C L I N I C A L A N D E X P E R I M E N TA L
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Clin Exp Optom 2018; 101: 618–619
Eyelid, Conjunctival, and
Orbital Tumors. An Atlas
and Textbook, third edition
Jerry A Shields, Carol L Shields
Wolters Kluwer 2015, 824 pages, $456.00
Reviewed by: MARK ROTH OAM
Melbourne, Australia
E-mail: mark@eyecare.net.au
DOI:10.1111/cxo.12618
Warning. Do not read
this book at night. The
contents and images
can induce nocturnal
clinical self-doubt and
ophthalmic-related hal-
lucinations. Recurrent,
mental images of pre-
vious patients and
their diagnoses can
return. That patient with the conjunctival
lump I examined. Was that an angry pingue-
cula or a conjunctival intraepithelial neopla-
sia? The sun-loving retiree with yet another
benign eyelid seborrheic keratosis or was it
masquerading as squamous cell carcinoma?
It is often difficult to differentiate clini-
cally between the benign and malignant
lesions. A symphysis between normal and
abnormal tissue can be a diagnostic
dilemma. To obfuscate and perplex us fur-
ther, there are the atypical presentations
that confute any claim of how straightfor-
ward it is to diagnose a lesion. Additionally,
like many ophthalmic presentations, the
diagnosis can be transitive. For a very expe-
rienced clinician or an ocular oncology
expert, the diagnosis is usually painless. No
sweat. But frankly, for a mere general oph-
thalmologist or an optometrist, would that
it were so simple.
For example, in primary eye care we are
often exposed to many degenerative actinic
lesions which can simulate a conjunctival
neoplasm, such as pinguecula and pterygium.
Clinical and Experimental Optometry 101.4 July 2018
618
Book review
They can sometimes be atypical and simulate
a malignant conjunctival neoplasm, particu-
larly squamous cell carcinoma. Look at the
comparative differential diagnosis images in
this book. It suddenly challenges our clinical
assessment and thought processes to be more
analytical, methodical and alert for the next
patient. This textbook and atlas in either
hard cover or available as an e-book becomes
a clinical companion and fosters us to
become more experienced clinicians.
Shields and Shields master the mammoth
topic of tumours in and around the eye. In
this updated and revised third edition,
brought thoroughly up to date with recent
clinical and scientific innovations, world-
renowned authorities Dr Jerry Shields and
Dr Carol Shields from the Wills Eye Hospital
provide outstanding guidance on recogni-
tion, evaluation and treatment of ocular
tumours, highlighted by more than 3,000
stunning photographs and surgical drawings.
The textbook encompasses a clinically
logical approach to this vast topic and is
divided into three parts. ‘Tumours of the
eyelids’ (15 chapters), ‘Tumours of the
conjunctiva’ (10 chapters) and ‘Tumours
of the orbit’ (16 chapters). This is a logical
clinical order as one would usually think to
examine the eyelids first. Thereafter, the
chapter information is partitioned into
general considerations, clinical features,
pathology and diagnosis. The study and
perusal experience is effortless as the
reader is not swamped with unremitting
text. Each disease is presented as an entity
in an easy to follow format: a concise
description with references on the left-
hand page and six illustrations on the
right-hand page.
The images depict in precise photographic
detail the gross and microscopic features that
distinguish each type of lesion. Professional
drawings and intraoperative photographs
demonstrate key surgical principles and pro-
cedures as a vital educational tool for oph-
thalmology registrars. Additionally, there are
panoramic, surgical images and diagnostic
testing images from multiple modalities, and
updated, high-resolution magnetic reso-
nance imaging (MRI) and computed tomog-
raphy (CT) scans.
As well as a synoptic view of disease sub-
groups, there are multiple tables that con-
dense relevant information. As an exam-
ple, the differential diagnosis of pigmented
conjunctival and epibulbar lesions would
be a daily part of primary eye care. The rel-
evant table on this topic lists the possible
differential diagnoses such as nevus, pri-
mary acquired melanosis, melanoma et
cetera. The table then associates the key
clinical features of the examination such as
anatomic location, colour, depth, margins,
laterality and other features, and provides
evidenced-based prognosis for progression.
These tables are extremely functional.
One of the advantages of a new or
updated textbook is that it should provide a
scholarly and comprehensive overview of
new and advancing clinical information.
Shields and Shields do not disappoint. They
cover new information on evolving condi-
tions such as immunoglobulin G4 orbital
inflammatory disease, solitary fibrous
tumour of the orbit, and lymphoid prolifera-
tions of the orbit, conjunctiva and globe.
New methods of non-surgical therapy such
as topical chemotherapy, intravenous che-
motherapy, immunotherapy and biological
therapy with rituximab for lymphoma and
other systemic conditions, are also discussed.
The new information on classification of var-
ious tumours is of increasing importance.
When further reading and/or research is
required, the presentation of references at
the end of a chapter can often seem inac-
cessible and mind-numbing to peruse. In
Shields and Shields the references are pre-
sented with purpose. They are astutely
divided into sub-headings such as reviews,
imaging, management, histopathology and
case reports.
With the print edition, there is automatic
access to the interactive e-book edition,
which can be downloaded to your tablet
(denomination of choice) or smartphone,
or accessed online. The key word here is
© 2017 Optometry Australia

interactive. It is not just a facsimile or a
PDF version of the printed textbook. The
e-book turns this reference into an authori-
tative, gold standard lumps and bumps
search engine. Forget about Dr Google.
Are you going to trust Dr Google with a
lump on your patient’s eye?
The interactive features include the com-
plete book content with enhanced naviga-
tion and powerful search applications. As a
test run, I entered ‘papilloma’ into the
search engine which returned 62 matches.
They could be sub-divided into relevance,
content order and type. Clicking on the
© 2017 Optometry Australia
clinical pictures unfolded images in amaz-
ing resolution on the iPad. I could make
notes, save highlights or create a bookmark
for future use. Each individual will have a
preference over using a textbook as
opposed to its electronic, digital form or
you can take an egalitarian perspective like
me, and use both modalities.
Professor Frederick A. Jakobiec, in his
foreword to this book, remarks ‘What makes
this textbook a distinctively authoritative
resource is the combination of the unri-
valled clinical experience of Carol and Jerry
Shields as practising clinical ophthalmic
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Book Review
oncologists and their intimate familiarity
with the appropriate literature.’ He is cor-
rect and when this vast topic is complemen-
ted by an intelligible and accessible format,
it reaffirms its status as the gold standard in
this area. This textbook and atlas should be
mandatory for optometrists and ophthalmol-
ogists in training. For practising clinicians, it
sits with just a few other books that can be
deemed as classic ophthalmic textbooks in
terms of stature, importance and value.
For outstanding information and visual
clarity in ocular tumour diagnosis…noth-
ing else comes close.
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