Kanski's Clinical Ophthalmology: A

Systematic Approach 9th Edition John

Salmon
Visit to download the full and correct content document:
https://ebookmass.com/product/kanskis-clinical-ophthalmology-a-systematic-approac
h-9th-edition-john-salmon/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Kanski’s Clinical Ophthalmology. A Systematic Approach

9th Edition John F. Salmon

https://ebookmass.com/product/kanskis-clinical-ophthalmology-a-
systematic-approach-9th-edition-john-f-salmon/

-Kanski's Clinical Ophthalmology: A Systematic Approach

Textbook 9th Edition John F. Salmon

https://ebookmass.com/product/kanskis-clinical-ophthalmology-a-
systematic-approach-textbook-9th-edition-john-f-salmon/

Kanski’s clinical ophthalmology : a systematic approach

8th Edition Bradley Bowling

https://ebookmass.com/product/kanskis-clinical-ophthalmology-a-
systematic-approach-8th-edition-bradley-bowling/

Kanskiu2019s Clinical Ophthalmology E Book: A

Systematic Approach 8th Edition, (Ebook PDF)

https://ebookmass.com/product/kanskis-clinical-ophthalmology-e-
book-a-systematic-approach-8th-edition-ebook-pdf/
Synopsis Of Clinical Opthalmology 4th Edition John R.
Salmon

https://ebookmass.com/product/synopsis-of-clinical-
opthalmology-4th-edition-john-r-salmon/

Kanski's Synopsis of Clinical Ophthalmology 4th Edition

John F.Salmon

https://ebookmass.com/product/kanskis-synopsis-of-clinical-
ophthalmology-4th-edition-john-f-salmon/

Goldberger’s Clinical Electrocardiography: A Simplified

Approach 9th Edition Ary L. Goldberger

https://ebookmass.com/product/goldbergers-clinical-
electrocardiography-a-simplified-approach-9th-edition-ary-l-
goldberger/

Auditing & Assurance Services: A Systematic Approach

10th Edition William Messier Jr

https://ebookmass.com/product/auditing-assurance-services-a-
systematic-approach-10th-edition-william-messier-jr/

A topical approach to life-span development 9th Edition

John W. Santrock

https://ebookmass.com/product/a-topical-approach-to-life-span-
development-9th-edition-john-w-santrock/
KANSKI’S
Clinical
Ophthalmology
A Systematic Approach
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
Seventh edition 2011
Eighth edition 2016
Ninth edition 2020

The right of John F. Salmon to be identified as author of this work has been asserted by him in accordance with
the Copyright, Designs and Patents Act 1988.

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 contribu-
tors 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.

ISBN: 978-0-7020-7711-1
978-0-7020-7712-8

Content Strategist: Kayla Wolfe

Content Development Specialist: Kim Benson/Sharon Nash
Project Manager: Julie Taylor
Design: Amy Buxton
Illustration Manager: Paula Catalano
Marketing Manager: Claire McKenzie

Printed in China

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

 v
Dedication.......................................................................viii
In Memoriam.....................................................................ix
Preface to the Ninth Edition................................................x
Abbreviations.....................................................................xi
1 Examination Techniques....................... 1
Introduction.......................................................................2
Psychophysical tests..........................................................2
Perimetry...........................................................................9
Slit lamp biomicroscopy of the anterior segment..............20
Fundus examination.........................................................21
Tonometry........................................................................27
Gonioscopy......................................................................30
Central corneal thickness.................................................36
2 Eyelids.............................................. 37
Introduction.....................................................................38
Non-neoplastic lesions....................................................39
Benign epidermal tumours...............................................43
Benign pigmented lesions................................................44
Benign adnexal tumours..................................................47
Miscellaneous benign tumours.........................................47
Malignant tumours...........................................................50
Disorders of the eyelashes...............................................60
Allergic disorders.............................................................66
Immune-related inflammation..........................................66
Bacterial infections..........................................................67
Viral infections.................................................................68
Blepharitis.......................................................................70
Ptosis..............................................................................74
Ectropion.........................................................................80
Entropion.........................................................................85
Miscellaneous acquired disorders....................................87
Cosmetic eyelid and periocular surgery............................91
Congenital malformations................................................93
3 Lacrimal Drainage System.................. 99
Introduction...................................................................100
Acquired obstruction......................................................105
Congenital obstruction...................................................108
Chronic canaliculitis.......................................................109
Dacryocystitis................................................................110
4 Orbit................................................ 113
Introduction...................................................................114
Thyroid eye disease........................................................118
Infections.......................................................................124
Non-infective inflammatory disease...............................126
Non-neoplastic vascular abnormalities...........................129
Contents
Cystic lesions.................................................................131
Vascular tumours...........................................................134
Lacrimal gland tumours.................................................140
Neural tumours..............................................................142
Lymphoma.....................................................................144
Rhabdomyosarcoma......................................................147
Metastatic tumours........................................................148
The anophthalmic socket...............................................150
Craniosynostoses...........................................................153
5 Dry Eye........................................... 155
Introduction...................................................................156
Sjögren syndrome..........................................................158
Clinical features.............................................................158
Investigation..................................................................159
Treatment.......................................................................162
6 Conjunctiva..................................... 167
Introduction...................................................................168
Bacterial conjunctivitis...................................................171
Viral conjunctivitis..........................................................177
Allergic conjunctivitis.....................................................180
Conjunctivitis in blistering mucocutaneous disease........188
Miscellaneous disorders of the conjunctiva....................194
Degenerations...............................................................197
Subconjunctival haemorrhage........................................200
7 Cornea............................................ 203
Introduction...................................................................204
Bacterial keratitis...........................................................209
Fungal keratitis..............................................................216
Herpes simplex keratitis.................................................218
Herpes zoster ophthalmicus...........................................224
Interstitial keratitis.........................................................229
Protozoan keratitis.........................................................232
Helminthic keratitis........................................................234
Bacterial hypersensitivity-mediated
corneal disease..........................................................234
Rosacea........................................................................236
Peripheral corneal ulceration/thinning...........................238
Neurotrophic keratopathy...............................................241
Exposure keratopathy.....................................................242
Miscellaneous keratopathies..........................................243
Corneal ectasia..............................................................248
Corneal dystrophy..........................................................252
Corneal degeneration.....................................................261
Metabolic keratopathy....................................................266
Contact lenses...............................................................268
Congenital anomalies of the cornea and globe...............270
vi Contents
8 Corneal and Refractive Surgery........ 275
Keratoplasty..................................................................276
Keratoprostheses...........................................................283
Refractive procedures....................................................283
9 Episclera and Sclera........................ 291
Anatomy........................................................................292
Episcleritis.....................................................................292
Immune-mediated scleritis.............................................293
Porphyria.......................................................................300
Infectious scleritis..........................................................300
Scleral discolouration....................................................301
Blue sclera....................................................................301
Miscellaneous conditions...............................................302
10 Lens................................................ 307
Acquired cataract..........................................................308
Management of age-related cataract..............................311
Congenital cataract........................................................335
Ectopia lentis.................................................................338
Abnormalities of lens shape...........................................342
11 Glaucoma........................................ 345
Introduction...................................................................346
Ocular hypertension.......................................................347
Overview of glaucoma....................................................349
Primary open-angle glaucoma.......................................349
Normal-tension glaucoma..............................................367
Primary angle-closure glaucoma....................................370
Classification of secondary glaucoma............................378
Pseudoexfoliation..........................................................379
Pigment dispersion syndrome and
pigmentary glaucoma.................................................381
Neovascular glaucoma...................................................383
Inflammatory glaucoma.................................................385
Steroid-induced glaucoma.............................................388
Lens-related glaucoma..................................................389
Traumatic glaucoma.......................................................390
Ghost cell ‘glaucoma’.....................................................392
Iridocorneal endothelial syndrome.................................392
Glaucoma associated with intraocular tumours..............394
Glaucoma secondary to epithelial ingrowth....................394
Iridoschisis....................................................................395
Primary congenital glaucoma.........................................395
Iridocorneal dysgenesis..................................................399
Glaucoma in phacomatoses...........................................403
Medical treatment of glaucoma......................................404
Laser treatment of glaucoma.........................................407
Trabeculectomy..............................................................412
Non-penetrating glaucoma surgery.................................419
Minimally invasive glaucoma surgery (MIGS)..................420
Drainage shunts.............................................................421
12 Uveitis............................................. 423
Classification.................................................................424
Clinical features.............................................................424
Investigation..................................................................429
Treatment.......................................................................432
Immunomodulatory therapy for
non-infectious uveitis.................................................433
Uveitis in spondyloarthropathies....................................435
Fuchs uveitis syndrome..................................................437
Uveitis in juvenile idiopathic arthritis (JIA)......................439
Uveitis in bowel disease.................................................441
Uveitis in renal disease..................................................442
Intermediate uveitis.......................................................443
Vogt–Koyanagi–Harada (VKH) syndrome.........................445
Sympathetic ophthalmitis..............................................448
Lens-induced uveitis......................................................449
Sarcoidosis....................................................................450
Behçet disease..............................................................454
Parasitic uveitis..............................................................456
Viral uveitis....................................................................465
Fungal uveitis.................................................................473
Bacterial uveitis.............................................................477
Miscellaneous idiopathic chorioretinopathies.................484
13 Retinal Vascular Disease.................. 495
Retinal circulation..........................................................496
Diabetic retinopathy.......................................................496
Non-diabetic retinopathy................................................513
Retinal venous occlusive disease...................................514
Retinal arterial occlusive disease...................................525
Ocular ischaemic syndrome...........................................531
Hypertensive eye disease...............................................532
Sickle-cell retinopathy....................................................533
Thalassaemia retinopathy..............................................536
Retinopathy of prematurity.............................................536
Retinal artery macroaneurysm.......................................540
Primary retinal telangiectasia.........................................543
Eales disease................................................................546
Radiation retinopathy.....................................................546
Purtscher retinopathy.....................................................547
Valsalva retinopathy.......................................................549
Lipaemia retinalis..........................................................549
Retinopathy in blood disorders.......................................550
14 Acquired Macular Disorders............. 555
Introduction...................................................................556
Clinical evaluation of macular disease...........................557
Investigation of macular disease....................................558
Age-related macular degeneration..................................572
Retinal angiomatous proliferation...................................589
Polypoidal choroidal vasculopathy..................................589
Peripheral exudative haemorrhagic
chorioretinopathy.......................................................591
Idiopathic choroidal neovascularization..........................591
Vitreomacular interface disorders...................................592
Central serous chorioretinopathy....................................598
Idiopathic macular telangiectasia...................................601
Cystoid macular oedema...............................................602
 Contents
vii
Microcystic macular oedema..........................................604
Degenerative myopia......................................................604
Angioid streaks..............................................................607
Choroidal folds..............................................................609
Hypotony maculopathy...................................................610
Solar retinopathy...........................................................610
Focal choroidal excavation.............................................611
Dome-shaped macula...................................................612
Low visual aids..............................................................613
15 Hereditary Fundus Dystrophies......... 615
Introduction...................................................................616
Investigation..................................................................616
Generalized photoreceptor dystrophies...........................619
Macular dystrophies.......................................................631
Generalized choroidal dystrophies..................................640
Hereditary vitreoretinopathies........................................641
Albinism........................................................................649
Cherry-red spot at the macula.......................................652
16 Retinal Detachment......................... 653
Introduction...................................................................654
Peripheral lesions predisposing to
retinal detachment.....................................................657
Posterior vitreous detachment........................................663
Retinal breaks................................................................666
Rhegmatogenous retinal detachment.............................668
Tractional retinal detachment.........................................681
Exudative retinal detachment.........................................681
Pars plana vitrectomy.....................................................683
17 Vitreous Opacities........................... 691
18 Strabismus...................................... 697
Introduction...................................................................698
Amblyopia.....................................................................707
Clinical evaluation..........................................................708
Pseudostrabismus.........................................................726
Heterophoria..................................................................727
Vergence abnormalities..................................................727
Esotropia.......................................................................728
Exotropia.......................................................................733
Congenital cranial dysinnervation disorders....................735
Monocular elevation deficiency......................................737
Brown syndrome............................................................737
Alphabet patterns..........................................................738
Surgery..........................................................................739
Complications of strabismus surgery..............................742
Botulinum toxin chemodenervation................................743
19 Neuro-ophthalmology....................... 745
Neuroimaging................................................................746
Optic nerve....................................................................751
Pupils............................................................................779
Chiasm..........................................................................786
Retrochiasmal pathways................................................792
Ocular motor nerves.......................................................795
Supranuclear disorders of ocular motility.......................806
Nystagmus.....................................................................809
Ocular myopathies.........................................................814
Miller Fisher syndrome...................................................819
Neurofibromatosis.........................................................819
Migraine........................................................................820
Neuralgias.....................................................................823
Facial spasm.................................................................824
Disorders of circadian rhythm.........................................825
Neuro-ophthalmology of space flight..............................825
20 Ocular Tumours................................ 827
Benign epibulbar tumours..............................................828
Malignant and premalignant epibulbar tumours.............833
Iris tumours...................................................................839
Iris cysts........................................................................841
Ciliary body tumours......................................................843
Tumours of the choroid..................................................846
Neural retinal tumours...................................................860
Retinal vascular tumours................................................868
Primary intraocular lymphoma.......................................872
Tumours of the retinal pigment epithelium......................875
Paraneoplastic syndromes.............................................878
21 Ophthalmic Side Effects of
Systemic Medication....................... 881
Eyelids...........................................................................882
Cornea..........................................................................882
Ciliary effusion...............................................................882
Lens..............................................................................883
Uveitis...........................................................................884
Retina............................................................................884
Optic nerve....................................................................889
Visual cortex..................................................................890
22 Trauma............................................ 891
Eyelid trauma.................................................................892
Orbital trauma...............................................................894
Trauma to the globe.......................................................898
Chemical injuries...........................................................912
Thermal burns................................................................916
Index.............................................................................917
 Dedication
This book is dedicated to my wife Susie,
to my children Mark and Nicola,
and to my sister, Margaret, who initially awakened my interest in ophthalmology
 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,
I am reminded of a quotation from Lewis Carroll’s Alice’s Adven-
tures in Wonderland: “What is the use of a book”, thought Alice,
“without pictures or conversations?”. The ninth edition of this
classic textbook is filled with beautiful illustrations and consider-
able information and is intended to be a useful and comprehensive
basis for general ophthalmic practice. It has been a privilege to
work on this remarkable book and I am grateful to Jack Kanski
and the staff of Elsevier for entrusting me with the task.
The challenge has been to cover the entire field of ophthalmol-
ogy for a worldwide audience without depending on subspecialists
to prepare each chapter. In order to do this, I have maintained Jack
Kanski’s unique approach of presenting core clinical knowledge
in a systemic and succinct form. Brad Bowling has had a sig-
nificant influence on the two previous editions and his accuracy
and meticulous attention to detail has been extremely helpful. I
have reverted to the format that was used in the sixth edition by
starting with an initial chapter on examination techniques. Special
investigations remain in the chapters where they are most relevant.
Each chapter has been updated and the latest evidence-based
diagnostic and therapeutic approaches have been covered, includ-
ing genetics, immunotherapy and imaging techniques. Many
new illustrations have been added and better examples of a range
of conditions have been used. Jack Kanski’s idea of including
important ‘tips’ has been reintroduced. I have included sufficient
practical information for trainees to manage common ophthalmic
conditions in the clinic and enough detail on rare conditions to
enable them to prepare for their examinations without resorting
to the internet.
I have been extremely fortunate to have received help from
colleagues past and present, to whom I wish to express my grate-
ful thanks. The photographers and research staff at the Oxford
Eye Hospital have been wonderfully supportive. Jack Kanski
generously gave me his huge collection of images. My friends in
South Africa, Tony Murray (strabismus) and Trevor Carmichael
(cornea), provided help with the text and images of pathology
that are not easily found in developed countries. I received many
pictures from Jonathan Norris and Elizabeth Insull (oculoplas-
tics), Darius Hildebrand and Manoj Parulekar (paediatrics),
Peter Issa and Christine Kiire (medical retina), Bertil Damato
(ocular oncology), Martin Leyland (corneal surgery), C.K. Patel
(vitreoretinal surgery), Patsy Terry (ultrasound) and Pieter Pre-
torius (neuroradiology). Mitch Ménage provided good pictures of
common conditions. Aude Ambresin and Carl Herbort (Switzer-
land) supplied state-of-the-art retinal images. I have kept many
of the outstanding pictures that Chris Barry and Simon Cheng
(Australia) provided for the eighth edition. Single examples of
rare conditions have been kindly provided by a number of col-
leagues throughout the United Kingdom and elsewhere and their
contribution has been recognized next to the images provided.
Other individuals have helped substantially with previous editions
of Clinical Ophthalmology, including Terry Tarrant, the artist who
produced the meticulous ocular paintings. I also wish to thank
Kim Benson, Sharon Nash, Kayla Wolfe, Julie Taylor, Anne Collett
and the production team at Elsevier.
The ninth edition of Kanski’s Clinical Ophthalmology could not
have been produced in the time available without the help of my
assistant, Carolyn Bouter, whose resilience, diligence, intelligence
and skill were evident throughout the 6 months that she worked
with me. I have also had the good fortune to work with Jonathan
Brett, a world-class photographer and artist, whose genius is
present in hundreds of the images included in this edition. My
wife, Susie, has been extremely supportive throughout this project
and her happy and helpful nature has made the task a pleasant and
enjoyable experience.
John F. Salmon
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
INTRODUCTION
Patients with ophthalmic disease must have their vision accurately
measured and their eyes need to be examined using specialized
techniques. Special investigations should be used to supplement
the findings of clinical examination. Electrophysical tests, fluores-
cein angiography and optical coherence tomography are discussed
in later chapters.
PSYCHOPHYSICAL TESTS
Visual acuity
Snellen visual acuity
Distance visual acuity (VA) is directly related to the minimum
angle of separation (subtended at the nodal point of the eye)
between two objects that allow them to be perceived as distinct.
In practice, it is most commonly carried out using a Snellen chart,
which utilizes black letters or symbols (optotypes) of a range of
sizes set on a white chart (Fig. 1.1), with the subject reading the
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. 1.1 Snellen visual acuity chart
• Pinhole VA: a pinhole (PH) aperture compensates for the
effect of refractive error, and consists of an opaque occluder
perforated by one or more holes of about 1 mm diameter (Fig.
1.2). However, PH acuity in patients with macular disease and
posterior lens opacities may be worse than with spectacle cor-
rection. If the VA is less than 6/6 Snellen equivalent, testing is
repeated using a pinhole aperture.
• 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
• Counting (or counts) fingers (CF) denotes that the patient is
able to tell how many fingers the examiner is holding up at a
specified distance (Fig. 1.3), usually 1 metre.
• Hand movements (HM) is the ability to distinguish whether
the examiner’s hand is moving when held just in front of the
patient.
• Perception of light (PL): the patient can discern only light
(e.g. pen torch), but no shapes or movement. Careful occlu-
sion of the other eye is necessary. If poor vision is due solely
to a dense media opacity such as cataract, the patient should
Fig. 1.2 Pinhole
Fig. 1.3 Testing of ‘counts fingers’ visual acuity
 1
CHAPTER
Examination Techniques 3

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
4 Psychophysical Tests
and the height of the letters. The letter signs are rectan-
gular rather than square, as with the EDTRS chart. A 6/6
letter is 5' in height by 4' in width.
o The distance between two adjacent letters on the same row
is equal to the width of a letter from the same row, and
the distance between two adjacent rows is the same as the
height of a letter from the lower of the two rows.
o Snellen VA values and logMAR VA are listed to the right
and left of the rows respectively.
• The ETDRS (Early Treatment Diabetic Retinopathy Study)
chart is calibrated for 4 m. This chart utilizes balanced rows
comprising Sloan optotypes, developed to confer equivalent
legibility between individual letters and rows. ETDRS letters
are square, based on a 5 x 5 grid, i.e. 5' x 5' for the 6/6 equiva-
lent letters at 6 m.
• Computer charts are available that present the various forms
of test chart on display screens, including other means of
assessment such as contrast sensitivity (see below).
TIP LogMAR charts are commonly used in clinical trials
because they are the most accurate method of measuring VA.
Near visual acuity
Near vision testing can be a sensitive indicator of the presence of
macular disease. A range of near vision charts (including logMAR
and ETD RS versions) or a test-type book can be used. The book or /
chart is held at a comfortable reading distance and this is measuredi'
and noted. The patient wears any necessary distance correcfion
together with a presbyopia correction if applicable (usually their
own reading spectacles). The smallest type legible is recorde for
each eye individually and then using both eyes together (Fig. 1.6).
Contrast sensitivity
• Principles. Contrast sensitivity is a
visual system to distinguish an object against its background.
Fig. 1.6 Near visual acuity using a magnifying lens
A target must be sufficiently large to be seen, but must also
be of high enough contrast with its background. A light grey
letter will be less well seen against a white background than a
black letter. Contrast sensitivity represents a different aspect
of visual function to that tested by the spatial resolution tests
described above, which all use high-contrast optotypes.
o Many conditions reduce both contrast sensitivity and
VA, but under some circumstances (e.g. amblyopia, optic
neuropathy, some cataracts, and higher-order aberra-
tions), visual function measured by contrast sensitivity can
be reduced whilst VA is preserved.
o Hence, if patients with good VA complain of visual
symptoms (typically evident in low illumination), contrast
sensitivity testing may be a useful way of objectively dem-
onstrating a functional deficit. Despite its advantages, it
has not been widely adopted in clinical practice.
• The Pelli-Robson contrast sensitivity letter chart is viewed
at 1 metre and consists of ows of letters of equal size (spatial
frequency of 1 cycle per degree) but with decreasing contrast of
0.15 log units for groups oQ!,Jree letters (Fig. 1.7). The patient
reads down the rows of letters until the lowest-resolvable
group of hree is reached.
• Sinusoidal (sine wave) gratings require the test subject to
view a seque ce of increasingly lower contrast gratings.
• Spaeth Richman contrast sensitivity test (SPARCS) is per-
formed on a personal computer with internet access. It can be
accessea online. Each patient is supplied with an identification
number and instructions on how to do the test. The test takes
.,:5-10 minutes per eye and measures both central and peripheral
I contrast sensitivity. Since the test is based on gratings it can be
used on illiterate patients.
V R s K D R
N H C s 0 K
s C N 0 z V
C N H z 0 K
N 0 D
Fig. 1.7 Pelli-Robson contrast sensitivity letter chart

Amsler grid
The Amsler grid evaluates the 20° of the visual field centred on
fixation (Fig. 1.8). It is principally useful in screening for and mon-
itoring macular disease, but will also demonstrate central visual
field defects originating elsewhere. Patients with a substantial risk
of choroidal neovascularization (CNV) should be provided with
an Amsler grid for regular use at home.
TIP An Amsler grid is a simple and easy method of monitoring
central visual field and is commonly abnormal in patients with
macular disease.
Charts
There are seven charts, each consisting of a 10-cm outer square
(Figs 1.9 and 1.10).
• Chart 1 consists of a white grid on a black background, the
outer grid enclosing 400 smaller 5-mm squares. When viewed
at about one-third of a metre, each small square subtends an
angle of 1°.
• Chart 2 is similar to chart 1 but has diagonal lines that aid fixa-
tion for patients with a central scotoma.
• Chart 3 is identical to chart 1 but has red squares. The red-on-
black design aims to stimulate long wavelength foveal cones.
It is used to detect subtle colour scotomas and desaturation in
toxic maculopathy, optic neuropathy and chiasmal lesions.
• Chart 4 consists only of random dots and is used mainly to
distinguish scotomas from metamorphopsia, as there is no
form to be distorted.
Fig. 1.8 Amsler grid superimposed on the macula. The central
fixation dot of the grid does not coincide with the foveal
anatomical centre in this image
(Courtesy of A Franklin)
1
CHAPTER
Examination Techniques 5
• Chart 5 consists of horizontal lines and is designed to detect
metamorphopsia along specific meridians. It is of particular
use in the evaluation of patients describing difficulty reading.
• Chart 6 is similar to chart 5 but has a white background and
the central lines are closer together, enabling more detailed
evaluation.
• Chart 7 includes a fine central grid, each square subtending an
angle of a half degree, and is more sensitive.
Technique
The pupils should not be dilated, and in order to avoid a photo-
stress effect, the eyes should not yet have been examined on the
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.
• One eye is covered.
• The patient is asked to look directly at the central dot with
the uncovered eye, to keep looking at this, and to report any
distortion or waviness of the lines on the grid.
• Reminding the patient to maintain fixation on the central dot,
he or she is asked if there are blurred areas or blank spots any-
where on the grid. Patients with macular disease often report
that the lines are wavy whereas those with optic neuropathy
tend to remark that some of the lines are missing or faint but
not distorted.
• The patient is asked if he or she can see all four corners and all
four sides of the square – a missing corner or border should
raise the possibility of causes other than macular disease, such
as glaucomatous field defects or retinitis pigmentosa.
The patient may be provided with a recording sheet and pen
and asked to draw any anomalies (Fig. 1.11).
Fig. 1.9 Amsler grid chart
(Courtesy of A Franklin)
6 Psychophysical Tests

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
 1
CHAPTER
Examination Techniques 7

when ophthalmoscopy is equivocal, as in mild cystoid macular
oedema or central serous retinopathy. It may also differentiate
visual loss caused by macular disease from that caused by an
optic nerve lesion.
• Techniques
○ The best-corrected distance VA is determined.
○ The patient fixates on the light of a pen torch or an indi-
rect ophthalmoscope held about 3 cm away for about 10
seconds (Fig. 1.12A).
○ The photostress recovery time (PSRT) is the time taken
to read any three letters of the pre-test acuity line and is
normally between 15 and 30 seconds (Fig. 1.12B).
○ The test is performed on the other, presumably normal,
eye and the results are compared.
○ The PSRT is prolonged relative to the normal eye in
macular disease (sometimes 50 seconds or more) but not
in an optic neuropathy.
Colour vision testing
Introduction
Assessment of colour vision is useful in the evaluation of optic
nerve disease and in determining the presence of a congenitally
anomalous colour defect. Dyschromatopsia may develop in retinal
dystrophies prior to the impairment of other visual parameters.
Colour vision depends on three populations of retinal cones,
each with a specific peak sensitivity: blue (tritan) at 414–424 nm,
green (deuteran) at 522–539 nm and red (protan) at 549–570 nm.
Normal colour perception requires all these primary colours to
match those within the spectrum. Any given cone pigment may
be deficient (e.g. protanomaly – red weakness) or entirely absent
(e.g. protanopia – red blindness). Trichromats possess all three
types of cones (although not necessarily functioning perfectly),
while absence of one or two types of cones renders an individual
a dichromat or monochromat, respectively. Most individuals with
congenital colour defects are anomalous trichromats and use
abnormal proportions of the three primary colours to match those
in the light spectrum. Those with red–green deficiency caused by
abnormality of red-sensitive cones are protanomalous, those with
abnormality of green-sensitive cones are deuteranomalous and
those with blue–green deficiency caused by abnormality of blue-
sensitive cones are tritanomalous. Acquired macular disease tends
to produce blue–yellow defects, and optic nerve lesions red–green
defects.
Colour vision tests
• The Ishihara test is designed to screen for congenital protan
and deuteran defects. It is simple, widely available and fre-
quently used to screen for a red–green colour vision deficit.
The test can be used to assess optic nerve function. It consists
of a test plate followed by 16 plates, each with a matrix of dots
arranged to show a central shape or number that the subject
is asked to identify (Fig. 1.13A). A colour-deficient person will
only be able to identify some of the figures. Inability to identify
the test plate (provided VA is sufficient) indicates non-organic
visual loss.
• The City University test consists of 10 plates, each containing
a central colour and four peripheral colours (Fig. 1.13B) from
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
Another random document with
no related content on Scribd:
"Oh," said Zep, feeling rather proud, "I just picked it up, I guess."
"Well," said the monarch, "there is nothing like it to my mind.
Perhaps you've read my famous poem on the subject? Have you?"
"No," said Zep, "I never heard of it."
"Humph!" said the Emperor, looking rather disappointed. "You're not
very literary, are you? However, there is no reason why you should
not hear it now. Listen."

When I was a lad, I said to myself

As I hooked the jam from the pantry shelf,
"I may grow up and I may grow old
But I hope I'll never do as I'm told.
"For all the fun I've ever had,
"Has always come from being bad."

So I started out on my wild career,

And I did so well that I'm Emperor here,
Where you're told to do this, and you simply don't—
And you're asked to do that, and you say you won't.
And my what a lot of fun I've had—
For I never mind, and I'm awful bad.

"You can see," said the Emperor, when he had finished, "what a
splendid place you have come to. And as the years pass, I hope you
may find it even more delightful."
"As the years pass," repeated Zep. "Why—why, I can't stay here for
years. What would my folks say?"
"If you ask me," put in the Poppykok, "I should say they'd say: 'thank
goodness, he's gone at last.'"
"Yes," said the Emperor, "it's only in Obstinate Town that people like
boys like you. Everywhere else they think you're a nuisance. Didn't
you know that?"
"Why—why, no," said Zep. "I—I thought everybody liked me."
"Ho, ho, ho!" roared the Poppykok, shaking with merriment.
"Hee, hee, hee!" cackled the Emperor, "my word, that's good! You
ought to send that to a comic paper. He thought everybody liked
him."
"Well," said Zep, sulkily, "they always acted as though they did. I—I
like people to like me. But as long as they don't I'll never go back."
"That's the stuff," said the Emperor. "Don't you do it. You stay here
with me and enjoy yourself. Do as you please. Be as cranky as you
like. Why, I wouldn't be surprised if you'd be a popular idol some day
if you go on the way you've begun."
So Zep settled down in Obstinate Town determined to enjoy himself
with all his might. And because he was a prince, the Emperor let him
live in the palace and eat his meals at the royal table.
However, he did not care much for the meals. You never could get
what you wanted. When you asked the royal butler for cold chicken,
he would always tell you he would rather you took cold ham. And if
you wanted stewed kidneys, the butler right away said he preferred
to give you broiled oysters. No matter what you asked for, the
stubborn old butler always insisted on giving you something else,
whether you liked it or not. And such an arrangement made Zep
awfully cross.
"I don't see why you have such a butler," he said to the Emperor.
"When I ask our butler at home for anything, he gives it to me quick.
He wouldn't dare give me anything else. If he did my father would
hang him."
"Humph!" responded the Emperor, "it seems to me your father must
be a very cruel person. The idea of hanging any one for wanting his
own way."
"But," said Zep, "it's so—so inconvenient. If they have their own way
how can you have yours?"
"Well," said the Emperor, "you can't, with a butler, unless you go to
the pantry and help yourself. And yet, why shouldn't he have his way
as well as you? Why shouldn't he?"
And the Prince did not know what to say to that. But nevertheless it
was tough to have every one else having their own way as well as
you. When you got in a trolley car and told the conductor to let you
off at a certain street, he would stop the car at another street, and
unless you were stronger than he, would put you off there no matter
how much you struggled and yelled. And one day, when the Emperor
and Zep were put off six blocks from their destination, the monarch
was dreadfully angry.
"I know I told you I thought other people ought to have their own way
the same as you and I," he said to Zep, "but when a conductor not
only puts me off his car before I want to get off, but kicks me into the
bargain, it's too much."
"That's what I think," said Zep, "and if I were you I'd issue a royal
decree saying that only the upper classes can have their own way
always, and that the lower classes can only have their own way,
when it suits the upper classes."
"A good idea," said the Emperor, "I'll do it."
And despite the fact that it made the lower classes fairly purple with
indignation, the decree was issued at once, and Zep, and the
Emperor, and the rest of the upper classes, did as they liked
whenever they wanted to, and had a fine time doing it.
"I tell you what," said the Emperor to the Prince one morning after
breakfast as he finished reading the paper, "that was a grand idea of
yours, Zep, about letting the lower classes have their own way only
when it suited us. Life has been much sweeter ever since."
"I think so, too," said Zep, "except that if nobody else could have
their own way, it would be sweeter still."
"Hum," said the monarch, "I never thought of that. And the more I
think of it, the more I think you're right. I know what I'll do. I'll issue
another decree putting all the upper classes into the lower classes,
except myself. Then I can do whatever I want, no matter what
anybody says."
"But," said Zep, "you wouldn't put me in the lower classes, would
you?"
"Why not," replied the Emperor. "Suppose I wanted my own way
about something at the same time that you wanted your own way
about it, the only way it could be managed without a fight, would be
for you to be in the lower classes where you couldn't have your own
way unless it suited me. See?"
"Yes," said Zep, sulkily, "I see, but I don't think it's fair. Why not put
yourself in the lower classes and let me stay in the upper class?"
"Impossible," said the Emperor, "for if any one ever belonged to the
upper classes an Emperor does."
"So does a prince," said Zep.
"Not necessarily," replied the monarch. "I had a dog named Prince
once, but you never heard of a dog named Emperor, did you?"
And as Zep could think of nothing to say to that, the Emperor issued
his decree, and Zep and all the rest of the upper classes were put in
the lower classes, and the monarch enjoyed himself more than ever.
But if the Emperor enjoyed himself, Zep and the rest of the upper
classes did not. For if they wanted to do something the Emperor
always wanted them to do something different. And if he did not want
that, he wanted them to do something nobody could do. And as Zep
lived in the palace he had it worse than anybody else.
He was told to hold his breath for an hour; to stand on his ear for half
an hour, and not wink for fifteen minutes. And when he did not do
what he was told because he could not, the Emperor stuck pins in
him and dared him to yell.
"See here," said Zep to the monarch, "I used to like you but I don't a
bit any more. I'm going back home right off."
"Very well," said the Emperor, "go ahead. I'm tired of you anyway.
The idea of a strong, healthy boy not being able to stand on his ear,
and making such a fuss, too, because a few pins are stuck in him.
Go on, go back home."
"But," said Zep, "how will I get there? I—I don't know the way."
"Of course you don't," replied the monarch, "nobody does. There
isn't any way."
"Isn't any way?" repeated the Prince in a tone of horror. "Why—why,
have I got to stay here with you always?"
The Emperor nodded. "Sure thing, unless a Kokkipop sends you
back. The Poppykoks bring you here and the Kokkipops send you
back. But as no one ever wants to go back it's mighty hard to find a
Kokkipop, so I guess I'll be sticking pins in you for some time yet.
Ho, ho, ho!"
Well, you can be sure when the Emperor said that and laughed
about it, too, Zep felt about as gloomy as he ever had in his life.
"Oh, dear," he said, "what on earth shall I do? If only I can get away
from this nasty old place I'll never want my own way again. I'll be a
different boy. I never—"
"Here, here," put in the Emperor, sternly, "stop that talk. You mustn't
say such things as that. No one ever talks about not wanting their
own way in Obstinate Town. It's downright treason. Do you want to
go to prison? But anyhow, I don't suppose you meant it."
"Indeed, I did," said Zep, "I meant every word I said. I'm tired of
having my own way—it's silly. Look at the mess it's got me into. I'm
going to be different—"
"Stop!" shrieked the Emperor, at the top of his lungs, "stop, I say!
You'll have a Kokkipop here in another moment, and oh, how I hate
'em. I hate 'em worse than—than spiders. And—and, my goodness
gracious sakes alive, you've brought one—you've brought one. Run,
run, or the Kokkipop will get you!"
And with that the Emperor dived under his throne, while the Prince,
looking about with a startled air, did not know whether to flee or not.
And then, as he hesitated, a very brisk old gentleman, dressed in
bright yellow, came into the room.
"Did you call?" he asked Zep.
"Call," said the boy, "why—why, no. What do you mean?"
"Did you call for a Kokkipop?" repeated the other testily. "And for
mercy's sake don't say you didn't, for I've been waiting for a call all
my life. I was a young man when I joined the Kokkipops, and in all
that time I have never been called until now. So I hope you did call.
Did you?"
"Well," said Zep, "I said I wanted to go home, if that's what you
mean."
"And you said you didn't want your own way any more, didn't you?"
inquired the Kokkipop, eagerly.
"Yes," replied the Prince, "I did. And I don't."
"He does, too," put in the Emperor, sticking his head out from under
his throne. "He doesn't mean what he says. He's just mad at me for
sticking pins in him."
"I don't believe it," said the Kokkipop, scowling at the Emperor,
"you're just trying to keep me out of a job." Then he turned to the
Prince. "You did mean what you said, didn't you?"
"I certainly did," said Zep, "and—"
"Whoopee!" yelled the Kokkipop, joyfully, "then I have got a job at
last."
Whereupon he took off his coat, rolled up his sleeves, and began to
paste magic postage stamps all over the Prince. "There," he said,
standing off to admire his work, "I guess that will take you back all
right."
"Take him back," sneered the Emperor, crawling from under his
throne, "why it'll take him twice over. You've put excess postage on
him. Shows what a Kokkipop knows about his business."
"Is that so," retorted the Kokkipop, "well, I know enough to send this
boy where you won't stick pins in him any more, and where he won't
want his own way any more." He turned to Zep. "Isn't that so?"
"Yes, indeed," said the Prince.
"Then," responded the Kokkipop, "here's to a quick and comfortable
trip. Good-by, I'll see you later."
"No—wait!" shouted the Emperor, running toward Zep, "don't go. I'll
put you in the upper classes again. I'll—"
But it was no use. Once again Zep felt himself leap into the air, and
whiz, and whiz, and whiz, even faster than he had before. And then
just as he was beginning to get used to the whizzing and rather
enjoy it, he commenced to descend in a graceful curve, and
presently landed with a bump in the gardens adjoining his father's
palace. And there, sitting on the grass, was the Kokkipop waiting for
him.
"Greeting," said the Kokkipop, "did you have a nice trip?"
"Fine," said Zep, "but of course I'm glad it's over and that I'm safe
home again. And of course I'm awfully obliged to you for getting me
out of such a scrape."
"Oh, that's all right," said the Kokkipop, as he peeled off the magic
postage stamps, "it's been a pleasure to help you. And who knows
but you may try to have your own way again and be taken back to
Obstinate Town. And if you do, don't forget I'm always glad to get a
job."
"All right," said Zep, "I won't, but I never expect to visit Obstinate
Town again if I can help it."
And sure enough Zep never did. From that moment he was a
changed boy, so much so that it really worried his father, the king.
"I don't understand it," said the King to his Prime Minister. "He does
just what I tell him and never whines; and when he takes a walk he
jumps about a foot if a leaf falls on him. I don't understand it."
But if the King did not, Zep did, and was determined no Poppykok
should get another chance at him.
 TOOBAD THE TAILOR
Once there lived in the city of Vex a tailor named Toobad, which was
a very good name for him, for he really was too bad for anything, in
fact, he was downright wicked. And not only was he wicked but he
was also deceitful, because he was really not a tailor at all but an
enchanter or conjuror, and only practiced a tailor's trade to fool the
fathers, and grandfathers, and uncles, and big brothers of the little
boys of Vex, and make them pay him money. And this is the way he
did it:
He put a sign in his window and offered to make clothes for
gentlemen very, very cheap out of the very, very best materials that
would never wear out, and of course when he offered to do that all
the fathers, and grandfathers, and uncles, and big brothers went and
ordered their suits from him as quick as they could. But after the
clothes were made and the fathers, and grandfathers, and uncles,
and big brothers had put them on, then they found out, when it was
too late, what sort of a person Toobad was, for they had to keep on
paying, and paying, and paying for the clothes forever and forever. If
they did not the suits they were wearing got tighter and tighter until
their breath was almost squeezed out of them.
It was no use to try to get the clothes off because they simply would
not come off. So you can imagine how cross and miserable all the
fathers, and grandfathers, and uncles, and big brothers in Vex were.
Now there were lots of little boys in Vex, but the most interesting one
was a bright little fellow named Winn, because in his family there
happened to be a father, and a grandfather, and an uncle, and a big
brother all wearing suits made by Toobad the Tailor, whereas the
other boys only had a father, or a grandfather, or an uncle, or a big
brother. None of them had all four together, and therefore did not
have as much cause to dislike Toobad as Winn had.
Of course when Winn's father, and grandfather, and his uncle and
his big brother, had paid for their suits once and Toobad had told
them they must keep right on paying every week, they said they
would not. But after the suits had squeezed them once or twice, and
after they had tried to get the clothes off and found they could not,
they changed their minds. And every Saturday night as soon as they
got their salaries they rushed right down to Toobad's shop and paid
him, so they would have a comfortable Sunday, which did not please
Winn's mother at all because it left very little to buy food with.
"Good gracious," she used to say to Winn's father, and grandfather,
and uncle, and big brother, "if you keep on giving that tailor half your
money, I don't know how I'll get along."
"Indeed," said Winn's father, who was very fat, "and if I don't pay it I
don't know how I'll get along. I've got to breathe, haven't I?"
"Yes," said Winn's grandfather, and his uncle, and his big brother,
who were all as fat as his father, "we would much rather breathe
than eat."
"All right, then," said Winn's mother, "go ahead and breathe but don't
blame me if you starve also, for food is so high, I can buy very little
with the money you give me."
And when she said that Winn's father, and his grandfather, and his
uncle, and his big brother would groan awfully, which made Winn
and his mother as blue as indigo, for they knew if Toobad was not
paid, the clothes Winn's father, and grandfather, and uncle and big
brother wore would squeeze them tighter and tighter so they could
not work at all, and yet if he was paid there would not be enough
money left to keep the wolf from the door.
So finally Winn determined to go and see Toobad and try and coax
him not to be so hard on his folks. "Maybe if I offer to be his errand
boy," he said, "he'll agree to let us stop paying for a while until we
catch up with our grocery bills."
But when he got to the tailor's shop he had a very hard time to coax
Toobad into having an errand boy. "No, no," said the enchanter,
testily, "I don't need an errand boy, and even if I did need one I need
the money your family pays me much more."
"But think how stylish it is for a tailor to have an errand boy," said
Winn. "All fashionable tailors send clothes home to their customers.
They never ask customers to come after their clothes. I should think
you'd be ashamed not to have an errand boy."
So, finally, after talking and talking, Toobad agreed to hire Winn as
his errand boy, and instead of giving him wages to let his family stop
paying for their clothes for a few weeks.
"But remember this," said the tailor, "you are not to tell any one about
the arrangement, because if you do all my customers will want to
stop paying until they get caught up on their grocery bills."
So Winn promised to keep the matter secret and the next morning
started in on his duties.
Now it happened that one of the first persons he delivered clothes to
was a second cousin of his mother's aunt. This second cousin had
not heard of the trouble in Winn's family because Winn's father, and
grandfather, and uncle, and big brother had been afraid to tell any
one what Toobad had done to them for fear their clothes would
squeeze them worse than ever. So when Winn delivered his
mother's aunt's second cousin's clothes he did not know whether to
warn him about putting them on or not. And while he was trying to
make up his mind about it, his mother's aunt's second cousin went
into another room to get the money to pay for the clothes, and when
he came out he had the clothes on.
"Gee whiz," he said proudly, "don't they fit me grand?"
"Maybe they do," said Winn, "but I was just going to tell you not to
put them on, because now you can't get them off, and you've got to
keep on paying for them forever and forever."
"What!" yelled his mother's aunt's second cousin.
And then with another yell he began tearing at the clothes with all his
might, trying to get them off, but of course it was no use for although
he almost turned himself inside out, they stuck to him like sticking
plaster.

He began tearing at his clothes with all his might

"You're a nice one!" he shouted, shaking his finger under Winn's

nose. "You ought to be arrested. How dared you sit there and let me
put these awful things on? I just hope your father, and your
grandfather, and your uncle, and your big brother get stuck the same
way. I certainly do!"
"They are stuck," said Winn. "They've been stuck for some time.
That is why I am working for Toobad. And I'm very sorry I did not
warn you about the clothes in time."
And then he told his mother's aunt's second cousin what a fix his
folks were in and how if you did not pay for the clothes every week
they squeezed you until you did.
"Sakes alive!" groaned his mother's aunt's second cousin, "isn't it
dreadful the trouble some people have? Here I am all dressed up
fine but I can't enjoy it a bit after what you've told me."
Then he escorted Winn to the door and said he never wanted to see
his face again. "I'm sorry to have to say it," he continued, "but until
you came a little while ago my life was full of sunshine and now it is
nothing but a mud puddle. But I forgive you. Good-by!"
Well, you may be sure Winn felt terribly gloomy as he went back to
Toobad's shop. When he hired out as the tailor's errand boy in order
to help his family, he had not thought how he would be bringing
distress into other families by delivering Toobad's enchanted clothes.
But he could see now, after the scene with his mother's aunt's
second cousin, how selfish and wicked it was for him to help Toobad
get other people into trouble in order to make things easier for his
own folks. So he determined that he would give up his job right
away.
"I've decided not to be your errand boy any longer," he said to the
enchanter, as he handed him the money he had received from his
mother's aunt's second cousin. "I find you are too wicked to work
for."
"Humph!" said the tailor, "and why am I any wickeder now than I was
this morning? You were glad to work for me then."
"I know," said Winn, "but I have just seen my mother's aunt's second
cousin turn from a carefree, happy person into a miserable wretch,
and all because I delivered him one of your enchanted suits of
clothes. And I cannot help you in your crimes any longer even if my
family do suffer. Good afternoon!"
"Good afternoon nothing!" shouted Toobad. "Come back here at
once. Yesterday when I did not want an errand boy you talked me
into having one, and now that I've gotten used to having one you
want me to do without one. Well, I shan't do it. You'll work for me
whether you want to or not."
And with that he stretched out his hand toward Winn and then drew it
back and when he drew it back something mysterious drew Winn
back also, and though he tried to get to the door he could not move.
"Now," said Toobad, "will you work for me or not?"
"No," said Winn, firmly, "I will never work for you if I can help it."
"Very well, then," said the enchanter, "you shall work for me because
you cannot help it."
And with that he repeated the alphabet backward like lightning,
wiggling his fingers at the same time, and in a flash Winn was
transformed into a tailor's dummy, after which Toobad placed him on
the sidewalk outside his shop with one of the enchanted suits on him
and with a sign on his breast which read:
TAKE ME HOME FOR $3.75
so people could see what fine, cheap clothes were sold inside.
And maybe Winn did not feel bad as he stood there day after day not
even able to roll his eyes or move or speak. And on Saturday night
he felt particularly bad because his father, and his grandfather, and
his uncle, and his big brother came by the shop arm in arm, all
whistling merrily because they did not have to pay Toobad any
money that week and were going to a movie instead.
"My, my!" they exclaimed, when they saw Winn by the door, "doesn't
that image look exactly like our Winn, but of course it cannot be
because it's made of wax." And then the next moment they went on
their way as happy as larks.
"Oh, dear!" said Winn to himself, miserably, "whatever am I going to
do? How am I ever going to escape from this terrible tailor? If only I
could think of some way."
And later when Toobad had brought him indoors and shut the shop,
and gone off to bed and left him standing in a dark corner, he
thought and thought with all his might, for he felt if he did not find
some way to break the enchantment he might as well die.
And then as he was still puzzling over the problem he heard a
stealthy step, and into the room came Toobad in his nightgown,
holding a lighted candle in his hand, and Winn saw that he was
walking in his sleep. And not only was he walking in his sleep but he
was talking in his sleep also, and this is what he was saying:

Of all the gents who wear my clothes

Not one has ever guessed, sir,
That he could break the magic spell
By pulling down his vest, sir.
Oh, yes, indeed, there is no need
Why he should be distressed, sir,
If he but knows enchanted clothes
Are governed by the vest, sir.

And when Winn heard what he was saying he knew right away that if
he could only escape he could easily get his father, and grandfather,
and uncle, and big brother out of the power of Toobad the tailor, for
he only had to tell them to pull down their vests and they would be
rid forever of the hateful clothing they were wearing. But alas, it was
one thing to want to get home, and another to get there, for while he
was transformed into a tailor's dummy he was utterly helpless and
could only stand and watch Toobad as he wandered about the shop
with his eyes shut and the lighted candle in his hand.
And then all of a sudden something happened that transformed him
from a tailor's dummy into a very real boy, for Toobad, not seeing
where he was going, bumped right into him and the flame of the
candle came right against Winn's nose—only for a moment—but it
was long enough to scorch it and to make Winn yell—ouch! at the
top of his lungs, and to joggle all the enchantment out of him. And if
you did not believe an enchanted person can be cured by scorching
his nose, just get yourself enchanted and scorch your nose and see
if it does not work.
Anyway, it cured Winn, and not only that but it woke Toobad up. And
when the tailor found himself in his shop with his nightgown on, and
found Winn changed from a dummy into a regular boy again, he was
furious.
"Zounds!" he shrieked, dancing up and down, "how the—what the—
where did I come from and how did you get all right again?"
And when Winn told him he was more furious than ever. "Well," he
said, "I'll soon fix you anyway." And thereupon he began to say the
alphabet backward the same as he had done before, but by the time
he had said three letters and before the enchantment had had time
to work, Winn rushed at him and knocked the candle to the floor. And
then while the shop was in darkness he unhooked the door and ran
home as fast as he could. When he got there it was past midnight
and of course every one was asleep, but by and by his mother heard
him knocking and let him in.
And you may be sure it did not take his father, or his grandfather, or
his uncle, or his big brother long to hop out of bed where they had
been sleeping with their clothes on because they could not get them
off. And maybe they were not surprised when they learned that Winn
had really been the tailor's dummy they had seen outside the shop.
And maybe they were not delighted when they found that Winn knew
of a way for them to get rid of the enchanted clothes. And maybe
they did not pull down their vests in a hurry as soon as Winn had
finished telling them about it.
"My gracious," said Winn's grandfather, as he peeled the last of the
hated garments from him, "I feel twenty years younger. And I can
hardly wait until morning to get my hands on that villainous tailor."
"Nor I," said Winn's father.
"Me, too," said Winn's uncle.
"I daren't tell you what I'll do to him," said Winn's big brother.
And the first thing after breakfast they all went around to Toobad's
shop dressed in their old clothes, and each one of them kept his
word so well that Toobad was laid up in the hospital for a week. And
every time he got well and came out again a fresh batch of victims
was waiting to send him back again, for Winn had gone all about the
city telling everybody who had bought the enchanted clothes, how to
pull down their vests and get rid of them. And, of course, one of the
first persons he told after his immediate family was his mother's
aunt's second cousin. But as his mother's aunt's second cousin had
forgotten to put on his vest when he donned his enchanted suit, he
could not pull his vest down. And so the only thing to do was to give
him chloroform and skin the clothes off him a little strip at a time.
After which they sent him to the hospital also, where he lay in bed
right alongside of Toobad the tailor.
And perhaps that is the reason Toobad is still in the hospital, for after
Winn's mother's aunt's second cousin got well, he refused to go
home, but sat down on the hospital steps to wait for Toobad. And
neither Winn's father, nor his grandfather, nor his uncle, nor his big
brother, were able to coax him away.
But as for Winn, he did not try to coax him, indeed he soon forgot all
about his mother's aunt's second cousin, for all the persons in Vex
who had been wearing Toobad's enchanted clothes, began sending
Winn presents to show their gratitude, and when you have sixteen
gold watches, and a couple of ponies, and skates, and air guns, and
pretty much every sort of a thing that a boy likes, you cannot think of
much else.
The best you can do is just to enjoy yourself, and if you think Winn is
not doing that, take a trip to Vex some day and you will soon find out.
 THE SNOOPING-BUG
Once there was a Snooping Bug that lived in a glass jar on a shelf in
the cottage of a Fairy Godmother. Now fairy godmothers are always
nice, but this Fairy Godmother was very nice, and the reason she
kept the Snooping Bug a prisoner in a jar on her shelf was because
she was afraid he would go about and get folks into trouble. And
another thing that showed she was unusually nice was that every
week-end she always invited a little prince or princess to be her
guest. And this story opens just as Prince Pranc, the only son of the
king of a nearby city, had arrived to spend several days with his Fairy
Godmother.
"Now, Pranc," said the Fairy Godmother, "I want you to have the
happiest kind of a time, and you'll have it without doubt if you don't
get into mischief."
"Oh, that's all right," replied the Prince, as he watched the Fairy
Godmother unpack his trunk, "if I get into mischief you just send me
home again."
"Yes," said the Fairy Godmother, "but suppose you are not here to
send home again; suppose you have disappeared. Don't forget this
is an enchanted house and that strange things can happen in an
enchanted house."
"Phew!" said Pranc, "I almost wish I hadn't come."
"Not at all," replied the Fairy Godmother, "there is nothing to be
alarmed about. You could sit on a keg of gunpowder and be perfectly
safe if you didn't explode the powder. But in case you should get into
trouble, put this ring on your finger and turn it around and around
when danger threatens."
"Oh, thank you," said the Prince, slipping on the ring. "I don't feel so
worried now."
Then the Fairy Godmother took him all over the cottage and showed
him the wonderful belongings she had, and last of all she took him
into her study and there Pranc saw the Snooping Bug in his jar on
the shelf.
"What's that?" he asked.
And the Fairy Godmother told him it was a Snooping Bug. "And this
one," she continued, pointing to another jar on the shelf, "has a
Sulking Bug in it; and this one—next to it, is a Crying Bug. If they got
out of the jars they'd bite you, and you'd start in to snoop, or sulk, or
cry."
"Whoever heard of such a thing," said the Prince. "It can't be."
"It can't, eh," said the Fairy Godmother. "Just put your finger on the
top of this bottle when I take the cork out."
And with that she took the magic stopper out of the Crying Bug bottle
and Pranc stuck his finger in. And then—ping—the next moment
something bit it, and the next moment he burst out crying, boo-hoo—
boo-hoo, as loud as he could. And as he was a boy who hardly ever
cried, he felt awfully ashamed of himself.
"Oh, dear," he sobbed, "I hate to cry this way, but—but—"
"Don't worry," said the Fairy Godmother, as she corked the bottle
again, "he only gave you a little bite. You'll be over it in a minute."
And presently the tears stopped rolling down Pranc's cheeks and he
was all right once more.
"My goodness," he said, as he wiped his eyes, "I wouldn't like that to
happen again."
"Then," said the Fairy Godmother, "see that you keep hands off
these bottles. As long as the bugs stay in the bottles everything will
be all right, but if they once get out they'll bite every girl and boy they
find. That is why I keep them prisoners. I don't care for snooping,
sulking or crying children, nor does any one else."
Then she told Pranc that she would have to leave him for awhile. "I
have been invited to the christening of a princess," she said.
So she put on her gossamer cloak and her diamond studded bonnet,
kissed her hand to Pranc and went off to the christening. But so
interested was Pranc in the bugs on the shelf he hardly noticed her
going, for the Sulking Bug looked so mad it almost startled him, and
the Crying Bug had cried so much his bottle was half full of tears and
he looked almost as mad as the Sulking Bug. But when it came to
the Snooping Bug, it was a very different affair altogether, for the
Snooping Bug, although he had a sly sort of expression in his big,
pop eyes, was real jolly looking as he slowly scratched his shoulder
blade with his hind leg. And when he saw the Prince looking at him,
he winked one eye and then turned a couple of somersaults, which
made the Prince laugh like anything.
"Gee whiz," he exclaimed, "I like this bug."
And in order to get a better look at the creature he reached the jar
down from the shelf and carried it over to the window, or at least he
started to, but before he got there he stumbled—bing—the jar
slipped from his hands, fell to the floor with a crash and broke into a
thousand pieces, leaving the Snooping Bug kicking in the midst of
the fragments.
 The jar broke into a thousand pieces

"Oh," cried the Prince, "I must get something to put him in or he'll get
away."
"Nonsense," remarked the Snooping Bug. "I'm not going away. You
couldn't drive me away. I'm going to stay with you. But do get me out
of this mess, please."
So Pranc, not suspecting anything, stooped to pick the Snooping
Bug up and then as he did so—zip, the Bug bit his finger and in
about eight seconds he changed from a first class little boy who
always minded his own business and did not pry into things, into a