facts of recent history in the light of
which we have acted or are to act hereafter, be treason, then
Washington was a traitor; then Jefferson was a traitor; then
Jackson was a traitor; then Franklin was a traitor; then
Sumner was a traitor; then Lincoln was a traitor; then Webster
was a traitor; then Clay was a traitor; then Corwin was a
traitor; then Kent was a traitor; then Seward was a traitor;
then McKinley, within two years, was a traitor; then the
Supreme Court of the United States has been in the past a nest
and hotbed of treason; then the people of the United States,
for more than a century, have been traitors to their own flag
and their own Constitution.
"'We are presented with an issue that can be clearly and

sharply stated as a question of constitutional power, a
question of international law, a question of justice and
righteousness, or a question of public expediency. This can be
stated clearly and sharply in the abstract, and it can be put
clearly and sharply by an illustration growing out of existing
facts.
"The constitutional question is: Has Congress the power, under

our Constitution, to hold in subjection unwilling vassal
States?
"The question of international law is: Can any nation

rightfully convey to another sovereignty over an unwilling
people who have thrown off its dominion, asserted their
independence, established a government of their own, over whom
it has at the time no practical control, from whose territory
it has been disseized, and which it is beyond its power to
deliver?
"The question of justice and righteousness is: Have we the

right to crush and hold under our feet an unwilling and
subject people whom we had treated as allies, whose
independence we are bound in good faith to respect, who had
established their own free government, and who had trusted us?
"The question of public expediency is: Is it for our advantage

to promote our trade at the cannon's mouth and at the point of
the bayonet?
"All these questions can be put in a way of practical

illustration by inquiring whether we ought to do what we have
done, are doing, and mean to do in the case of Cuba; or what
we have done, are doing, and some of you mean to do in the
case of the Philippine Islands.
"It does not seem to me to be worth while to state again at

length the constitutional argument which I have addressed to
the Senate heretofore. It has been encountered with eloquence,
with clearness and beauty of statement, and, I have no doubt,
with absolute sincerity by Senators who have spoken upon the
other side. But the issue between them and me can be summed up
in a sentence or two, and if, so stated, it can not be made
clear to any man's apprehension, I despair of making it clear
by any elaboration or amplification. I admit that the United
States may acquire and hold property, and may make rules and
regulations for its disposition. I admit that, like other
property, the United States may acquire and hold land. It may
acquire it by purchase. It may acquire it by treaty. It may
acquire it by conquest. And it may make rules and regulations
for its disposition and government, however it be acquired.
When there are inhabitants upon the land so acquired it may
make laws for their government. But the question between me
and the gentlemen on the other side is this: Is this
acquisition of territory, of land or other property, whether
gained by purchase, conquest, or treaty, a constitutional end
or only a means to a constitutional end? May you acquire,
hold, and govern territory or other property as an end for
which our Constitution was framed, or is it only a means
toward some other and further end? May you acquire, hold, and
govern property by conquest, treaty, or purchase for the sole
object of so holding and governing it, without the
consideration of any further constitutional purpose? Or must
you hold it for a constitutional purpose only, such as the
making of new States, the national defense and security, the
establishment of a seat of government, or the construction of
forts, harbors, and like works, which, of course, are
themselves for the national defense and security?
"I hold that this acquisition, holding and governing, can be

only a means for a constitutional end—the creation of new
States or some other of the constitutional purposes to which I
have adverted. And I maintain that you can no more hold and
govern territory than you can hold and manage cannon or fleets
for any other than a constitutional end; and I maintain that
the holding in subjection an alien people, governing them
against their will for any fancied advantage to them, is not
only not an end provided for by the Constitution, but is an
end prohibited therein. … It is an end which the generation
which framed the Constitution and the Declaration of
Independence declared was unrighteous and abhorrent. So, in my
opinion, we have no constitutional power to acquire territory
for the purpose of holding it in subjugation, in a state of
vassalage or serfdom, against the will of its people.
"It is to be noted just here that we have acquired no

territory or other property in the Philippine Islands, save at
few public buildings. By every other acquisition of territory
the United States became a great land owner. She owned the
public lands as she had owned the public lands in the
Northwest ceded to her by the old States. But you own nothing
in the Philippines. The people own their farms and dwellings
and cities. The religious orders own the rest. The Filipinos
desire to do what our English ancestors did in the old days
when England was Catholic. The laity feared that the Church
would engross all the land. So they passed their statute of
mortmain. You have either got to let the people of the
Philippine Islands settle this matter for themselves, or you
must take upon you the delicate duty of settling it for them.
{643}
Your purchase or conquest is a purchase or conquest of nothing
but sovereignty. It is a sovereignty over a people who are
never to be admitted to exercise it or to share it. In the
present case we have not, I repeat, bought any property. We
have undertaken to buy mere sovereignty. There were no public
lands in the Philippine Islands, the property of Spain, which
we have bought and paid for. The mountains of iron and the
nuggets of gold and the hemp-bearing fields—do you purpose to
strip the owners of their rightful title? We have undertaken
to buy allegiance, pure and simple. And allegiance is just
what the law of nations declares you can not buy. …
"I have been unable to find a single reputable authority more

than twelve months old for the power now claimed for Congress
to govern dependent nations or territories not expected to
become States. The contrary, until this war broke out, has
been taken as too clear for reasonable question. I content
myself with a few authorities. Among them are Daniel Webster,
William H. Seward, the Supreme Court of the United States,
James Madison.
"Daniel Webster said in the Senate, March 23, 1848: 'Arbitrary
governments may have territories and distant possessions,
because arbitrary governments may rule them by different laws
and different systems. We can do no such thing. They must be
of us, part of us, or else strangers. I think I see a course
adopted which is likely to turn the Constitution of the land
into a deformed monster, into a curse rather than a blessing;
in fact, a frame of an unequal government, not founded on
popular representation, not founded on equality, but on the
grossest inequality; and I think that this process will go on,
or that there is danger that it will go on, until this Union
shall fall to pieces. I resist it to-day and always! Whoever
falters or whoever flies, I continue the contest!'
"James Madison said in the Federalist: 'The object of the

Federal Constitution is to secure the union of the thirteen
primitive States, which we know to be practicable; and to add
to them such other States as may arise in their own bosoms, or
in their neighborhood, which we can not doubt will be
practicable.'
James Madison,
Federalist, Number 14.
"William H. Seward said: 'It is a remarkable feature of the

Constitution of the United States that its framers never
contemplated colonies, or provinces, or territories at all. On
the other hand, they contemplated States only, nothing less
than States, perfect States, equal States, as they are called
here, sovereign States. … There is reason—there is sound
political wisdom in this provision of the Constitution
excluding colonies, which are always subject to oppression,
and excluding provinces, which always tend to corrupt and
ultimately to break down the parent State.'
Seward's Works
Volume 1, page 122.
'By the Constitution of the United States, there are no

subjects, Every citizen of any one State is a free and equal
citizen of the United States. Again, by the Constitution of
the United States there are no permanent provinces or
dependencies.'
Seward's Works
Volume 4, page 167.
"The Supreme Court of the United States, in the case of

Fleming vs. Page, said: 'The genius and character of our
institutions are peaceful; and the power to declare war was
not conferred upon Congress for the purposes of aggression or
aggrandizement, but to enable the Government to vindicate by
arms, if it should become necessary, its own rights and the
rights of its citizens. A war, therefore, declared by
Congress, can never be presumed to be waged for the purpose of
conquest or the acquisition of territory; nor does the law
declaring the war imply an authority to the President to
enlarge the limits of the United States by subjugating the
enemy's country.'
"Our territories, so far, have all been places where Americans

would go to dwell as citizens, to establish American homes, to
obtain honorable employment, and to build a State. Will any
man go to the Philippine Islands to dwell, except to help
govern the people, or to make money by a temporary residence?
…
"When hostilities broke out, February 5, 1899, we had no

occupancy of and no title of any kind to any portion of the
Philippine territory, except the town and bay of Manila.
Everything else was in the peaceful possession of the
inhabitants. In such a condition of things, Mr. President,
international law speaks to us with its awful mandate. It
pronounces your proposed action sheer usurpation and robbery.
You have no better title, according to the law of nations, to
reduce this people to subjection than you have to subjugate
Mexico or Haiti or Belgium or Switzerland. This is the settled
doctrine, as declared by our own great masters of
jurisprudence. You have no right, according to tho law of
nations, to obtain by purchase or acquisition sovereignty over
a people which is not actually exercised by the country which
undertakes to convey it or yield it. We have not yet completed
the acquisition. But at the time we entered upon it, and at
the time of this alleged purchase, the people of the
Philippine Islands, as appears by General Otis's report, by
Admiral Dewey's report, and the reports of officers for whom
they vouched, held their entire territory, with the exception
of the single town of Manila. They had, as appears from these
reports, a full organized government. They had an army
fighting for independence, admirably disciplined, according to
the statement of zealous advocates of expansion.
"Why, Mr. President, is it credible that any American

statesman, that any American Senator, that any intelligent
American citizen anywhere, two years ago could have been found
to affirm that a proceeding like that of the Paris treaty
could give a just and valid title to sovereignty over a people
situated as were the people of those islands? A title of
Spain, originally by conquest, never submitted to nor admitted
by the people of the islands, with frequent insurrections at
different times for centuries, and then the yoke all thrown
off, a constitutional government, schools, colleges, churches,
universities, hospitals, town governments, a legislature, a
cabinet, courts, a code of laws, and the whole island occupied
and controlled by its people, with the single exception of one
city; with taxes lawfully levied and collected, with an army
and the beginning of a navy.
{644}
"And yet the Senate, the Congress enacted less than two years
ago that the people of Cuba—controlling peaceably no part of
their island, levying no taxes in any orderly or peaceable
way, with no administration of justice, no cabinet—not only of
right ought to be, but were, in fact, a free and independent
State. I did not give my assent to that declaration of fact. I
assented to the doctrine that they of right ought to be. But I
thought the statement of fact much calculated to embarrass the
Government of the United States, if it were bound by that
declaration; and it has been practically disregarded by the
Administration ever since. But the question now is a very
different one. You not only deny that the Filipinos are, but
you deny that they of right ought to be free and independent;
and you recognize Spain as entitled to sell to you the
sovereignty of an island where she was not at the time
occupying a foot of territory, where her soldiers were held
captives by the government of the island, a government to
which you had delivered over a large number of Spanish
prisoners to be held as captives. And yet you come here to-day
and say that they not only are not, but they of right ought
not to be free and independent; and when you are pressed you
answer us by talking about mountains of iron and nuggets of
gold, and trade with China.
"I affirm that you can not get by conquest, and you can not
get by purchase, according to the modern law of nations,
according to the law of nations as accepted and expounded by
the United States, sovereignty over a people, or title to a
territory, of which the power that undertakes to sell it or
the power from whom you undertake to wrest it has not the
actual possession and dominion. … You cannot buy a war. More
than this, you cannot buy a tyrant's claim to subject again an
oppressed people who have achieved their freedom. …
"Gentlemen tell us that the bill of the Senator from Wisconsin

is copied from that introduced in Jefferson's time for the
purchase of Louisiana. Do you claim that you propose to deal
with these people as Jefferson meant to deal with Louisiana?
You talk of Alaska, of Florida, of California; do you mean to
deal with the Philippines as we mean to deal with Alaska and
dealt with Florida or California?
"I have spoken of the Declaration of Independence as a solemn

affirmation of public law, but it is far more than that. It is
a solemn pledge of national faith and honor. It is a baptismal
vow. It is the bedrock of our republican institutions. It is,
as the Supreme Court declared, the soul and spirit of which
the Constitution is but the body and letter. It is the light
by which the Constitution must be read. … There is expansion
enough in it, but it is the expansion of freedom and not of
despotism; of life, not of death. Never was such growth in all
human history as that from the seed Thomas Jefferson planted.
The parable of the mustard seed, than which, as Edward Everett
said, 'the burning pen of inspiration, ranging heaven and
earth for a similitude, can find nothing more appropriate or
expressive to which to liken the Kingdom of God,' is repeated
again. 'Whereunto shall we liken it, or with what comparison
shall we compare it? It is like a grain of mustard seed,
which, when it is sown in the earth, is less than all the
seeds that be in the earth. But when it is sown, it groweth
up, and becometh greater than all herbs, and shooteth out
great branches, so that the fowls of the air may lodge under
the shadow of it.' This is the expansion of Thomas Jefferson.
It has covered the continent. It is on both the seas. It has
saved South America. It is revolutionizing Europe. It is the
expansion of freedom. It differs from your tinsel, pinchbeck,
pewter expansion as the growth of a healthy youth into a
strong man differs from the expansion of an anaconda when he
swallows his victim. Ours is the expansion of Thomas
Jefferson. Yours is the expansion of Aaron Burr. It is
destined to as short a life and to a like fate. …
"There are 1,200 islands in the Philippine group. They extend

as far as from Maine to Florida. They have a population
variously estimated at from 8,000,000 to 12,000,000. There are
wild tribes who never heard of Christ, and islands that never
heard of Spain. But among them are the people of the island of
Luzon, numbering 3,500,000, and the people of the Visayan
Islands, numbering 2,500,000 more. They are a Christian and
civilized people. They wrested their independence from Spain
and established a republic. Their rights are no more to be
affected by the few wild tribes in their own mountains or by
the dwellers in the other islands than the rights of our old
thirteen States were affected by the French in Canada, or the
Six Nations of New York, or the Cherokees of Georgia, or the
Indians west of the Mississippi. Twice our commanding
generals, by their own confession, assured these people of
their independence. Clearly and beyond all cavil we formed an
alliance with them. We expressly asked them to co-operate with
us. We handed over our prisoners to their keeping; we sought
their help in caring for our sick and wounded. We were told by
them again and again and again that they were fighting for
independence. Their purpose was as well known to our generals,
to the War Department, and to the President, as the fact that
they were in arms. We never undeceived them until the time
when hostilities were declared in 1899. The President declared
again and again that we had no title and claimed no right to
anything beyond the town of Manila. Hostilities were begun by
us at a place where we had no right to be, and were continued
by us in spite of Aguinaldo's disavowal and regret and offer
to withdraw to a line we should prescribe. If we crush that
republic, despoil that people of their freedom and
independence, and subject them to our rule, it will be a story
of shame and dishonor. …
"But we are told if we oppose the policy of our imperialistic

and expanding friends we are bound to suggest some policy of
our own as a substitute for theirs. We are asked what we would
do in this difficult emergency. It is a question not difficult
to answer. I for one am ready to answer it.
"1. I would declare now that we will not take these islands to
govern them against their will.
"2. I would reject a cession of sovereignty which implies that

sovereignty may be bought and sold and delivered without the
consent of the people. Spain had no rightful sovereignty over
the Philippine Islands. She could not rightfully sell it to
us. We could not rightfully buy it from her.
"3. I would require all foreign governments to keep out of

these islands.
"4. I would offer to the people of the Philippines our help in

maintaining order until they have a reasonable opportunity to
establish a government of their own.
{645}
"5. I would aid them by advice, if they desire it, to set up a

free and independent government.
"6. I would invite all the great powers of Europe to unite in

an agreement that that independence shall not be interfered
with by us, by themselves, or by any one of them with the
consent of the others. As to this I am not so sure. I should
like quite as well to tell them it is not to be done whether
they consent or not.
"7. I would declare that the United States will enforce the
same doctrine as applicable to the Philippines that we
declared as to Mexico and Haiti and the South American
Republics. It is true that the Monroe Doctrine, a doctrine
based largely on our regard for our own interests, is not
applicable either in terms or in principle to a distant
Asiatic territory. But, undoubtedly, having driven out Spain,
we are bound, and have the right, to secure to the people we
have liberated an opportunity, undisturbed and in peace, to

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Kanski’s Clinical Ophthalmology.

First edition 1984

Content Strategist: Kayla Wolfe

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

Dedication.......................................................................viii Cystic lesions.................................................................131

8 Corneal and Refractive Surgery........ 275 Investigation..................................................................429

11 Glaucoma........................................ 345 13 Retinal Vascular Disease.................. 495

Microcystic macular oedema..........................................604 19 Neuro-ophthalmology....................... 745

Preface to the Ninth Edition

5-FU 5-fluorouracil MMC mitomycin C

PS posterior synechiae SJS Stevens–Johnson syndrome

• Pinhole VA: a pinhole (PH) aperture compensates for the

Very poor visual acuity

Fig. 1.2 Pinhole

readily be able to determine the direction from which the light

Amsler grid • Chart 5 consists of horizontal lines and is designed to detect

Fig. 1.8 Amsler grid superimposed on the macula. The central

Fig. 1.10 Amsler charts 2–7

Light brightness comparison test

• The Hardy–Rand–Rittler test is similar to the Ishihara, but

Plus lens test

Fig. 1.15 (A) Hill of vision; (B) isopter plot

Fig. 1.17 Humphrey perimeter and printout

Fig. 1.18 Octopus perimeter and printout

over 33%. In patients who consistently fail to achieve good reli-

Testing patterns indication of disease severity rather than unreliability. The

Single Field Analysis Eye: Right

Total Deviation Pattern Deviation

© 2010 Carl Zeiss Meditec

Fig. 1.20 Humphrey perimeter – SITA-Fast printout (see text)

Single Field Analysis Eye: Right

Single Field Analysis Eye: Right

High-sensitivity field modalities

the latter being suitable for detailed assessment and monitor-

Expert exam #7693 [4-2 strategy] / Duration: 8′ 38″

Generated by MAIA s/n 4003

Fig. 1.25 MAIA perimetry and printout

Scleral scatter TIP A direct ophthalmoscope can be used at the bedside

Fig. 1.27 Technique of slit lamp biomicroscopy of the anterior

of fine epithelial and endothelial changes, such as epithelial cysts,

Fig. 1.30 Technique of direct ophthalmoscopy (see text)

• The ‘O’ on the illuminated lens dial of the ophthalmoscope

Fig. 1.33 (A) U-tear left of 12 o’clock and an island of lattice

Fig. 1.34 Preparation of the slit lamp for fundus examination.

○ When viewing different positions of the peripheral retina,

Fig. 1.38 (A) Principles of indirect ophthalmoscopy; (B) condensing lenses

Fig. 1.40 Appearance of retinal breaks in detached retina. (A)

Fig. 1.43 Goldmann tonometry. (A) Physical principles; (B) tonometer

patients and replaced regularly in accordance with the manufac-

Ocular response analyser and GONIOSCOPY

Applanation Signal Pressure (air pulse)

“In” Signal dslope1 “Out” Signal

Fig. 1.47 Corneal hysteresis as measured by the Ocular

• Other means of angle assessment, such as anterior segment

TIP Gonioscopy is an indispensable technique that allows

TIP Indentation gonioscopy is a useful technique to

Indentation (dynamic, compression) gonioscopy

○ Indentation is performed by gently pressing the lens pos-

The question of the ratification of all these treaties was

UNITED STATES OF AMERICA: A. D. 1900.

See (in this volume)

UNITED STATES OF AMERICA: A. D. 1900.

See (in this volume)