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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

patients (uncontrolled increase in IOP, severe proptosis, retinal ischemia, optic neu-
ropathy, severe bruit, involvement of the cortical veins).
• Treatment for all cases of carotid–cavernous fistula has been advocated but is
controversial.
Prognosis Up to 70% of dural sinus fistulas may resolve spontaneously.
Infections
Preseptal Cellulitis
Definition Infection of the eyelids not extending posterior to the orbital septum. The
globe and orbit are not involved.
Etiology Usually follows periorbital trauma or dermal infection. Suspect Staphylococ-
cus aureus in traumatic cases and Haemophilus influenzae (nontypeable) in children
5 years old.
Symptoms Eyelid swelling, redness, ptosis, and pain; low-grade fever.
Signs Eyelid erythema, edema, ptosis, and warmth (may be quite dramatic); visual
acuity is normal; full ocular motility without pain; no proptosis; the conjunctiva and
sclera appear uninflamed; an inconspicuous lid wound may be visible; an abscess may
be present.
Differential Diagnosis Orbital cellulitis, idiopathic orbital inflammation (IOI), dacryoad-
enitis, dacryocystitis, conjunctivitis, and trauma.
Lid erythema Lid edema Erythema
Fig 1.10 • Mild preseptal cellulitis with right Fig 1.11 • Moderate preseptal cellulitis
eyelid erythema in a young child. with left eyelid edema and erythema.
Evaluation
• Complete ophthalmic history with attention to trauma, sinus disease, recent dental work
or infections, history of diabetes or immunosuppression.
• Complete eye exam with attention to visual acuity, color vision, pupils, motility, exoph-
thalmometry, lids, conjunctiva, and sclera.
• Check vital signs, head and neck lymph nodes, meningeal signs (nuchal rigidity), and
sensorium.
• Lab tests: Complete blood count (CBC) with differential, blood cultures; wound culture
if present.
• Orbital and sinus CT scan in the absence of trauma or in the presence of orbital signs
to look for orbital extension and paranasal sinus opacification.
Another random document with
no related content on Scribd:
“Is Miss Comfort being evicted from house by your order?
Public opinion in arms. Answer.”
“Huh,” said Ned, “public opinion can’t be ‘in arms,’ you silly
chump.”
“That’s only two words less than mine,” said Bob.
“Well, we’ll see if we can’t get it into ten,” replied Laurie
untroubledly. “Now then!” He took up his pencil again. “We might say
‘Comfort’ instead of ‘Miss Comfort,’ but it doesn’t sound quite
respectful.”
“Leave out ‘from house,’” suggested Bob. “He will understand that
she isn’t being evicted from the stable!”
“That’s so! ‘Is Miss Comfort being evicted by your order? Public
opinion—er—’”
“‘Against it,’” offered Ned.
“‘Opposed,’” said Bob.
“I’ve got it!” exclaimed Laurie, erasing and starting a new draft.
“How’s this? ‘Have you authorized eviction aged sister-in-law?
Orstead indignant. Answer immediately.’ That ought to fetch him!
Only ten words, too!”
“How about sister-in-law?” asked Bob. “Will they call it one word or
three?”
“One, of course. Or ‘aged relative’ might do just as well. ‘Orstead
indignant’ will give him a jolt, I’ll bet!”
“What are you going to sign it?” asked Ned anxiously.
Laurie hadn’t thought of that. Bob suggested “Friend,” but Ned
reminded him that if they expected to get a reply they’d have to give
more of an address than that. Laurie took a deep breath and leaped
the Rubicon. He signed “Laurence S. Turner” boldly and drew a
heavy mark under it for emphasis. Ned shook his head doubtfully,
but Bob was thrilled.
“He will probably think you’re one of the town’s leading citizens,”
he chuckled.
“Well, so I am,” answered Laurie, “in this affair. Now we’ll go down
and get it off at night-rates.”
“Say,” said Ned, “we’re a set of dumb-bells! We could have sent a
night-letter of fifty words for the same price.”
“That’s so,” admitted Laurie. “I think a night-letter costs a little
more, though, doesn’t it? Anyway, this is more—more succinct. It
sounds more businesslike. What do you think?”
They agreed that it did, and presently, a fresh copy of the
message in his pocket, Laurie led the way from the room, followed
by the others. The languid youth who accepted the telegram at the
office appeared to hesitate over “sister-in-law,” but he made no
objection to its inclusion as one word, and he brightened perceptibly
as the sense of the message percolated in his mind. He looked
curiously at the three boys, re-read the message, and then shook his
head incredulously.
“Sick ’em, Prince,” he murmured.
The cost of the telegram was less than Laurie had dared hope it
would be, and in the first moment of relief he magnanimously offered
to pay a full half. Fortunately for his purse, though, the others
insisted on sharing equally, and, the second moment having now
arrived, Laurie allowed them to do it.
Returning to school, Ned was preyed on by doubts. Now that the
telegram was an accomplished fact, he spoke dismally of the laws
concerning libel. When Laurie refused to be concerned he wanted to
know what they were to do if Mr. Goupil wired back that he had
authorized Miss Comfort’s eviction. Laurie wasn’t prepared to
answer that question. “We’ll cross that bridge when we come to it,”
he replied with dignity.
As a matter of fact, Laurie didn’t intend to do anything in such a
case. He had saved his face, and that was sufficient. After this he
meant to refrain from too much talking and keep out of affairs that
didn’t concern him. Unfortunately, as he was to discover, it is
frequently easier to start than it is to stop, and to make good
resolutions than to follow them!
As he secretly considered the episode ended, Laurie would have
put Miss Comfort and Mr. A. G. Goupil completely out of his mind for
the rest of the evening if Ned hadn’t insisted on speculating as to the
effect of the telegram on the addressee. Ned just couldn’t seem to let
the subject alone. Laurie became very much bored, and when Ned,
later, came out with the brilliant suggestion of having Miss Comfort
added to the school faculty as professor of pastry Laurie threw a
book at him.
The following morning Kewpie was absolutely exasperating when
they met beside the gymnasium. He had brought his precious book
with him and insisted on pausing between pitches to study diagrams
and directions, occasioning long waits and leaving Laurie with
nothing to do save indulge in feeble sarcasms that affected Kewpie
no whit. Kewpie was struggling with what he earnestly told Laurie
was an out-drop. Laurie sarcastically replied that Kewpie was at
liberty to call it anything he pleased, out-drop, floater, in-shoot, or
fade-away; they all looked the same to him when Kewpie pitched
’em! Kewpie looked almost hurt, and Laurie recalled Polly’s
injunction not to discourage the aspirant for pitching honors, and so
presently told Kewpie that one of his offerings “looked pretty good.”
After that Kewpie cheered up a lot and pitched a ball high over the
back-stop.
All that day Laurie looked for a telegram. It was, he thought,
inconceivable that the Goop guy, as he privately called Mr. A. G.
Goupil, should delay in answering such a communication, and when,
after school was over for the day, no telegram had been delivered at
East Hall, he hurried down to the telegraph office and made
inquiries. The man in charge, who was not the one who had been on
duty the evening before, went to a deal of trouble before informing
Laurie that no message had been received. Going back, Laurie
pondered. It might mean that Mr. Goupil had chosen to communicate
with his lawyer instead of him, Laurie. Or it might mean that Mr.
Goupil was taking time to consider the matter. Laurie dismissed the
business from his mind, and, although well ahead of time, went over
to the gymnasium and leisurely donned his baseball togs. There had
been talk of getting out on the field to-day, but the turf was still a little
too soft.
In the baseball cage four other early arrivals were on hand; Nate
Beedle, Hillman’s first-choice pitcher, Captain Dave Brewster, third
baseman, Gordon Simkins, in-field candidate, and Elkins Thurston.
The last two were passing, while Beedle and Brewster sat on the
floor with their backs against the wire.
“Hello, Nod!” greeted Nate. “Hear you’ve started a kindergarten for
pitchers, sonny.”
Nate was a nice chap, and Nod didn’t mind being “ragged” by him
a bit. “Yes, that’s so,” Laurie agreed. “Want to join?”
The others laughed; all save Elk. Elk, tossing the ball back to
Simkins, sneered, “The way I got it, Proudtree’s trying to teach
Turner how to catch!”
“Fact is,” replied Laurie, “it’s sort of mutual. Kewpie’s improving his
pitching, and I’m improving my catching.”
“Can he pitch at all?” asked Dave Brewster.
“Kewpie? Well, he hasn’t much just now, but—”
“But you’re teaching him the trick, eh?” jeered Elk. “Say, Nate,
you’d better watch out or you’ll lose your job.”
Nate laughed good-naturedly. “That’s right. I’ll say one thing,
though. If Kewpie could pitch the way he can play center I’d be
worried. Does he think he can get on the squad, Nod?”
“Guess he’d like to.”
“He’s got a swell chance,” said Elk.
“Oh, I don’t know,” answered Laurie. “They took you on.”
“Is that so? Don’t get fresh, youngster. I suppose you think you’ve
got such a pull with Pinky that he’ll take on any fellow you
recommend. Say, Nate, can’t you just see Proudtree running
bases?” And Elk laughed vociferously.
Laurie, just at present inclined to resent anything that Elk said,
merely on general principles, found cause for added resentment
now. Kewpie was both friend and pupil, and consequently
disparagement of Kewpie was disparagement of him. Simkins’s
remark that Kewpie had shown pretty good speed on the football
field was cut into by Laurie with:
“He isn’t out to become a sprinter, Elk. He’s going to be a pitcher.
You don’t expect a pitcher to be much of a hand on the bases. As for
his chance of getting on the squad, well, when I get through with him
I guess he can have a place if he wants it.”
“When you— Oh, my sainted aunt!” cried Elk. “When you get
through with him! What do you know about pitching, I’d like to know?
You’re a swell teacher, you are! You never caught behind the plate
until two or three weeks ago.”
“What of it? That doesn’t prevent me from knowing a natural-born
pitcher when I see him. And if—”
“Natural-born pitcher! Kewpie Proudtree? Don’t make me laugh! I’ll
bet he can’t pitch a straight ball!”
“Can’t, eh? Listen, Elk. Kewpie’s a better pitcher right now than
you are a catcher. If he wasn’t I wouldn’t bother with him.”
“Oh, piffle! He can’t pitch and you can’t teach him, kid. And as for
catching, if I dropped every ball that comes over I wouldn’t be
shooting my mouth off, you fresh guy!”
“I get my glove on ’em, and that’s more than you do, Elk, old son.
And if you think I don’t know what I’m talking about when I say that
Kewpie’s got the making of a pitcher, why, you just keep your eyes
open.”
“Sure! You’re going to have him on the squad next week, I
suppose!”
“No, not next week, but I’ll tell you one thing. He will be pitching for
this team before the season’s over!”
“What!” It was a chorus of blank incredulity. Then there was
laughter, through which struggled Nate’s voice saying, “Nod, you’re
as crazy as a coot!” The burst of merriment acted on Laurie
somewhat like a wet sponge on the face of a sleeper. He awoke
suddenly to the enormity of his assertion, and caution urged him to
prompt retraction, or, at least, compromise. But there was Elk
Thurston grinning and sneering, his very attitude a challenge. Laurie
swallowed hard and summoned a smile of careless ease to his
countenance.
“You heard what I said,” he remarked calmly.
Then Coach Mulford came in, and the die was cast. Laurie waved
a nonchalant hand to Dave Brewster. In appearance he looked as
care-free and untroubled as any person there, but to himself he was
saying bitterly, “There, you poor fish, you’ve been and gone and
done it again!”
CHAPTER VII
POLLY APPROVES
P ractice over, Laurie set out to find Ned. He was very low in his
mind, was Laurie, and he wanted comfort in the worst way. But
Ned wasn’t in the room. The door of No. 15, across the corridor, was
half ajar, and through it issued the voice of Kewpie. “That you, Nid?”
inquired Kewpie. “Say, come in here. I’ve—”
“No!” replied Laurie emphatically as he hurried, toward the stairs.
Kewpie Proudtree was the last person in the whole world he wanted
to hold converse with just then. In fact, he wasn’t sure that he would
be able to control himself in Kewpie’s presence. Murder, he reflected
gloomily, had been committed for less cause than he had!
He set out toward the Widow Deane’s, going the long way around,
since he had no heart for Bob Starling’s questions and surmises
regarding Mr. A. G. Goupil. He had so thoroughly forgotten that flinty-
hearted person that he had not even looked on the table in No. 16 to
see if the telegram had arrived, and only the thought of encountering
Bob had reminded him of it. Turning into Garden Street, he heard
some one call: “Oh, Ned! Oo-ee!” It was no new thing to be mistaken
for Ned. During the first two months, or thereabouts, of their stay at
Hillman’s, he and Ned had been daily, hourly, almost constantly
mistaken one for the other, and even to this moment such mistakes
were not uncommon, which, considering the fact that the twins were
as alike as two peas, was not unnatural. He wasn’t Ned, but he
turned to see who was calling. It proved to be Mae Ferrand. She was
on the opposite side of the street waving to him. Laurie crossed with
little enthusiasm.
“Hello,” he said. “I’m looking for him, too, Mae.”
“Oh, it’s Laurie!” she exclaimed. “I do wish you boys wouldn’t
dress just alike!”
“We don’t,” said Laurie somberly. “He’s wearing brown stockings,
and I’m wearing green.” He looked down at them. “Sort of green,
anyway.”
“Just as though any one could tell you by that,” laughed Mae. “Are
you going to Polly’s?”
Laurie acknowledged that he was, and they went on together.
“Isn’t it too bad about that poor, dear little Miss Comfort?” asked
Mae. “Polly told you, didn’t she?”
Laurie nodded. “Yes,” he answered. “Yes, it is too bad. At her age,
too. Eighty-something, isn’t she?”
“Why, no, of course not! The idea! She can’t be a day over sixty-
five.”
“Oh!” Laurie sounded a trifle disappointed. “Well, that’s different,
isn’t it?”
“Yes, I suppose it is,” agreed Mae without, however, quite getting
his point of view, “but it doesn’t make it much easier for her, I guess.”
“N-no.” Laurie was acquiring something close to distaste for the
subject. “Well, something may turn up,” he added vaguely, “before
the first of the month.”
“I hope so,” said Mae. But she didn’t sound hopeful. Laurie was
glad when she changed the subject with her next remark, although
he could have chosen a more welcome one: “Polly says that the—
the conspiracy is working just beautifully, Laurie. She says that
Kewpie Proudtree is quite like another boy the last day or two. Is he
doing any better with his pitching?”
Laurie turned and regarded her balefully. “Better? No, and he
never will,” he answered disgustedly. “Why that poor prune couldn’t
pitch ball if—if—” He stopped, suddenly recalling his statements
made in the cage a scant hour and a half since. He felt rather
confused. Mae nodded sympathetically.
“Well, I think it’s darling of you to take so much trouble with him,”
she said. “Sometimes I think that friendship means so much more
with boys than it does with girls.”
“Friendship!” blurted Laurie.
“Why, yes, don’t you call it friendship? Every one knows what
great pals you and Kewpie have been all winter. I think it’s perfectly
lovely!”
“Huh,” growled Laurie.
“For goodness’ sake, what is the matter with you to-day?” asked
Mae concernedly. “You’re—you’re awfully funny!”
Laurie summoned a mirthless and hollow laugh. “I’m all right,” he
replied, “only I—I’ve got a lot of things to think of just now, and—”
Further explanation was spared him, for just then they reached the
shop and Laurie opened the door with a sigh of relief. Ned was
there, and so were Polly and Mrs. Deane. Laurie morosely declined
the offer of a soda, slung himself to a counter, met the surprised and
mildly disapproving gaze of the Widow, and got down again. The
talk, interrupted by their arrival, began once more. Of course it was
about Miss Comfort. (Mrs. Deane had been to see her that
forenoon.) She hadn’t heard again from the lawyer or from her
brother-in-law, and she had begun to pack her things. Laurie felt
Ned’s gaze on him and turned. Ned’s look was inquiring. Laurie
didn’t know what he meant by it, and frowned his perplexity. Ned
worked around to him and whispered in his ear.
“Did it come? Did you get it?” he asked.
“Get what?”
“Shut up! The telegram, you chump!”
“Oh! No, I don’t think so.”
“You don’t think—” began Ned in impatient sibilation.
“What are you two whispering about?” inquired Polly.
“Oh, nothing,” answered Ned airily.
“Ned Turner, don’t tell fibs,” said Polly severely. “There’s
something going on that we don’t know about, Mae. Mama’s in on it,
too. I can tell. She can no more hide a secret than she can fly. And I
don’t think,” ended Polly with deep pathos, “that it’s very nice of you
to have a secret from Mae and me.”
Ned looked concerned and apologetic. He viewed Laurie
inquiringly. “Shall we tell them?” he asked. Laurie shrugged.
“I don’t care,” he answered moodily.
“Oh, of course, if you don’t want us to know,” began Polly very
haughtily. Laurie managed a most winning smile.
“Of course I do,” he assured her. “I—I was going to tell you,
anyhow.”
Polly didn’t look wholly convinced, but, “Well?” she said. “Go on
and tell, then.” Laurie waved toward Ned.
“Let him do it,” he said.
So Ned confessed about the telegram to Mr. Goupil, taking rather
more credit to himself than, perhaps, the facts warranted—
something that might have brought a protest from Laurie had that
youth been any longer interested in what to him seemed now a
closed incident. Polly exclaimed applaudingly; Mae clapped her
hands; and Mrs. Deane, proud of the fact that for once in her life she
had managed, if only for a few short hours, to keep something secret
from her daughter, beamed. Then praise was fairly lavished on
Laurie and Ned, the former receiving the lion’s share, since the
brilliant idea had been born in his stupendous brain. Laurie looked
decidedly bored, and the feminine portion of the assembly credited
his expression to modesty.
“Oh, Laurie,” exclaimed Polly, “I think you’re perfectly wonderful!
Don’t you, Mae?”
Mae was enthusiastically affirmative.
“It was just the one absolutely practical thing to do,” continued
Polly. “And I don’t see how Mr. Gou—Gou—whatever his name is—
will dare to go on with his disgusting plan, do you? If that telegram
doesn’t make him perfectly ashamed of himself, it—it—well, it ought
to!”
“Sort of funny, though,” said Ned, “that he hasn’t answered before
this. If he doesn’t answer at all—well, do you think we ought to send
him another, Laurie?”
Laurie shook his head. “No good,” he said briefly.
“Oh, but he will answer it,” declared Polly. “Why, he’d simply have
to! His own self-respect would—would demand it!”
“Of course!” agreed Mae. “Maybe there’s a telegram waiting for
you now, Laurie.”
“That’s so.” Laurie spoke with more animation. “Let’s go and see,
Ned.”
“I didn’t say anything about it to Miss Comfort,” observed Mrs.
Deane in the tone of one asking commendation.
“Oh, no, you mustn’t,” said Polly. “If—if nothing came of it, after all,
she’d be too disappointed. Laurie, if Mr. Whatshisname still insists on
—on things going ahead as they are going, what will you do then?”
“Me?” Laurie regarded her unemotionally. Then he shrugged.
“Why, I guess that would settle it, wouldn’t it? Isn’t anything more I
could do, is there? Or any of us?”
“Oh, Laurie!” exclaimed Mae in vast disappointment. Polly, though,
only laughed.
“Don’t be silly, Mae,” she said. “Of course he’s only fooling. You
ought to know Laurie well enough to know that he isn’t going to give
up as easily as all that. I’ll just bet you anything he knows this very
minute what he means to do. Only he doesn’t want to tell us yet.”
“I don’t, either,” protested Laurie vehemently. “Look here, this isn’t
any affair of mine, and—and—”
“Just what I told him,” said Mrs. Deane agreeably. “I think he’s
been very nice to take such an interest and so much trouble, but I’m
sure he can’t be expected to do any more, Polly.”
Polly smiled serenely. She shared the smile between her mother
and a disquieted Laurie. Then she slipped an arm around Mae and
gave her a squeeze. “We know, don’t we, Mae?” she asked.
Laurie stared helplessly for a moment. Then he seized Ned by the
arm and dragged him toward the door. “Come on,” he said
despairingly. “Come on home!”
“Say,” demanded Ned, once they were on the street, “what in the
world’s the matter with you?”
“Matter with me?” repeated Laurie a trifle wildly. “The matter with
me is that I talk too blamed much! That’s the matter with me! The
matter with me—”
“Yes, yes,” agreed Ned soothingly, “yes, yes, old-timer. But what’s
the present difficulty? Of course they don’t really expect us to find a
home for Miss Comfort, if that’s what’s biting you.”
“Well, I should hope not! But—but, listen, Neddie. Do you think
Kewpie knows enough about pitching to ever amount to a hill of
beans? Do you think that, if he practised like anything all spring, he
could—could get on the team?”
“Why, no, of course not,” replied Ned calmly. “Haven’t you said so
yourself a dozen times?”
“Yes. Yes, and now I’ve gone and said he could!”
“Who could? Could what?”
“Kewpie. Be a pitcher and get on the team.”
“Are you plumb loco?” asked Ned in astonishment.
“No.” Laurie shook his head mournfully. “No, it isn’t that. I—I just
talk too blamed much.”
“Well, who have you been talking to now? Get it off your chest,
partner.”
So Laurie told him. The narrative lasted until they had reached
their room, and after, and when, at last, Laurie ended his doleful tale
Ned looked at him in silence for a long, long moment. Finally, “You
half-portion of nothing!” breathed Ned pityingly. “You—you poor fish!”
“Well, what could I do?” asked Laurie. “I wasn’t going to let Elk
make me look like a fool.”
“Huh! What do you think you look like now?”
Laurie began to prepare for supper without replying. He acted as if
chastened and worried. Ned watched him for a minute in frowning
perplexity. At last the frown vanished. “Well, what are you going to
do?” he asked.
Laurie shrugged. “How do I know? I did think that maybe
somehow or other Kewpie could learn to pitch, but I guess you’re
right about him. He never could.”
“No, but he’s got to!” was Ned’s astounding answer. “We’ve got to
see that he does, Laurie. You’ve said you were going to make a
pitcher of him—”
“I didn’t actually say I was going to do it.”
“Well, some one. You’ve said he was going to pitch on the team
this season. You might as well have said that I was going to be made
President. But you said it and, by heck, you’ve got to make good or
perish in the attempt. The honor of the Turners—”
“Looks to me like the honor of the Turners is going to get an awful
jolt,” murmured Laurie despondently. “Making a pitcher out of Kewpie
— Gee, Ned, the fellow who made a purse out of a pig’s ear had a
snap!”
“It’s got to be done,” reiterated Ned firmly. “After supper we’ll
decide how. Hold on, though! We don’t actually have to have him a
real pitcher, son. All we have to do is to get him on the team just
once, even if it’s only for two minutes, don’t you see?” Ned’s tone
was triumphant.
“Yes, but how can we do that if he doesn’t know how to pitch? I
don’t see that that’s going to make it any easier.”
“Maybe, maybe not. Anyhow, it helps. There might be some way of
faking him on there. Well, we’ve got nearly three months to do it in,
Laurie, so cheer up. Let’s go and eat. A truce to all trouble! The bell
rings for supper—”
“Of cold meat as chewy as Indian rupper!” completed Laurie.
“Quitter!” laughed Ned, pushing him through the door.
CHAPTER VIII
KEWPIE AGREES
“K ewpie!”
“Yeah?”
“Come on over here!” It was Laurie calling from the doorway of No.
16. The door across the corridor opened, and the somewhat sleepy
countenance of Kewpie peered forth inquiringly. The hour was 9:40.
“What do you want?” asked Kewpie. “I’m just going to bed. I’m
tired, Nod.”
“You come over here,” was the stern, inexorable answer. “Ned and
I want to talk to you.”
“Well, gosh, I tell you I’m sleepy,” muttered Kewpie, but he crossed
the hall and followed Laurie into No. 16. Kewpie was chastely clad in
a suit of out-size pajamas, which were white with a broad blue stripe
at short intervals. Kewpie in night attire looked about half again as
large as he did when more or less confined in street costume. Laurie
thrust the visitor into the arm-chair. Kewpie subsided with a long sigh
and blinked wonderingly, first at Nid and then at the determined Nod.
Then he placed a large and pudgy hand in the neighborhood of his
face and yawned cavernously.
“What’s the matter with you fellows?” he inquired. “What are you
looking at me like that for?”
“Kewpie,” said Ned, “do you honestly think you can ever learn to
pitch?”
“What!” Kewpie woke up a trifle. “I can pitch right now. Who says I
can’t?”
“I do,” said Laurie emphatically. “You can pitch now just about as
well as a toad can fly. What we want to know is whether, if you
practise hard and keep at it, you can learn.”
Kewpie looked hurt. “Say, what’s the matter with my drop-ball?” he
asked indignantly. “I suppose you think you could hit that, eh? Well,
I’d like to see you try it.”
“Cut out the bunk, Kewpie,” said Ned sternly. “We’re talking
business now. You know plaguey well you wouldn’t last ten seconds
against a batter, the way you’re pitching now. Laurie says you’ve got
a fair drop, when you get it right, and that’s all you have got. You
haven’t—haven’t— What is it he hasn’t got, Laurie?”
“He hasn’t got anything except that drop. He can’t pitch a straight
ball with any speed—”
“I don’t want to. Any one can hit the fast ones.”
“And he hasn’t a curve to his name. About all he has got is a
colossal nerve.”
“Nerve yourself,” replied Kewpie. “I don’t pretend to be a Joe
Bush, or—or—”
“Can you learn?” demanded Ned. “If Laurie and I help every way
we know how, if you study that book of yours, if you practise hard
every day for—for two months, say, will you be able to pitch decently
at the end of that time?”
Kewpie was plainly puzzled by this sudden and intense interest in
him; puzzled and a trifle suspicious. “What do you want to know for?”
he asked slowly.
“Never mind. Answer the question.” Ned was very stern.
“Sure, I’d be able to pitch after two months. Bet you I’d have
everything there is.”
“All right,” replied Ned. “Here’s the dope. Laurie and Elk Thurston
and Nate Beedle and two or three more were talking in the gym this
afternoon, and Elk said you were no good and never would be able
to pitch, and—”
“Elk!” interrupted Kewpie contemptuously. “He’s just a big blow-
hard, a bluff, a—”
“Never mind that. Laurie said you could pitch and that before the
season was over you’d be pitching on the nine. Get that?”
Kewpie nodded, glancing from one to the other of the twins, but he
seemed at a loss for words. Finally, though, he asked awedly, “Gosh,
Nod, did you tell ’em that?”
“Yes, like a blamed idiot I did! I guess I had a brain-storm or
something. Well, never mind that now. What do you say?”
“Me?” Kewpie cleared his throat. “Well, now, look here, I never told
you I could pitch on the team, did I?”
“If you didn’t you might just as well have,” answered Laurie
impatiently. “You’ve been cracking yourself up for a month. Now,
what Ned and I want to know—”
“Well, but hold on! How would I get to pitch, with Nate Beedle and
two or three others there? Gosh, those sharks have been at it for
years!”
“Never you mind how,” said Ned sharply. “That’s not the question.
Laurie’s gone and put himself in a hole, and you’ve got to help pull
him out. Will you do it?”
Kewpie was again silent for a moment. Then he nodded. “Sure,”
he said dubiously. “I’ll do what I can, but—”
“There aren’t any ‘buts,’” declared Ned. “If you’ll take hold
seriously and do your best and learn to pitch—well, fairly decently,
Kewpie, Laurie and I’ll look after the rest of it. We’ll see that you get
your chance somehow with the team.”
“How are you going to do it?” asked Kewpie.
Ned shrugged. “Don’t know yet. That’ll come later. Now, what do
you say? Will you be a game sport and buckle into it, or are you
going to throw us down? You’ll have to quit bluffing about what you
can do and work like the dickens, Kewpie. You’ll have to quit eating
sweet stuff and starchy things and get rid of about ten pounds, too.
Well?”
Kewpie looked solemnly back at Ned for an instant. Then he
nodded shortly. “I’ll do it,” he said soberly. “Let’s go.”
The next day, which was a Saturday, the baseball candidates
forsook the gymnasium and went out on the field. The ground was
still soft in spots, and the diamond was not used. There was a long
session at the batting-net and plenty of fielding work to follow, and of
course, the pitching staff unlimbered and “shot ’em over” for awhile.
Beedle, Pemberton, and Croft comprised the staff at present, with
two or three aspirants applying for membership. George Pemberton
fell to Laurie’s share. Pemberton was not so good as Nate Beedle,
but he had done good work for the team last year and he was a
“comer.” Laurie, taking Pemberton’s shoots in his big mitten, for the
first time since he had been transferred from the out-field to a
position behind the plate, watched his pitcher’s work. Before this,
Laurie had concerned himself wholly with the ball. Now he gave
attention to the behavior of Pemberton, studying the latter’s stand,
his wind-up, the way his body and pitching arm came forward, the
way the ball left his hand. More than once Laurie became so
engrossed with the pitcher that the ball got by him entirely. He even
tried to discern how Pemberton placed his fingers around the sphere
in order to pitch that famous slow one of his that had foiled the best
batsmen of the enemy last spring. But at the distance Laurie couldn’t
get it.
Pemberton was eighteen, tall, rather thin, rather awkward until he
stepped into the box and took a baseball in his capable hand. After
that he was as easy and graceful as a tiger. The difference between
Pemberton’s smooth wind-up and delivery and Kewpie’s laborious
and jerky performance brought Laurie a sigh of despair. As he
stopped a high one with his mitt and quite dexterously plucked it
from the air with his right hand, Laurie was more than ever
convinced that the campaign on which he and Ned and Kewpie had
embarked last evening so grimly and determinedly was foredoomed
to failure. Gee! Kewpie would never be able to pitch like George
Pemberton if he lived to be a hundred years old and practised
twenty-four hours a day! Laurie almost wished that he had been born
tongue-tied! Later, returning to the gymnasium, Laurie ranged
himself beside Pemberton. He had provided himself with a ball, and
now he offered it to the pitcher. “Say, George, show me how you
hold it for that floater of yours, will you?” he said.
Pemberton took the ball good-naturedly enough. “What are you
trying to do, Nod?” he asked. “Get my job away from me? Well,
here’s the way I hold it.” He placed his long fingers about the ball
with careful regard for the seams. “But holding it isn’t more than half
of it, Nod. You see, you’ve got to flip it away just right. Your thumb
puts the drag on it, see? When you let go of it it starts away like this.”
Pemberton swung his arm through slowly and let the ball trickle from
his hand. Laurie recovered it from a few paces away and stared at it
in puzzled fashion. He guessed he wouldn’t be able to learn much
about pitching that way. Pemberton continued his explanation
carelessly. “You see, you’ve got to start it off with the right spin.
That’s what keeps it up after a straight ball would begin to drop. Now
you take the ‘fade-away.’ I can’t pitch it, but I know how it’s done.
You start it like this.”
Laurie listened and looked on with only perfunctory interest. It
wasn’t any use, he decided. Learning Pemberton’s stuff and
teaching it to Kewpie was beyond his abilities. Besides, when he
came to think about it, it didn’t seem quite fair. It was too much like
stealing another fellow’s patent. Of course there wasn’t more than
one chance in ten that Kewpie would progress to the stage where he
might burst on the Hillman’s baseball firmament as a rival to
Pemberton, but ... just the same.... The next time Pemberton let the
ball go Laurie picked it up and dropped it in his pocket.
The next day, Sunday, saw Ned and Laurie walking toward the
Widow Deane’s shortly after dinner was over. It had become a
custom to go for a walk on Sunday afternoons, when the weather
was gracious, with Polly and Mae and, sometimes, Bob Starling or
some of the other fellows. To-day, however, there were indications
that a late dinner was still going on at the Starlings’, and the twins
didn’t stop for Bob. It had rained during the night but a warm sun had
long since removed all signs of it. Along the streets bordering School
Park doors and windows were open to the spring-like air. In the park
the few benches were occupied, and, beyond, in the paved yard of
the high school, some small youths were indulging somewhat noisily
in an amusement suspiciously like baseball. Of course it couldn’t be
baseball, as Laurie pointed out, since the town laws sternly forbade
that game on Sundays. At the further corner of Pine Street a small
white house with faded brown shutters stood sedately behind a
leafless and overgrown hedge of lilac. The twins viewed the house
with new interest, for it was there that Miss Comfort lived. Ned
thought that through a gap in the hedge he had glimpsed a face
behind one of the front windows.
“Reckon this is her last Sunday in the old home,” observed Ned. It
sounded flippant, and probably he had meant that it should, but
inside him he felt very sorry for the little old lady. It was not much of a
house, as houses went even in Orstead, but it was home to Miss
Comfort, and Ned suddenly felt the pathos of the impending
departure.
Laurie grunted assent as they turned the corner toward the little
blue painted shop. “Guess we aren’t going to hear from the Goop,”
he said. “It’s three days now.”
“We—ell, he might be away or something,” answered Ned.
“I don’t believe so,” said Laurie. “He didn’t answer Miss Comfort’s
letter, and I guess he isn’t going to answer our telegram. The old
skinflint,” he added as an afterthought.

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

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

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

Content Strategist: Kayla Wolfe

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

Video Table of Contents ix Vertical Motility Disorders 63

CHAPTER 1 Eyelid Trauma 69

Graft-versus-Host Disease 160 Peripheral Anterior Synechiae 273

CHAPTER 10 Solar and Photic Retinopathy 407

Secondary Open-Angle Glaucoma 561 APPENDIX 595

Video 2.1 Torsional nystagmus.

Daniel Youngjun Choi, MD

Yaping Joyce Liao, MD, PhD

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

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

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

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

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

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

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

The following figure is courtesy of Thomas Loarie: 12.17.

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

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

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

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

Fig 1.1 ​• ​Orbital contusion

Fig 1.2 ​• ​Retrobulbar

Conjunctival chemosis Lid edema

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

Orbital floor (blow-out) fracture

Subconjunctival Orbital floor fracture

Fig 1.5 ​• ​Orbital computed tomography

Pediatric floor fracture

Medial wall (nasoethmoidal) fracture

Orbital roof fracture

Orbital apex fracture

• Ice compresses for the first 48 hours

Intraorbital Foreign Body

Fig 1.6 ​• ​Orbital computed tomography

Intraorbital foreign body

Fig 1.7 ​• ​Globe subluxation

Prognosis ​Good unless complications develop.

Carotid–Cavernous and Dural Sinus Fistulas

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

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

• Consider treatment with selective embolization or ligation for severely symptomatic

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

Lid erythema Lid edema Erythema

Fig 1.1 • Orbital contusion

Fig 1.2 • Retrobulbar

Fig 1.5 • Orbital computed tomography

Fig 1.6 • Orbital computed tomography

Fig 1.7 • Globe subluxation

Prognosis Good unless complications develop.

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

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

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