Full download test bank at ebook ebookmass.

com

Oxford Handbook of Ophthalmology

Alastair K. O. Denniston

CLICK LINK TO DOWLOAD

https://ebookmass.com/product/oxford-
handbook-of-ophthalmology-alastair-k-o-
denniston/

ebookmass.com
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

The Oxford Handbook of Criminal Process Darryl K Brown

https://ebookmass.com/product/the-oxford-handbook-of-criminal-
process-darryl-k-brown/

The Oxford Handbook of Evolutionary Psychology and

Romantic Relationships Justin K. Mogilski (Editor)

https://ebookmass.com/product/the-oxford-handbook-of-
evolutionary-psychology-and-romantic-relationships-justin-k-
mogilski-editor/

The Oxford Handbook of the History Phenomenology

(Oxford Handbooks)

https://ebookmass.com/product/the-oxford-handbook-of-the-history-
phenomenology-oxford-handbooks/

The Oxford Handbook of Daniel Defoe (Oxford Handbooks)

Seager

https://ebookmass.com/product/the-oxford-handbook-of-daniel-
defoe-oxford-handbooks-seager/
The Oxford Handbook of Religious Space Jeanne Halgren
Kilde

https://ebookmass.com/product/the-oxford-handbook-of-religious-
space-jeanne-halgren-kilde-2/

The Oxford Handbook of Polling and Survey Methods

(Oxford Handbooks)

https://ebookmass.com/product/the-oxford-handbook-of-polling-and-
survey-methods-oxford-handbooks/

The Oxford Handbook of Decadence Jane Desmarais

https://ebookmass.com/product/the-oxford-handbook-of-decadence-
jane-desmarais/

The Oxford Handbook of Pierre Bourdieu Unknown

https://ebookmass.com/product/the-oxford-handbook-of-pierre-
bourdieu-unknown/

The Oxford Handbook of Psychotherapy Ethics Trachsel

https://ebookmass.com/product/the-oxford-handbook-of-
psychotherapy-ethics-trachsel/
OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of
Ophthalmology
ii

Published and forthcoming Oxford Handbooks

Oxford Handbook of Clinical Medicine 6/​e (also available for PDAs and in
a Mini Edition)
Oxford Handbook of Clinical Specialties 7/​e
Oxford Handbook of Accident and Emergency Medicine 2/​e
Oxford Handbook of Acute Medicine 2/​e
Oxford Handbook of Anaesthesia 2/​e
Oxford Handbook of Applied Dental Sciences
Oxford Handbook of Cardiology
Oxford Handbook of Clinical and Laboratory Investigation 2/​e
Oxford Handbook of Clinical Diagnosis
Oxford Handbook of Clinical Haematology 2/​e
Oxford Handbook of Clinical Immunology and Allergy 2/​e
Oxford Handbook of Clinical Surgery 2/​e
Oxford Handbook of Critical Care 2/​e
Oxford Handbook of Dental Patient Care 2/​e
Oxford Handbook of Dialysis 2/​e
Oxford Handbook of Endocrinology and Diabetes
Oxford Handbook of ENT and Head and Neck Surgery
Oxford Handbook for the Foundation Programme
Oxford Handbook of Gastroenterology and Hepatology
Oxford Handbook of General Practice 2/​e
Oxford Handbook of Genitourinary Medicine, HIV and AIDS
Oxford Handbook of Geriatric Medicine
Oxford Handbook of Medical Sciences
Oxford Handbook of Obstetrics and Gynaecology
Oxford Handbook of Oncology
Oxford Handbook of Ophthalmology
Oxford Handbook of Palliative Care
Oxford Handbook of Practical Drug Therapy
Oxford Handbook of Psychiatry
Oxford Handbook of Public Health Practice 2/​e
Oxford Handbook of Rehabilitation Medicine
Oxford Handbook of Respiratory Medicine
Oxford Handbook of Rheumatology
Oxford Handbook of Tropical Medicine 2/​e
Oxford Handbook of Urology
Oxford Handbook of
Ophthalmology
Fourth edition
International edition

Alastair K.O. Denniston

Consultant Ophthalmologist
& Hon. Professor
Queen Elizabeth Hospital Birmingham,
University Hospitals Birmingham NHSFT,
& University of Birmingham, UK
& NIHR Biomedical Research Centre at
Moorfields Eye Hospital and
UCL Institute of Ophthalmology, UK

Philip I. Murray
Professor of Ophthalmology
& Hon. Consultant Ophthalmologist
University of Birmingham, UK
Birmingham & Midland Eye Centre,
Sandwell & West Birmingham Hospitals NHS Trust, UK

This international edition is only for sale in: Afghanistan,

Africa, Bangladesh, Bhutan, Cambodia, China, Egypt, India,
Indonesia, Iraq, Jordan, Laos, Malaysia, Myanmar, Nepal,
Pakistan, Philippines, Syria, Taiwan, Thailand, Turkey,
Vietnam, and Yemen (excluding Australia, Canada, Europe,
Hong Kong, Ireland, New Zealand, UK, and US); and not
for export therefrom. This edition is not for sale in any
other country in the world.

1
iv

1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2018
The moral rights of the authors have been asserted
First Edition published in 2006
Second Edition published in 2009
Third Edition published in 2014
Fourth Edition published in 2018
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2017954547
ISBN 978–0–19–881675–1
This international edition is only for sale in: Afghanistan, Africa, Bangladesh, Bhutan,
Cambodia, China, Egypt, India, Indonesia, Iraq, Jordan, Laos, Malaysia, Myanmar, Nepal,
Pakistan, Philippines, Syria, Taiwan, Thailand, Turkey, Vietnam, and Yemen (excluding
Australia, Canada, Europe, Hong Kong, Ireland, New Zealand, UK, and US); and not
for export therefrom. This edition is not for sale in any other country in the world.
Printed and bound in China by
C&C Offset Printing Co., Ltd.
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-​to-​date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-​pregnant
adult who is not breast-​feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
 v

Foreword

It is my great pleasure to write the foreword for this fourth edition of the
Oxford Handbook of Ophthalmology by Alastair Denniston and Phil Murray.
It is over a decade since the first edition was launched, a period which
has seen spectacular advances which have directly impacted patient care.
Previously untreatable diseases are now treatable, with targeted biological
therapies delivered on a hitherto unimagined scale, and gene and cell-​based
therapies becoming a reality. Previously invisible pathology is now revealed
through multi-​modal imaging with resolution of a few microns and ultra-​
widefield capture. National datasets offer the evaluation of outcomes from
hundreds of thousands of patients on a routine basis and enable previously
untestable hypotheses to be assessed.
As we seek to keep pace with this progress, there is an even greater
need to retain a clear understanding of the principles and practice of oph-
thalmology. The Oxford Handbook of Ophthalmology has become a valued
and trusted friend for generations of trainees learning their skills, preparing
for exams, and delivering excellent clinical care. For the more experienced
among us, it continues to be a remarkably useful vade mecum that ensures
we are always up-​to-​date, particularly in areas outside of our subspecialty
interest. This new edition of the Oxford Handbook is again fully revised and
updated throughout, reflecting the latest scientific knowledge, national
guidelines, and international recommendations. Although the text contin-
ues to evolve, the handbook remains true to its original aims, and its highly
logical format makes it both easier to learn the theory and faster to navigate
when you need to put it into practice.
It has always been remarkable to see how much the authors have man-
aged to pack into a relatively small volume, but they seem to have found
room for even more in this edition. In addition, it is now supported by
an online supplement, allowing the reader to access accompanying clinical
images and other material to help the learning experience. Key advances
covering every aspect of eye care are included, and there is greater
emphasis on the evidence underlying these developments. This is achieved
by an excellent authorship team which represents all specialties, with estab-
lished clinical leaders balanced by senior trainees to ensure that the text
is up-​to-​the-​minute and relevant. The scope of the book recognizes the
holistic nature of clinical care and the varying domains in which we work.
This new edition of the handbook will continue to help you to improve
the care of your patients. The patient remains at the heart of all we do.
The Oxford Handbook of Ophthalmology has an essential place among the
books that help us all learn, enjoy, and deliver the wonderful specialty that
is Ophthalmology.
Sir Peng Tee Khaw
Professor & Consultant Ophthalmic Surgeon,
Director, National Institute for Health Research Biomedical Research
Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology,
London, 2018
vi
 vii

Preface to the
fourth edition
This is an exciting, but also transitional, time for all those involved in the
care of patients with eye disease. On the one hand, we can do more than
ever before for our patients. Scientific advances mean that we can diagnose
earlier, treat previously ‘untreatable’ conditions, and monitor disease more
precisely. On the other hand, almost every health service in the world has a
major capacity problem—​the number of patients with sight-​threatening dis-
ease increases with demographic change; the care of each patient is becom-
ing more costly; and the expectation of patients is rising all the time. Our
great challenge for the next 10 years is likely to be less about incremental
advances in diagnostics or therapeutics, but more about how to deliver
what is already here on the huge scale that is required.
And this brings us to the point of this book.
The Oxford Handbook of Ophthalmology 4E continues to bring together
the most up-​to-​date knowledge of disease, clinical skills, investigations, and
treatment, within one portable and easily navigable volume. We hope that
it is more than just a repository of knowledge. As we anticipate a future
in which the slit-​lamp is replaced by whole-​eye multi-​modal imaging and
the human diagnostic process is overtaken by machine-​learning algorithms,
there is an even greater need to teach both the scientific method—​that
drives innovation and discovery—​and the art of ophthalmic care—​those
critical aspects of human-​to-​human interaction that enables patients to feel
valued and heard as they seek to make sense of their condition and its
treatment.
It is our great privilege—​on behalf of a wonderful team of authors—​to
present to you this fourth edition of the Oxford Handbook of Ophthalmology.
Whatever your role—​and wherever you are in the world—​we trust that
this edition will continue to inform and inspire you as you care for patients
suffering with ocular disease.
AKOD, PIM
2018
vi

viii

Preface to the
first edition
Welcome to the first edition of the Oxford Handbook of Ophthalmology.
The aspiration of the OHO is to be your portable repository of knowl-
edge, accessible in emergencies and easily dipped in and out of between
examining patients. It provides immediate access to the detailed clinical
information you need—​in casualty, clinic, and theatre, and on the wards.
It is also highly suitable for revision for postgraduate examinations. It is not
exhaustive and we would expect it to complement, rather than replace,
your collection of desktop ophthalmology heavyweights.
The core of the book comprises a systematic synopsis of ophthalmic
disease directed towards diagnosis, interim assessment, and ongoing man-
agement. Assessment boxes for common clinical conditions and algorithms
for important clinical presentations illustrate this practical approach. The
information is easily accessed, being presented in standard format with
areas of importance being highlighted. Key sections for the trainee include:
clinical skills, aids to diagnosis, and investigations and their interpretation.
Basic perioperative care and advanced life support protocols are included,
since specialists often find their general medical knowledge somewhat hazy
at times of crisis.
Primarily intended for ophthalmologists, this handbook is a valuable
resource for anyone working with ophthalmic patients, whether optom-
etrists, orthoptists, ophthalmic nurses, or other health professions in oph-
thalmology. While the earlier pages may be thumbed mainly by the trainee,
it is envisaged that even the experienced Consultant will find the OHO use-
ful. We have tried to include information that you would not easily find
elsewhere: vision in context (low vision, registration and benefits, driving
requirements), management of systemic disease (diabetes, thyroid disor-
ders, systemic immunosuppression), a glossary of eponymous syndromes,
and NICE and RCOphth guidelines.
Although we have endeavoured to provide up-​ to-​
date, accurate,
evidence-​based information, any comments would be gratefully received
so that we can make future editions even better. Point your web browser
to: www.oup.co.uk/​academic/​medicine/​handbooks/​ where you will be
able to have your say and to download any updates.
We hope the OHO will be an essential addition to your personal library
of ophthalmology textbooks and be an invaluable companion to you in your
practice of ophthalmology.
Alastair K.O. Denniston, Philip I. Murray
2006
 ix

Chapter authors

Clinical skills Uveitis

Prof Alastair K.O. Denniston Prof Alastair K.O. Denniston
Prof James Wolffsohn Prof Philip I. Murray
Ms Rosie Auld
Prof Philip I. Murray Vitreoretinal
Mr Kwesi N. Amissah-​Arthur
Investigations and their Mr Ash Sharma
interpretation
Miss Susan P. Mollan Medical retina
Dr Antonio Calcagni Mr Omar Mahroo
Mr Pearse A. Keane Mr Kamron N. Khan
Ocular trauma Prof Alastair K.O. Denniston
Mr Pearse A. Keane
Maj Richard J. Blanch
Miss Saaeha Rauz Orbit
Surg Cdr Malcolm Woodcock Mr Matthew Edmunds
Mr Aidan T. Murray Mr Aidan T. Murray
Mr Andrew Coombes Mr Omar M. Durrani
Prof Alastair K.O. Denniston
Lids Intraocular tumours
Mr Aidan T. Murray Mrs Hibba Quhill
Miss Saaeha Rauz Mr Manoj V. Parulekar
Prof Ian G. Rennie
Lacrimal
Mr Aidan T. Murray Neuro-​ophthalmology
Miss Susan P. Mollan
Conjunctiva
Miss Saaeha Rauz Strabismus
Mr Sam Gurney
Cornea Mr Joseph Abbott
Miss Saaeha Rauz
Mr Sai Kolli Paediatric ophthalmology
Sclera Mr Abdul-​Jabbar Ghauri
Mr Joseph Abbott
Prof Philip I. Murray
Miss Lucilla Butler
Mr Carlos E. Pavesio
Prof Alastair K.O. Denniston Refractive ophthalmology
Lens Mr Sai Kolli
Mr Sai Kolli Prof James S. Wolffsohn

Glaucoma Aids to diagnosis

Prof Peter Shah Mr Robert J. Barry
Miss Freda Sii Miss Susan P. Mollan
Dr Mark Chiang Mr Mike A. Burdon
Ass Prof Graham Lee Prof Philip I. Murray
Mr Imran Masood Prof Alastair K.O. Denniston
x

x CHAPTER AUTHORS

Vision in context Therapeutics

Mr Robert J. Barry Mr Avinash Manna
Prof Philip I. Murray Ms Elaine Mann
Prof Alastair K.O. Denniston Miss Vaneeta Sood
Prof Philip I. Murray
Surgery: anaesthetics Prof Alastair K.O. Denniston
and perioperative
care Evidence-​based
ophthalmology
Dr Shashi B. Vohra
Miss Priscilla Mathewson Prof Alastair K.O. Denniston
Prof Alastair K.O. Denniston Dr Merrick Moseley
Prof Philip I. Murray Prof Philip I. Murray
Resources
Surgery: theatre notes Miss Rupal Morjaria
Miss Priscilla Mathewson Mr Andrej Kidess
Prof Philip I. Murray Prof Philip I. Murray
Prof Alastair K.O. Denniston Prof Alastair K.O. Denniston
Laser Electronic resources
Mr Samer Elsherbiny Dr Mark Lane
Prof Alastair K.O. Denniston Prof Alastair K.O. Denniston
 xi

Author affiliations

Mr Joseph Abbott Miss Lucilla Butler

FRCOphth MA FRCSEd(Ophth) FRCOphth
Consultant Ophthalmologist Consultant Ophthalmologist &
Birmingham Children’s Hon. Senior Lecturer
Hospital NHSFT Birmingham & Midland Eye Centre,
Sandwell & West Birmingham
Mr Kwesi N. Hospitals NHS Trust
Amissah-​Arthur Birmingham Women’s NHSFT
MBChB FRCOphth FGCS University of Birmingham
Senior Lecturer & Consultant
Ophthalmologist Dr Antonio Calcagni
University of Ghana Medical School MD
Korle Bu Teaching Hospital, Ghana Consultant Electrophysiologist
Moorfields Eye Hospital NHSFT
Ms Rosie Auld
CBE Dr Mark Chiang
Head of Orthoptic Services MBBS MPhil FRANZCO
Birmingham & Midland Eye Centre, Consultant Ophthalmologist
Sandwell & West Birmingham Queensland Eye Institute &
Hospitals NHS Trust University of Queensland
Brisbane, Australia
Mr Robert J. Barry
BMedSc MBChB FRCOphth PhD Mr Andrew Coombes
NIHR Academic Clinical Lecturer BSc MBBS FRCOphth
University of Birmingham Consultant Ophthalmologist
West Midlands Deanery Royal London Hospital
Barts Health NHS Trust
Maj Richard J. Blanch
BSc(Hons) PhD MRCS(Ed) Prof Alastair K.O.
FRCOphth RAMC Denniston
RCDM Clinical Lecturer PhD MRCP FRCOphth
Royal Centre for Defence Medicine Consultant Ophthalmologist &
University of Birmingham Hon. Professor
University Hospitals Birmingham University Hospitals
NHSFT Birmingham NHSFT
University of Birmingham
Mr Mike A. Burdon University of Bristol
MRCP FRCOphth NIHR Biomedical Research
Consultant Ophthalmologist Centre at Moorfields Eye
University Hospitals Hospital and UCL Institute of
Birmingham NHSFT Ophthalmology
xi

xii AUTHOR AFFILIATIONS

Mr Omar M. Durrani Mr Sai Kolli

MBBS FRCS FRCOphth MA PhD FRCOphth
Clinical Professor of Ophthalmology Consultant Ophthalmologist
Cleveland Clinic University Hospitals
Abu Dhabi Birmingham NHSFT
Mr Matthew Edmunds Dr Mark Lane
PhD MRCP FRCOphth FEBO MB BSc
Clinical Lecturer Specialist Trainee (Ophthalmology)
University of Birmingham West Midlands Deanery
Mr Samer Elsherbiny Ass Prof Graham Lee
FRCS(Ed) FRCOphth MMed MBBS MD MMEd Sc (Ophth)
Consultant Ophthalmologist FRANZCO
South Warwickshire NHSFT Consultant Ophthalmologist
University Hospitals Birmingham University of Queensland,
Birmingham and Midland Eye Brisbane, Australia
Centre, Sandwell & West Mater Hospital, Brisbane,
Birmingham Hospitals NHS Trust Australia
Mr Abdul-​Jabbar Ghauri Mr Omar Mahroo
FRCOphth MA PhD FRCOphth
Consultant Ophthalmologist Consultant Ophthalmologist
Birmingham & Midland Eye Centre, Moorfields Eye Hospital NHSFT
Sandwell & West Birmingham Guy’s and St Thomas’ NHSFT
Hospitals NHS Trust
Ms Elaine Mann
Mr Sam Gurney BSc GPhC FRPharmS
BSc (Hons) MBChB (Hons) Advanced Clinical Pharmacist
FRCOphth (Ophthalmology, ENT, Max-​Fax
Specialist Trainee (Ophthalmology) and Dental)
West Midlands Deanery Leeds Teaching Hospitals
NHS Trust
Mr Pearse A. Keane
MD FRCOphth Mr Avinash Manna
NIHR Clinician Scientist & Hon. MA MBBS FRCOphth
Consultant Consultant Ophthalmologist
NIHR Biomedical Research Centre University Hospitals
at Moorfields Eye Hospital and Birmingham NHSFT
UCL Institute of Ophthalmology
Mr Imran Masood
Mr Kameron N. Khan BSc MBChB MRCS(Ed)
MD PhD FRCOphth FRCOphth
Consultant Ophthalmologist Consultant Ophthalmologist
Leeds Teaching Hospitals NHS Trust Birmingham & Midland Eye Centre,
Sandwell & West Birmingham
Mr Andrej Kidess Hospitals NHS Trust
MD University Hospitals
Consultant Ophthalmologist Birmingham NHSFT
University Hospitals Birmingham Institute for Glaucoma
Birmingham NHSFT Research
 AUTHOR AFFILIATIONS xiii

Miss Priscilla Mathewson Mr Carlos E. Pavesio

MA MBBChir FRCOphth MD FRCOphth
Specialist Trainee (Ophthalmology) Consultant Ophthalmologist &
West Midlands Deanery Hon. Senior Lecturer
Moorfields Eye Hospital NHSFT
Miss Susan P. Mollan NIHR Biomedical Research Centre
FRCOphth at Moorfields Eye Hospital and
Consultant Ophthalmologist & UCL Institute of Ophthalmology
Institute Clinical Fellow
University Hospitals Mrs Hibba Quhill
Birmingham NHSFT MRCOphth
University of Birmingham Specialist Trainee (Ophthalmology)
Yorkshire and the Humber
Miss Rupal Morjaria Deanery
FRCOphth
Specialist Trainee (Ophthalmology) Miss Saaeha Rauz
West Midlands Deanery PhD FRCOphth
Clinical Senior Lecturer in
Dr Merrick Moseley Ophthalmology & Hon. Consultant
BSc PhD Ophthalmologist
Hon Senior Research Fellow University of Birmingham
City, University of London Birmingham & Midland Eye
Centre, Sandwell & West
Mr Aidan T. Murray Birmingham Hospitals
FRCOphth NHS Trust
Consultant Ophthalmologist
Birmingham & Midland Eye Centre, Prof Ian G. Rennie
Sandwell & West Birmingham MBChB FRCS FRCOphth
Hospitals NHS Trust Professor of Ophthalmology
University Hospitals University of Sheffield
Birmingham NHSFT Royal Hallamshire
Hospitals NHSFT
Prof Philip I. Murray
PhD FRCP FRCS FRCOphth Prof Peter Shah
Professor of Ophthalmology & FRCOphth
Hon. Consultant Ophthalmologist Consultant Ophthalmologist &
University of Birmingham Hon. Professor of Ophthalmology
Birmingham & Midland Eye Centre, University Hospitals
Sandwell & West Birmingham Birmingham NHSFT
Hospitals NHS Trust NIHR Biomedical Research
Centre at Moorfields Eye
Mr Manoj V. Parulekar Hospital and UCL Institute of
MS FRCS Ophthalmology
Consultant Ophthalmologist Birmingham & Midland Eye
Birmingham Children’s Centre, Sandwell & West
Hospital NHSFT Birmingham Hospitals NHS Trust
Oxford University Hospitals Birmingham Institute for
NHSFT Glaucoma Research
vxi

xiv AUTHOR AFFILIATIONS

Mr Ash Sharma Dr Shashi B. Vohra

FRCOphth FRCA
Consultant Ophthalmologist Consultant Anaesthetist
Birmingham & Midland Eye Centre, Birmingham & Midland Eye
Sandwell & West Birmingham Centre, Sandwell & West
Hospi​tals NHS Trust Birmingham Hospitals
NHS Trust
Miss Freda Sii
FRCOphth Prof James S. Wolffsohn
Senior Fellow in Ophthalmology MBA PhD FCOptom
University Hospitals Deputy Dean & Professor of
Birmingham NHSFT Optometry
Birmingham & Midland Eye Centre, Life and Health Sciences
Sandwell & West Birmingham Aston University
Hospitals NHS Trust
Birmingham Institute for Glaucoma Surg Cdr Malcolm
Research Woodcock
NIHR Biomedical Research Centre MSc DAvMed MRCOphth
at Moorfields Eye Hospital and FRCSEd RNR
UCL Institute of Ophthalmology Consultant Ophthalmologist
Worcestershire Acute Hospitals
Miss Vaneeta Sood NHS Trust
FRCOphth Air Branch Royal Naval Reserve
Consultant Ophthalmologist
University Hospitals
Birmingham NHSFT
 xv

Acknowledgements

As authors and editors of this book, we are privileged to coordinate a won-

derful team of ophthalmologists, orthoptists, optometrists, visual scientists,
ophthalmic technicians, and other professionals who care for people with
eye disease. These people are not only experts in their fields but are pas-
sionate about ensuring that this wisdom is passed on to the rest of us.
These authors continue to distil the complexities of their subspecialties in a
way that is concise, clear, memorable, and easily applied in clinic, theatre, or
eye casualty. We are deeply indebted to them, and the junior authors who
assisted them, for all their hard work.
There are also many senior ophthalmologists who, like us, can measure
the passage of the years by their contributions to successive editions of this
Handbook. Significant contributors to previous editions include: Miss Susan
Mollan, Mr Arun Reginald, Mr Geraint Williams, Mr Paul Tomlins, Mr Anil
Arilakatti, Miss Rosemary Robinson, Mr Paul Chell, Miss Monique Hope-​
Ross, Mr Graham Kirkby, Miss Fiona Dean, Prof Sunil Shah, Mrs Waheeda
Illahi, Sonal Rughani, Mr Vijay Savant, Mr Sumit Dhingra, Mr Rajen Gupta,
Mr Joseph Abbott, Mr James Cameron, Mr James Flint, Mr Tahir Masoud,
Mr David Lockington, Mr Tom Jackson, Prof Mike Michaelides, Dr Steve
Colley, Mr Tim Matthews, Lt Col Andrew Jacks, and Prof Adnan Tufail. We
also thank Rizwana Siddiqui, Musarrat Allie, and Dr Peter Good for images.
We are grateful to Angela Luck for yet more beautiful anatomical illustra-
tions and her ongoing appreciation of the artistic merits of the slit-​lamp.
We thank Andrew Miller (Focus Birmingham) and Talia Dewhurst (Eye
Clinic Liaison Officer, University Hospitals Birmingham NHSFT) for their
expert advice on the ‘Vision in context’ chapter, and Miss Tas Braithwaite
for her expertise in Autoimmune Retinopathy. We thank Altomed and John
Weiss for kindly giving us permission to include images of their surgical
instruments, and to all those who have advised on specific chapters for
this edition.
It has been a great pleasure to work with the staff of OUP throughout.
We thank Elizabeth Reeve and Michael Hawkes for their enthusiasm and
practical assistance, and Joyce Cheung for her superb copy-editing.
AD wishes to thank his wife (Sarah) for her support, patience, and
good humour and his two boys (Arran and Ewan) for contributing to the
manuscript by manually checking several hundred weblinks throughout the
book. AD particularly wants to acknowledge the hard work of the clini-
cal and research teams he is privileged to lead (thank you Jacqui Orpe,
Sue Southworth, and teams), and his clinical mentors (Phil Murray, Marie
Tsaloumas, Andrew Dick) for their ongoing advice and encouragement.
PIM wishes to thank his family (Tricia, Hannah, Ella) for trying to keep
out of his way while attempting to write this book but who really think he
is spending his time on ebay bidding for yet another Paul Smith T-​shirt. He is
grateful to Out of the Blue Big Band and The Soul Providers for keeping him
sane, and to Brentford FC who at last seem to be playing reasonable foot-
ball and are now starting to look like a Championship side. Finally, he thanks
xvi

xvi ACKNOWLEDGEMENTS

Hercules Stands whose amazing folding baritone sax stand has now allowed
him to get his baritone sax and everything needed for a gig into his Porsche.
AKOD, PIM
2018
Additional acknowledgements
We are indebted to a number of colleagues from across the UK and the
rest of the world who have given us invaluable feedback which has helped
direct the development of successive editions. We thank: Mr Ajay Tyagi,
Mr Sam Elsherbiny, Mr Sam Mirza, Mr Velota Sung, Dr Zakaria, Dr Hannah
Sharma, Mr Maged Nessim, Dr Imran Khan, Dr Anna Gao, Miss Lei Liu,
Mr Nachiketa Acharya, Mr James Denniston, Dr Estelle Manson-​Whitton,
Mr Ali Bell, Dr Ed Moran, Miss Vaneeta Sood, Miss Anne Williams,
Miss Katya Tambe, Dr Liz Justice, Mr Pravin Pandey, Miss Dipti Trivedi,
Mr Richard Lee, Dr Yih-​Horng Tham, Mr Mahmoud Radwan, Mr Noman
Nazir Ahmad, Miss Hina Khan, and Dr Maha Said.
 xvii

Contents

Symbols and abbreviations xix

Orthoptic abbreviations xxxix

1 Clinical skills    1
2 Investigations and their interpretation    51
3 Ocular trauma   109
4 Lids   151
5 Lacrimal   185
6 Conjunctiva   195
7 Cornea   241
8 Sclera   319
9 Lens   335
10 Glaucoma   381
11 Uveitis   443
12 Vitreoretinal 521
13 Medical retina   569
14 Orbit   663
15 Intraocular tumours   699
16 Neuro-​ophthalmology   727
17 Strabismus   819
18 Paediatric ophthalmology   855
19 Refractive ophthalmology   925
20 Aids to diagnosis   977
21 Vision in context  1011
22 Surgery: anaesthetics and perioperative care  1031
23 Surgery: theatre notes   1059
24 Laser   1073
xvii

xviii CONTENTS

25 Therapeutics 1089
26 Evidence-​based ophthalmology 1129
27 Resources 1159

Index 1185
 xix

Symbols and abbreviations

d decreased
i increased
l leads to
∆ prism dioptre
α alpha
β beta
γ gamma
♀ female
♂ male
1° primary
2° secondary
> greater than
< less than
≥ equal to or greater than
≤ equal to or less than
± plus or minus
7 approximately
°C degree Celsius
°F degree Fahrenheit
®
registered trademark
™
trademark
M website address
E cross-​reference
5-​FU 5-​fluorouracil
AA attendance allowance
AACG acute angle-​closure glaucoma
AAO American Academy of Ophthalmology
AAPOX adult-​onset asthma and periocular xanthogranuloma
AAU acute anterior uveitis
AAV adeno-​associated virus
ABiC ab interno canaloplasty
AC anterior chamber
ACCORD Action to Control Cardiovascular Risk in Diabetes
ACE angiotensin-​converting enzyme
ACh acetylcholine
ACIOL anterior chamber intraocular lens
x

xx SYMBOLS AND ABBREVIATIONS

AD autosomal dominant
ADEM acute disseminated encephalomyelitis
ADOA autosomal dominant optic atrophy
ADVIRC autosomal dominant vitreoretinal choroidopathy
A&E accident and emergency
AF atrial fibrillation
AGIS Advanced Glaucoma Intervention Study
AIDS acquired immune deficiency syndrome
AIIR angiotensin II receptor
AION anterior ischaemic optic neuropathy
AK arcuate keratotomy
ALA alpha-​linolenic acid
ALPI argon laser peripheral iridoplasty
ALT argon laser trabeculoplasty; alanine aminotransferase
AM amniotic membrane
AMD age-​related macular degeneration
AMG amniotic membrane grafting
AMN acute macular neuroretinopathy
ANA anti-​nuclear antibody
ANCA anti-​neutrophil cytoplasmic antibody
ANDA anatomically narrow drainage angle
AOA American Optometric Association
AOX adult-​onset xanthogranuloma
APAC acute primary angle closure
APCR activated protein C resistance
APMPPE acute posterior multifocal placoid pigment epitheliopathy
APTT activated partial thromboplastin time
AqH aqueous humour
AR autosomal recessive
ARA arachidonic acid
ARB autosomal recessive bestrophinopathy
ARC abnormal retinal correspondence
AREDS Age-​Related Eye Disease Study
ARN acute retinal necrosis
ARPE acute retinal pigment epitheliitis
ARR absolute risk reduction
ART antiretroviral therapy
AS anterior segment; ankylosing spondylitis
ASA American Society of Anesthesiologists
asb apostilb
 SYMBOLS AND ABBREVIATIONS xxi

ASD atrial septal defect

ASFA anterior segment fluorescein angiography
AST aspartate aminotransferase
ATP adenosine triphosphate
AV arteriovenous
AVM arteriovenous malformation
AVMD adult-​onset vitelliform macular dystrophy
Ax allergies
AZOOR acute zonal occult outer retinopathy
BAL bronchoalveolar lavage
BBS Bardet–​Biedl syndrome
BC base curve
BCC basal cell carcinoma
BCG bacille Calmette–​Guérin
BCL bandage contact lens
BCR birdshot chorioretinopathy
BCVA best-​corrected visual acuity
bd twice daily (bis in die)
BDUMP bilateral diffuse uveal melanocytic proliferation
BE base excess
BHL bilateral hilar lymphadenopathy
BM basement membrane
BMI body mass index
BNF British National Formulary
BP blood pressure; bullous pemphigoid
BRAO branch retinal artery occlusion
BRVO branch retinal vein occlusion
BSA body surface area
BSS balanced salt solution
BSV binocular single vision
BVD back vertex distance
C/​D cup disc ratio
C3F8 perfluoropropane
Ca2+ calcium ion
CAA Civil Aviation Authority
CAR cancer-​associated retinopathy
CAS clinical activity score
CCA common carotid artery
CCD charge-​coupled device
CCP cyclic citrullinated peptide
xxi

xxii SYMBOLS AND ABBREVIATIONS

cCSNB complete congenital stationary night blindness

CCT central corneal thickness
CCTV closed circuit television
CDC Centers for Disease Control and Prevention
C-​DCR canalicular dacryocystorhinostomy
CDI colour Doppler imaging
CF counting fingers
CFEOM congenital fibrosis of extraocular muscles
cGMP cyclic guanosine monophosphate
CHED congenital hereditary endothelial dystrophy
CHRPE congenital hypertrophy of retinal pigment epithelium
CHSD congenital hereditary stromal dystrophy
CIGTS Collaborative Initial Glaucoma Treatment Study
CK conductive keratoplasty
CL contact lens
CLAU conjunctival limbal autograft
cm centimetre
CMC carboxymethylcellulose
cmCSF centimetre of cerebrospinal fluid
CMO cystoid macular oedema
CMV cytomegalovirus
CNS central nervous system
CNSB congenital stationary night blindness
CNV choroidal neovascularization
CO2 carbon dioxide
COMS Collaborative Ocular Melanoma Study
COPD chronic obstructive pulmonary disease
COSA chronic obstructive sleep apnoea
COX cyclo-​oxygenase
CPAP continuous positive airway pressure
CPEO chronic progressive external ophthalmoplegia
CQ chloroquine
CRAO central retinal artery occlusion
CRH corticotropin-​releasing hormone
CRP C-​reactive protein
CRVO central retinal vein occlusion
CSC central serous chorioretinopathy
CSF cerebrospinal fluid
CSMO clinically significant macular oedema
CSNB congenital stationary night blindness
 SYMBOLS AND ABBREVIATIONS xxiii

CSR central serous (chorio)retinopathy

CT computerized tomography
CTA computerized tomography angiography
CTL cytotoxic T lymphocyte
CTV computerized tomography venography
CVA cerebrovascular accident
CVI Certificate of Vision Impairment
CVS cardiovascular system
CVST cerebral venous sinus thrombosis
CWS cotton wool spot
CXR chest X-​ray
d day
D dioptre
Da dalton
DA dark adaptation/​adaptometry
DACE drain–​air–​cryotherapy–​explant
DALK deep anterior lamellar keratoplasty
dB decibel
DC dioptre cylinder
DCCT Diabetes Control and Complications Trial
DCG dacryocystography
DCR dacryocystorhinostomy
DD disc diameter
DED dry eye disease
DEWS II Dry Eye Workshop II
DHA docosahexaenoic acid
DIC disseminated intravascular coagulation
DIDMOAD diabetes insipidus, diabetes mellitus, optic atrophy, deafness
DKA diabetic ketoacidosis
dL decilitre
DLA disability living allowance
DLK diffuse lamellar keratitis deep lamellar keratoplasty
DMEK Descemet’s membrane endothelial keratoplasty
DMO diabetic macular oedema
DNA deoxyribonucleic acid
DOT directly observed therapy
DPP-​4 dipeptidyl peptidase-​4
DR diabetic retinopathy
ds double-​stranded (of nucleic acids)
DS dioptre sphere
vxi

xxiv SYMBOLS AND ABBREVIATIONS

DSG dacryoscintigraphy
DTaP/​IPV/​Hib diphtheria, tetanus, acellular pertussis, inactivated polio
vaccine, Haemophilus influenzae type b
DUSN diffuse unilateral subacute neuroretinitis
DVLA Driver and Vehicle Licensing Agency
DVD dissociated vertical deviation
DVT deep vein thrombosis
Dx drug history
DXA dual X-​ray absorptiometry
EBA epidermolysis bullosa aquista
EBV Epstein–​Barr virus
ECC enhanced corneal compensation
ECCE extracapsular cataract extraction
ECD Erdheim–​Chester disease
ECG electrocardiogram
ECM extracellular matrix
ECP endoscopic cyclophotocoagulation
EDI enhanced depth imaging
EDOF extended depth of focus
EDT electrodiagnostic test
EDTA ethylenediaminetetraacetic acid
EEG electroencephalogram
eGFR estimated glomerular filtration rate
ELISA enzyme-​linked immunosorbent assay
ELM external limiting membrane
EMA European Medicines Agency
EMEDOCT extramacular enhanced depth OCT
EMG electromyography
EMGT Early Manifest Glaucoma Trial
EMM erythema multiforme major
ENT ear, nose, and throat
EOG electro-​oculogram
EOM extraocular muscle
EPA eicosapentaenoic acid
EPT effective phaco time
EQ-​5D EuroQoL-​5D
ERD exudative retinal detachment
ERM epiretinal membrane
ERG electroretinogram
ESA employment and support allowance
 SYMBOLS AND ABBREVIATIONS xxv

ESCRS European Society of Cataract & Refractive Surgeons

ESR erythrocyte sedimentation rate
ETDRS Early Treatment Diabetic Retinopathy Study
ETROP Early Treatment in ROP (trial)
EU European Union
EUA examination under anaesthesia
EUGOGO European Group on Graves’ Ophthalmopathy
E–​W Edinger–​Westphal (nucleus)
EZ ellipsoid zone
FAME fingolimod-​associated macular oedema
FAF fundus autofluorescence
FAT family album test
FAZ focal avascular zone
FB foreign body
FBC full blood count
FDA Food and Drug Administration
FDT fluorescein dye disappearance test
FEF frontal eye field
FEVR familial exudative vitreoretinopathy
FFA fundus fluorescein angiography
FH family history
FHU Fuchs’ heterochromic uveitis
FIA Fédération Internationale de l’Automobile
fL femtolitre
FNA fine-​needle aspiration
FSH follicle-​stimulating hormone
FSL femtosecond laser
ft foot
FTA-​ABS fluorescent treponemal antibody absorption
g gram
G gauge
GA general anaesthesia
GAT Goldmann applanation tonometry
GCA giant cell arteritis
GCL ganglion cell layer
GCS Glasgow Coma Scale
GDP gross domestic product
GEN gaze-​evoked nystagmus
GI gastrointestinal
GLA gamma-​linolenic acid
xvi

xxvi SYMBOLS AND ABBREVIATIONS

Glau-​QoL Glaucoma Quality of Life

Glu glucose
GMS Grocott’s methenamine silver
GnRH gonadotropin-​releasing hormone
GP general practitioner
GPA granulomatosis polyangiitis
GPI generalized paresis of the insane
GRADE Grading of Recommendations Assessment, Development
and Evaluation
GSSG glutathione disulfide
GTN glyceryl trinitrate
GU genitourinary
GVHD graft-​versus-​host disease
Gy gray
h hour
Hb haemoglobin
HbA adult haemoglobin
HbA1c glycated haemoglobin
HCQ hydroxychloroquine
HCV hepatitis C virus
HES hospital eye service
HHV8 human herpesvirus 8
HIV human immunodeficiency virus
HLA human leucocyte antigen
HM hand movements
HPC history of presenting complaints
HPMC hydroxypropylmethylcellulose
HPV human papillomavirus
HR hazard ratio
HRCT high-​resolution computerized tomography
HRQoL health-​related quality of life
HRT Heidelberg retinal tomography; hormone replacement
therapy
HRVO hemiretinal vein occlusion
HSV herpes simplex virus
HTLV human T-​cell lymphotropic virus
HTLV-​1 human T-​cell lymphotropic virus type 1
Hx history
Hz hertz
HZO herpes zoster ophthalmicus
 SYMBOLS AND ABBREVIATIONS xxvii

IBD inflammatory bowel disease

ICA internal carotid artery
ICCE intracapsular cataract extraction
ICD implantable cardioverter–​defibrillator
ICE iridocorneal endothelial (syndrome)
ICG indocyanine green angiography
ICHD-​3 International Classification of Headache Disorders 3
ICP intracranial pressure
ICROP International Classification of Retinopathy of Prematurity
ICRS intracorneal ring segment
iCSNB incomplete congenital stationary night blindness
IFN interferon
IgA immunoglobulin A
IgE immunoglobulin E
IGF insulin-​like growth factor
IgG immunoglobulin G
IgM immunoglobulin M
IGRA interferon gamma release assay
IGT impaired glucose tolerance
IHD ischaemic heart disease
IHS International Headache Society
IIH idiopathic intracranial hypertension
IIHWOP idiopathic intracranial hypertension without papilloedema
IIIn oculomotor nerve
IIn optic nerve
IL interleukin
ILAR International League of Associations of Rheumatologists
ILM internal limiting membrane
IM intramuscular
in inch
INL inner nuclear layer
INO internuclear ophthalmoplegia
INR international normalized ratio
INS infantile nystagmus syndrome
IO inferior oblique
IOFB intraocular foreign body
IOL intraocular lens
IOOA inferior oblique overaction
IOP intraocular pressure
xxivi

xxviii SYMBOLS AND ABBREVIATIONS

IOPcc corneal compensated intraocular pressure

IOPg Goldmann-​correlated intraocular pressure
IPCV idiopathic polypoidal choroidal vasculopathy
IPD interpupillary distance
IPL intense pulsed light
IQ intelligence quotient
IR inferior rectus
IRMA intraretinal microvascular abnormalities
ISCEV International Society for Clinical Electrophysiology of Vision
IS-​OS inner segment–​outer segment
ITC iridotrabecular contact
ITEDS International Thyroid Eye Disease Society
ITP idiopathic thrombocytopenic purpura
ITU intensive therapy unit
IU international unit
IUGR intrauterine growth restriction
IUSG International Uveitis Study Group
IV intravenous
IVC inferior vena cava
IVMP intravenous methylprednisolone
IVn trochlear nerve
Ix investigation
J joule
JIA juvenile idiopathic arthritis
K+ potassium ion
KCS keratoconjunctivitis sicca
kDa kilodalton
kg kilogram
kHz kilohertz
KLAL keratolimbal allograft
KP keratic precipitate
kPa kilopascal
L litre
LA linolenic acid; local anaesthesia/​anaesthetic
LASEK laser-​assisted epithelial keratectomy
LASIK laser stromal in situ keratomileusis
LCA Leber’s congenital amaurosis
LEMS Lambert–​Eaton myasthenic syndrome
LESC limbal epithelial stem cell
 SYMBOLS AND ABBREVIATIONS xxix

LETM longitudinally extensive transverse myelitis

LFA-​1 lymphocyte function-​associated antigen-​1
LFT liver function test
LGN lateral geniculate nucleus
LGV large goods vehicles
LH luteinizing hormone
LHON Leber’s hereditary optic neuropathy
LIO left inferior oblique
LIR left inferior rectus
LMA laryngeal mask airway
LN lymph node; latent nystagmus
LOC loss of consciousness
LogMAR logarithm of the minimum angle of resolution
LP lumbar puncture
LPA laser protection advisor
LPS levator palpebrae superioris
LR lateral rectus
LRI limbal relaxing incision
LRP4 low-​density lipoprotein-​related receptor protein 4
LSO left superior oblique; laser safety officer
LSR left superior rectus
LTBI latent tuberculosis infection
LTK laser thermal keratoplasty
LTS lateral tarsal strip
LVL Low Vision Leaflet
m metre
MacTel macular telangiectasia
MALT mucosa-​associated lymphoid tissue
MAPK mitogen-​activated protein kinase
MAR melanoma-​associated retinopathy
MBq megabecquerel
MCH mean corpuscular haemoglobin
MCP multifocal choroiditis with panuveitis
MC&S microscopy, culture, and sensitivity
MCV mean corpuscular volume
MD mean deviation
MEWDS multiple evanescent white dot syndrome
mfERG multifocal electroretinogram
mfVEP multifocal visual evoked potential
x

xxx SYMBOLS AND ABBREVIATIONS

mg milligram
MG meibomian glands; myasthenia gravis
MGD meibomian gland dysfunction
MHC major histocompatibility complex
MHRA Medicines and Healthcare products Regulatory Agency
MHz megahertz
MI myocardial infarction
MIDD maternally inherited diabetes and deafness
MIGS minimally (micro-​) invasive glaucoma surgery
min minute
mJ millijoule
mL millilitre
MLF medial longitudinal fasciculus
MLN manifest latent nystagmus
mm millimetre
MMC mitomycin C
mmHg millimetre of mercury
mmol millimole
MMP matrix metalloproteinase; mucous membrane pemphigoid
mo month
MOG myelin oligodendrocyte glycoprotein
mol mole
MR medial rectus
MRA magnetic resonance angiography
MRCS microcornea, rod–​cone dystrophy, cataract, and
staphyloma
MRI magnetic resonance imaging
mRNA messenger ribonucleic acid
MRV magnetic resonance venography
MRSA meticillin-​resistant Staphylococcus aureus
ms millisecond
MS multiple sclerosis
MSA Motor Sports Association
MSICS manual small incision cataract surgery
MTMT maximal tolerated medical therapy
mTOR mammalian target of rapamycin
MuSK muscle-​specific tyrosine kinase
mW milliwatt
n. nerve
Na+ sodium ion
 SYMBOLS AND ABBREVIATIONS xxxi

NAA National Assistance Act

NaCl sodium chloride
NBM nil by mouth
NBX necrobiotic xanthogranuloma
Nd-​YAG neodymium-​yttrium-​aluminium-​garnet (laser)
NFI nerve fibre indicator
NF-​1 neurofibromatosis type 1
NF-​2 neurofibromatosis type 2
NFL nerve fibre layer
NHS National Health Service
NHSBT National Health Service Blood and Transplant
NIBP non-​invasive blood pressure
NICE National Institute for Health and Care Excellence
NK neurotrophic keratopathy
nm nanometre
NMO neuromyelitis optica
nmol nanomole
NMOSD neuromyelitis optica spectrum disorders
NNH number needed to harm
NNT number needed to treat
nocte at night
NorA noradrenaline
NPL no perception of light
NPDR non-​proliferative diabetic retinopathy
NPGS non-​penetrating glaucoma surgery
NPV negative predictive value
NRR neuroretinal rim
ns nanosecond
NSAID non-​steroidal anti-​inflammatory drug
NTG normal-​tension glaucoma
NVA neovascularization of the angle
NVD new vessels on the optic disc
NVE new vessels elsewhere
NVG neovascular glaucoma
NVI neovascularization of the iris
OcMMP ocular mucous membrane pemphigoid
OCP ocular cicatricial pemphigoid
OCT optical coherence tomography
OCTA optical coherence tomography angiography
od once daily
xxixi

xxxii SYMBOLS AND ABBREVIATIONS

O/​E on examination
OHT ocular hypertension
OHTS Ocular Hypertension Treatment Study
OIS ocular ischaemic syndrome
OKN optokinetic nystagmus
OMMP ocular mucous membrane pemphigoid
ONL outer nuclear layer
ONTT Optic Neuritis Study Group
OP oscillatory potential
OSS Ocular Staining Score
OSSN ocular surface squamous neoplasia
OTC over-​the-​counter
OVD ophthalmic viscosurgical device
PAC primary angle closure
PACG primary angle-​closure glaucoma
PAM primary acquired melanosis
PAMM paracentral acute middle maculopathy
PAN polyarteritis nodosa
PAS peripheral anterior synechiae; periodic acid–​Schiff
PAT prism adaptation testing
PC presenting complaint; posterior capsule
PCG primary congenital glaucoma
PCO posterior capsule opacification
PCIOL posterior chamber intraocular lens
PCR polymerase chain reaction
PCT prism cover test
PCV polypoidal choroidal vasculopathy; passenger-​carrying
vehicle
PDR proliferative diabetic retinopathy
PDS pigment dispersion syndrome
PDT photodynamic therapy
PE pulmonary embolism
PED pigment epithelial detachment
PEEP positive end-​expiratory pressure
PEP post-​exposure prophylaxis
PERG pattern electroretinogram
PESS post-​enucleation socket syndrome
PET positron emission tomography
PF preservative-​free
PFCL perfluorocarbon liquid
 SYMBOLS AND ABBREVIATIONS xxxiii

pg picogram
PGA prostaglandin analogue
PHMB polyhexamethylene biguanide
PI peripheral iridotomy
PIC punctate inner choroidopathy
PIP personal independence payment
PK penetrating keratoplasty
PL perception of light
PlGF platelet growth factor
Plt platelet
PMH past medical history
PMMA polymethyl methacrylate
pmol picomole
PND paroxysmal nocturnal dyspnoea
PNS peripheral nervous system
PO orally
POAG primary open-​angle glaucoma
POH past ophthalmic history
POHS presumed ocular histoplasmosis syndrome
PORN progressive outer retinal necrosis
PPA peripapillary atrophy
PPCD posterior polymorphous corneal dystrophy
PPD posterior polymorphous dystrophy
PPDR preproliferative diabetic retinopathy
ppm part per million
PPRF paramedian pontine reticular formation
PPV positive predictive value
PRK photorefractive keratectomy
prn as required
pRNFL peripapillary retinal nerve fibre layer
PRO patient-​reported outcome
PROM patient-​reported outcome measure
PRP panretinal photocoagulation
PR-​VEP pattern reversal visual evoked potential
PS posterior synechiae
PsA psoriatic arthritis
PSD pattern standard deviation
PSP progressive supranuclear palsy
PSS Posner-​Schlossman syndrome
PT prothrombin time
xvxi

xxxiv SYMBOLS AND ABBREVIATIONS

PTK phototherapeutic keratectomy

PTT prothrombin time
PUK peripheral ulcerative keratitis
PVD posterior vitreous detachment
PVR proliferative vitreoretinopathy
PVRL primary vitreoretinal lymphoma
PXE pseudoxanthoma elasticum
PXF pseudoexfoliation (syndrome)
q every (e.g. q 1 hour = every 1 hour)
QALY quality-​adjusted life year
QFT-​G QuantiFERON-​TB® Gold
QASP qualifying age for state pension credit
RA rheumatoid arthritis
rAAV recombinant adeno-​associated virus
RAF Royal Air Force
RAP retinal angiomatous proliferation
RAPD relative afferent pupillary defect
RAST radioallergosorbent test
RCC red cell count
RCES recurrent corneal erosion syndrome
RCOphth Royal College of Ophthalmologists
RCPCH Royal College of Paediatrics and Child Health
RCT randomized controlled trial
REP1 Rab escort protein-​1
RES recurrent erosion syndrome
RF rheumatoid factor
RGP rigid gas-​permeable (of contact lenses)
rhNGF recombinant human nerve growth factor
RIO right inferior oblique
RIR right inferior rectus
RK radial keratotomy
RLE refractive lens exchange
RNA ribonucleic acid
RNFL retinal nerve fibre layer
ROP retinopathy of prematurity
RP retinitis pigmentosa
RPE retinal pigment epithelium
RPR rapid plasma reagin
RRD rhegmatogenous retinal detachment
 SYMBOLS AND ABBREVIATIONS xxxv

RRMS relapsing–​remitting multiple sclerosis

rRNA ribosomal ribonucleic acid
RS respiratory system
RSO right superior oblique
RSR right superior rectus
RT-​PCR reverse transcriptase polymerase chain reaction
rtPA recombinant tissue plasminogen activator
RVI Referral of Vision Impairment
RVO retinal vein occlusion
s second
SAL sterility assurance level
SBS shaken baby syndrome
SC subcutaneous
SCC squamous cell carcinoma
SD standard deviation
SD-​OCT spectral domain optical coherence tomography
SF short-​term fluctuation
SF6 sulfur hexafluoride
SF36 Short Form-​36
SGLT-​2 sodium–​glucose cotransporter 2
SH social history
SHRM subretinal hyperreflective material
SI sight-​impaired
Si silicone (of oil)
SIGN Scottish Intercollegiate Guidelines Network
SINS surgery-​induced necrotizing scleritis
siRNA small interfering ribonucleic acid
SJS Stevens–​Johnson syndrome
SITA Swedish interactive threshold algorithm
SLD superluminescent diode
SLE systemic lupus erythematosus
SLM soft lens matter
SLO scanning laser ophthalmoscopy
SLT selective laser trabeculoplasty
SMILE small-​incision lenticule extraction
SO superior oblique
SOM Special Order Manufacturers
SOOF sub-​orbicularis oculi fat
SPC Summary of Product Characteristics
xxvi

xxxvi SYMBOLS AND ABBREVIATIONS

spp. species
SR superior rectus
SRF subretinal fluid
SSI severely sight-​impaired
SSPE subacute sclerosing panencephalitis
STIR short inversion time inversion recovery
SUN Standardization of Uveitis Nomenclature
SVC superior vena cava
SVP spontaneous venous pulsation
T3 triiodothyronine
T4 thyroxine
TAB temporal artery biopsy
TASS toxic anterior segment syndrome
TB tuberculosis
TED thyroid eye disease
TEN toxic epidermal necrolysis
TFOS Tear Film and Ocular Surface Society
TFT thyroid function test
TFBUT tear film break-​up time
TGF transforming growth factor
Th1 T-​helper 1
Th2 T-​helper 2
TI transillumination
TIA transient ischaemic attack
TIBC total iron binding capacity
TINU tubulo-​interstitial nephritis with uveitis
TNF tumour necrosis factor
TPC tenacious proximal convergence
TPHA Treponema pallidum haemagglutination assay
TRD tractional retinal detachment
TRH thyrotropin-​releasing hormone
TSE transmissible spongiform encephalitis
TSH thyroid-​stimulating hormone
TSS-​IOP Treatment Satisfaction Survey for Intraocular Pressure
TST tuberculin skin test
TTP thrombotic thrombocytopenic purpura
U unit
UBM ultrasound biomicroscopy
UC ulcerative colitis
 SYMBOLS AND ABBREVIATIONS xxxvii

U+E urea and electrolytes

UGH uveitis–​glaucoma–​hyphaema syndrome
UK United Kingdom
UKOPG UK Ophthalmic Pharmacy Group
UKPDS UK Prospective Diabetic Study
URTI upper respiratory tract infection
US ultrasound
USA United States
USP United States Pharmacopeia
UV ultraviolet
UVA ultraviolet A
UVB ultraviolet B
UVC ultraviolet C
VA visual acuity
Vn trigeminal nerve
Va,b,c ophthalmic, maxillary, and mandibular divisions of Vn
VCC variable corneal compensation
VCM1 Vision Core Module 1
VDRL venereal disease research laboratory (test)
VEP visual evoked potential
VEGF vascular endothelial growth factor
VF visual field
VH vitreous humour
VHL von Hippel–​Lindau syndrome
VIIn facial nerve
VIn abducens nerve
VIIn facial nerve
VISTA variable inter-​scan time acquisition
VKC vernal keratoconjunctivitis
VKH Vogt–​Koyanagi–​Harada syndrome
VOR vestibulo-​ocular reflex
VPV vitrectomy–​phacoemulsification–​vitrectomy
vs versus
VSD ventricular septal defect
VTE venous thromboembolism
VZV varicella-​zoster virus
WCC white cell count
WHO World Health Organization
wk week
xxixivi

xxxviii SYMBOLS AND ABBREVIATIONS

WNV West Nile virus

XD X-​linked dominant
XL X-​linked
XLRS X-​linked retinoschisis
XR X-​linked recessive
y year
 xxxix

Orthoptic abbreviations

ACS alternating convergent strabismus

ADS alternating divergent strabismus
AHP abnormal head posture
ARC abnormal retinal correspondence
BD base down (of prism)
BI base in (of prism)
BO base out (of prism)
BU base up (of prism)
BSV binocular single vision
CC Cardiff cards
CI convergence insufficiency
Conv XS convergence excess
CSM central steady maintained (of fixation)
CT cover test
DVD dissociated vertical deviation
DVM delayed visual maturation
Ecc fix eccentric fixation
EP esophoria
ET esotropia
E(T) intermittent esotropia
FCPL forced choice preferential looking
FL/​FLE fixing with left eye
FR/​FRE fixing with right eye
HP hyperphoria
HT hypertropia
Hypo hypophoria
HypoT hypotropia
KP Kay’s pictures
LCS left convergent strabismus
LDS left divergent strabismus
MLN manifest latent nystagmus
MR Maddox rod
MW Maddox wing
NPA near point of accommodation
NPC near point of convergence
Another random document with
no related content on Scribd:
“Hunter!” he whispered, and with cocked revolver, Thatcher moved
to his side.
“Well—heavens!”
The exclamation was not spoken in a loud voice; the hand of the
Indian prevented this, for it suddenly closed over the Californian’s
mouth, and he fell to the earth with the words dying on his lips.
New York Harry held a bloody knife in his hand, and Sam Thatcher,
the scout of five-and-twenty years, lay dead at his feet!
Quickly the scalp was jerked from the dead man’s head, and with an
ejaculation of triumph, the murderer turned toward the remaining
border-men.
He gained an elevated spot and looked down upon the couple,
waiting, ignorant of Thatcher’s doom, for his return.
For a moment the Modoc contemplated them, then deliberately
cocked a large navy revolver, and rested it on a shining rock.
No compunctions of conscience arrested the murderous design; the
trigger was drawn, and one of the hunters dropped like a stricken
bullock, without a cry or groan.
The last one, Luke Davis, looked up and caught a glimpse of the
shining pistol-barrel. Instantly he raised his carbine, but the Indian
sent another ball from the rock, and the hunter dropped on his
knees, then prone upon the ground—dead.
The scalping operation, as in Sam Thatcher’s case, followed the
consummation of treachery, and loaded with the arms of the
murdered men, New York Harry disappeared among the gray rocks.
Kit South’s warning had availed them naught; the hand of the traitor
was too swift for Thatcher’s eye. Had the Lava-Bed ranger stood in
his shoes, the result might have been an entirely different one.
The Indian soon disappeared below the surface of the lava
formations, and found himself in a high-ceiled corridor, whose sides
he could touch with his hands. He seemed familiar with its dubious
windings, for he pushed forward with alacrity, and surprised a score
of Modocs in a large cave, almost two miles from the spot where he
had entered the honeycomb.
“Mouseh missed Harry,” said the Modoc chief, greeting the Indian.
“Where he been?”
“To the camp of the blue-coats,” was the reply, in the Klamath
tongue, for New York Harry had spent many years among the
Klamaths, and therefore had acquired their language almost to the
entire exclusion of his own. “General going to send troops after
Mouseh to-morrow. He give Harry guns and pistols—see!”
He thrust the weapons forward, and in the action exposed the trio of
scalps that hung at his belt—a black, a brown and a sandy scalp.
“Where get these?” and a number of savages sprung forward with
cries of delight, as their chief put the interrogative.
“From their owners!” was the reply, and the story of his treachery fell
from the Indian’s lips.
The red rebels listened to it, highly pleased, and at the conclusion
clapped their approval.
“Where white Indian?” asked Harry, sweeping the crowd with the
keenest of sloe-black eyes.
“Dead!” said Jack, laconically.
“Dead?” echoed New York Harry.
“Dead and in the black river. Jack glad he’s gone. Good spy, good
scout; but a very dog!”
“Then where girl?” questioned the traitor.
“Oh, she in cave. Kit and Cohoon get away from Mouseh; but Artena
still in his fingers.”
“Good. The red girl is an accursed snake, and she should die.”
“She shall die!”
“Harry go now, if Mouseh has nothing for him to do,” said the spy,
after a long silence, during which Jack had been busy with his
thoughts.
The Modoc raised his head.
“Harry done well,” and here the chief’s eye fell upon the scalps. “He
be Mouseh’s spy now in place of the white Indian.”
“Mouseh,” and the speaker stepped nearer the chief rebel, “Harry
take three scalps to-night—the scalps of three brave men. Now, he
asks a favor of you.”
“Speak,” said Jack. “Harry is brave; he done much to-night.”
“He wants the pale girl now. Long ago he saw her in her lodge on
Lost River, and loved her pretty face.”
“If Mouseh gives pale flower to Harry, he will not leave the caves?”
“Not while a Modoc lives to fight the blue-coats!”
“The pale girl is Harry’s. What will he do with her?”
“Take her to the little cave which Mouseh knows is Harry’s.”
“It is well. But when the day comes, meet us here. As you say, the
blue-coats will come to-morrow, and we must meet them.”
“I will be here,” said the spy. “When New York Harry turns on
Mouseh, may the Great Spirit strike him with His bolts of fire.”
Then the Indian turned and glided from the cave as noiselessly as he
had entered.
He hurried away as though some important errand demanded
immediate attention, and a few minutes later he confronted the three
guards who stood before the cavern that contained Artena and our
whiter heroine.
A brief conversation with the guards enabled him to step into the
lighted place, and he confronted the captives with an exclamatory
salutation.
During the day just passed the imprisoned twain had slept but little,
although nature needed repose. The phantom of doom that hovered
over their heads served to keep their eyes painfully open, and their
thoughts were not of an enviable nature. Their guards had been as
reticent as statues concerning the designs of Mouseh against their
persons, but the women felt that at any moment the messenger of
death might arrive from the chief, and they would greet him with
open eyes—with every sense alive, keenly so.
’Reesa sprung to her feet when New York Harry’s exclamation fell
upon their ears; but Artena remained on the couch and looked
searchingly up into his eyes.
“So,” said ’Reesa, “Jack has sent for us at last.”
“No. Harry not take captives to Mouseh,” was the quick reply, and
there was an air of self-triumph in his mien. “The cave prisoners are
to be separated.”
“No! no!” and ’Reesa sprung to Artena. “Do not tear us apart.”
“The white girl is unfit to mate with the red traitress,” said Harry,
stepping forward and grasping ’Reesa’s arm. “Jack give you to New
York Harry, and you go with him now. White Indian dead, you see.”
“Yes, and I thank Heaven for it,” cried the scout’s daughter. “Artena,
he shall not—”
Before she could finish her sentence the Indian jerked her from the
Squaw Spy, and started back.
“Give her back to me!”
The cry sprung from Artena’s lips, and with the agility of the jungle-
tiger, she leaped from the couch, knife in hand.
But planting his feet firmly on the ground, the Indian met the charge,
and dexterously knocked the knife aside as it descended.
Then, before Artena could recover, he clutched her throat, and
hurled her with all his might back upon the couch.
“Is this the way you watch your captives?” he demanded, turning to
the guards who had watched the brief combat with bated breath, and
ready weapons. “Here, take the knife, and see that the scarlet tigress
has no more arms secreted upon her person. Mouseh shall hear of
this if you don’t watch his captive closer.”
With the last word he glanced at Artena, lying motionless on the
skins, then strode past the abashed sentries, and turned into the first
corridor that greeted his left hand.
“White girl’s Harry’s captive,” he said in a low tone, addressing the
burden that lay across his arm. “What does she say now? Surely she
recollects the Indians who used to lay flowers on her door-sill on Lost
River. Has the girl forgotten New York Harry? New York Harry—ha!
ha! ha!”
But ’Reesa South made no reply, and after an observation in the
dark, the Indian uttered an exclamation.
His captive was asleep.
Had her ears been on the alert she might have recognized the voice
in the laugh that rung through the gloom.
“This is the fifth passage,” said Harry, suddenly pausing before what
his band told him was the mouth of a subterranean corridor. “I
missed Doctor Frank among the chiefs, and may be that the fool has
played me false. I’ll see while I’m here, for I’m never coming back to
this spot again. Wonder what Jack would say to hear that! But,” as
he deposited his captive on the floor and ignited several lucifer
matches by striking them against the wall, “I’ve had enough of this
war, and when an Indian can save his neck, he’s a fool if he doesn’t.”
For a moment the matches burned blue, and then began to reveal
the interior of the cave.
Slowly a dark object on the floor grew into shape, and the Indian
started back when he recognized it.
It was the figure of an Indian, and the necklace of claws and snake’s
teeth that encircled the swollen and putrid neck, proclaimed him a
medicine-man.
“That’s enough,” said Harry, turning from the bloated carcass to his
prize. “Some strong medicine has killed even a doctor,” and with this
he left the cave.
He depended in a great measure on the guidance of his band, for
eyes could not avail aught in the cimmerian gloom and at last he
paused beside a narrow torrent that pushed its way over many a
rugged rock.
Overhead the stars shone with all the beautiful luster of planets, and
a fresh, cool night-breeze fanned the faces of the twain.
“I must cross this infernal river,” murmured the Indian, suddenly
turning his face up-stream. “And only a short distance up here I can
cross on a natural bridge made for devils—for the spirits of the
Modoc’s evil band.”
He took two steps forward when he suddenly halted, and grew into a
statue on the shore.
One hand covered ’Reesa’s lips, the other the hilt of a knife.
Something had dropped into the water from above—a lava pebble;
but who had loosened it?
He cast his eyes up at the stars, but they had been blotted out of
existence, at least to his orbs of vision.
Somebody was squeezing his person through the hole in the basaltic
ceiling!
There was no doubt of this.
Suddenly New York Harry started forward, knife in hand.
But he paused a second later, for a man had dropped upon the
shore—a man whom he could almost touch with his outstretched
arm. And the aperture was darkened again.
“All right,” whispered the man, in a cautious tone. “The coast is
clear.”
The Indian started, and hugged the black wall with his beautiful
captive. He dared not retreat, for the loose pebbles would betray
him.
Then he saw two other figures join the first, and after a short council
all glided away—down the river.
New York Harry drew a breath of relief, and resumed his journey
once more.
“If I wasn’t going away for good to-night,” he murmured, “I’d spoil the
plans of them three pale faced dogs. Perhaps Mouseh will discover
before day that Donald McKay is not dead—that he still tramps the
lava-beds, and that with Kit South and this pale girl’s dog of a lover.
Let them go. New York Harry is done mixing in their affairs; he
wouldn’t turn back now to save the whole Modoc nation!”
The next moment he reached the foot of a strange bridge, that
spanned the stream with a single arch.
To the person acquainted with the wondrous interior of the lava-
beds, the mention of this bridge will occasion no surprise. The great
convulsion of nature that cast the locale of our story into such a
horrid mold, fashioned the bridge, as the Modocs believe, for the
passage of evil spirits across the stream, and therefore no Indian
had the hardihood to approach the spot.
But “desperate diseases need desperate remedies.” None but a
giant could stem the torrent and gain the opposite bank by
swimming, and the bridge was the only avenue of escape that
presented itself to the traitor.
He secured a new hold on the girl, and griped the blade of the knife
with his teeth, as he climbed upon the structure and advanced.
It took the cunning of his right hand to steady him.
All at once he stopped and crouched to the stones, with a heart
suddenly stilled by terror.
A living object was on the bridge before him, but whether man or
beast he could not tell.
It was a moment of indescribable suspense.
The traitor, without knowing the nature of his foe, would not advance.
But he must cross the river; freedom, safety, lay beyond the further
bank.
At last he started forward again.
No noise.
Perhaps, after all, his senses had deceived him.
A step further.
Ah! there was an enemy on the bridge, for the traitor felt a hand
close on his throat.
It was the hand of an Indian!
New York Harry started up, dropping ’Reesa on the bridge as he did
so, and tried to cope with his still unseen antagonist!
 CHAPTER XIV.
ON THE EVE OF EXECUTION.
New York Harry, as the reader knows, recognized the trio that
dropped through the opening to the bank of the underground river.
They were Kit South, Evan Harris, and the indomitable chief of the
Warm Spring Indians, McKay.
When last the reader encountered the latter, he was leaping into the
river after shooting the red villain who was attempting to murder Kit
and Cohoon, disguised as Klamath runners, and asleep in Jack’s
cave.
Fortunately, the balls of the savage did not injure him, and his strong
arms stemmed the current, which was not so powerful as those of
several other streams running through the lava-beds.
But he was borne far down-stream before he reached the opposite
bank, and after dragging himself in the water, he lay exhausted upon
the wet stones for several hours. Many times he caught the glimmer
of torches that sought to reveal him to his foes; but their light did not
penetrate the gloom that enveloped him, and so he escaped
discovery.
He felt that his first shot had proved fatal, and congratulated himself
that he had rid the world of one hateful excrescence—Baltimore Bob.
For in the person of the would-be assassin who bent over Cohoon,
he recognized the white deserter; but was not aware that Rafe Todd
and Baltimore Bob were identical.
Bob would have a motive for slaying the spies. No doubt he had
penetrated their disguises, but could not convince Jack of their true
character. Therefore he would slay them himself, and after the deed
he would convince Mouseh that two spies had paid the penalty
attached to such a venture as theirs.
“I’m not going back to camp till I see what has become of Artena,”
muttered McKay, with determination. “I’m satisfied that the girl
wouldn’t leave me of her own accord, and I don’t see how an Indian
could take her off ’thout ’sturbin’ me. But I know what I can do. I can
get out o’ this and hunt one o’ the boys up, and lead him back to
Gillem with the news. I’ll do it.”
An examination of his revolvers proved that the waterproof cartridges
had sustained their reputation in his battle with the waves; but he
had been obliged to drop his carbine, in order to save his own life.
A great many tortuous windings brought him to daylight, but when
his eyes greeted it, he paused and shook his head.
He dared not leave the lava-caves and search for his scouts during
the day—so he accepted the situation and waited for darkness.
It came at last, and the captain of the scouts gained the outer crust
of the lava beds, and inaugurated the search for his men. Even
under the cover of darkness this service was extremely hazardous;
but he possessed information which must be conveyed to the Union
General before the next advance. At length the chief found one of his
men, who was at once relieved from duty and dispatched to the
camp with the important intelligence.
“I may await your return here, I may not,” he said to the messenger,
before dismissing him. “Something might turn up to call me away, so,
if you find me missing on your return, don’t be alarmed.”
He took up the scout’s position, and a few minutes later was startled
by a shot to his right.
“That means something,” he murmured, and as he vacated his spot,
for the purpose of inquiring into the noise, he was startled again by
two more pistol discharges in rapid succession.
These were the shots that consummated New York Harry’s
treachery.
The last shot told the half-breed that they were not signals, for a
death-cry reached his ears, and rapidly, but with caution, he neared
the fatal spot.
He found the scalped bodies of the hoodwinked scouts, and was
turning away, when a peculiar but not unfamiliar sound caused a
halt.
Somebody else had been attracted thither by the three death-shots.
Who could it be but Indians?
Noiselessly the scout crawled behind a rock, and with ready
weapons awaited the new-comers, for there seemed to be two.
The stars shone dimly upon the Lava-Beds, yet he could distinguish
objects at the distance of several paces, and when the foremost of
the new-comers came in sight, the scout, seeing at once that he was
not a Warm Spring Indian, drew back with his knife, but did not
strike.
The voice of the foremost man addressing his companion saved the
lives of both.
Then McKay spoke in a whisper:
“Kit?”
The figures paused, and the next minute the chief had joined his
rangers.
“The boys ar’ dead,” said Kit South. “I told Thatcher to watch that
Indian; but Harry war too much for them. I just want to git a hold on
him now. Sam and I war in ‘the war’ together under Canby, and
Jehu! now I want to kill the greaser who played traitor, and then shot
him.”
A brief conversation—in which the parties exchanged personal
narratives—followed, and they resolved to return to the lava caves,
and free Cohoon and the two women from the Indians’ power.
“So my dream won’t come true,” said Kit South, dejectedly, “for you
say you killed Rafe. Well, I’m glad on it, now. Do you think he and
New York Harry ar’ the same, eh ’Van?”
’Van Harris smiled, but did not reply. The argument was against him
now, and the scout saw that he did not like to acknowledge it.
“Well,” continued Kit, “I’ll consider Harry Rafe Todd when I catch him,
and treat the red devil accordingly.”
The trio vacated the spot, and in due time found themselves beside
the underground torrent, and within ten feet of the very man they
were hunting—the very girl, too.
But they knew it not, and, guided by McKay, hurried down-stream
toward the Bloody Cave, which, within the last forty-eight hours,
could lay additional claim to the appellation.
The mission of the three men was dangerous in every sense of the
term, and their movements told that they knew this.
Ever and anon they were compelled to pause and permit Indians to
flit by like dark-robed specters; but they did not put forth a hand to
take a life, for the death-cry might prove the harbinger of their own
doom.
The scouts were preparing for the coming day. Captain Jack knew
that the great guns of his white adversaries would open upon him
with the rising of the sun, and his braves were hastening to stations
already selected by his military eye.
The rescuers spoke not as they glided along, and at last they gained
the elevation from whose summit McKay and Artena had looked into
Bloody Cave.
“I thought we’d take a peep into the lion’s lair, first,” whispered
Donald to Kit, who crept at his side, young Harris having been left at
the river to watch for foes. “I think we’ll hardly—ha! the lion is at
home.”
The exclamation was called forth by the presence of Jack, alone in
the cave.
He stood erect with arms folded upon his breast, and eyes fastened
on the gallows which lately in the presence of his nation, he had
traced on the wall.
“Heavens! what a fine chance to end the Modoc war,” said Kit South,
and his hand involuntarily crept to his revolver. “But it won’t do to
drop him.”
“No,” said McKay regretfully. “We must let the greatest devil in these
parts go scot free. But if we catch him alone in one of these dark
halls we’ll end his days.”
“That we will; but look, Mack, he’s going to leave us. No, he sees
some one—there!”
The chief had turned to greet a young Indian who had just crossed
the threshold of the wide corridor.
“Now listen,” said McKay, and the scouts poked their heads forward
a degree.
“What brings Boston John to Mouseh?” questioned the Modoc chief,
not relishing the disturbance.
“Rattlesnake says that the red star has climbed the horizon,”
answered the trembling brave.
His words caused the chief to start, and a gold watch was drawn
from his bosom.
“Ha! ’tis near day!” exclaimed Jack, returning to its place of
concealment the memento of some butchered blue-coated boy.
“Artena’s time has come!”
Then he glanced once more at the pictured gallows, motioned the
boy away, and followed in his footsteps.
“He’ll guide us to Artena now,” said McKay, touching the border-
man’s arm.
“And to ’Reesa, for where Artena is there will we find my child.”
“Yes, yes. We follow Jack now, though he leads us into the jaws of
death. We can’t get around this cave and catch him on the other
side; we must run through it.”
A low whistle called Evan Harris from his duty, and the next minute
the trio flitted across the cave, and entered the corridor where Jack
had disappeared.
The danger of their undertaking was apparent now. At any moment
the hunted chief might turn upon them in the darkness, and dispatch
all three before an injury could be inflicted upon him.
But Captain Jack did not think of foes on his trail; he was intent upon
doing the deed promised at the rising of Mars—the execution of
Artena.
Already a spirit of mutiny existed in the Modoc ranks. The
Cottonwood branch of the tribe, containing such warriors as Hooker
Jim, Scar-faced Charley, and Shack Nasty Jim, were loud in their
expressions of disapproval of some of Jack’s actions, chief among
which was his leniency toward Artena.
After committing her to the guardianship of Scar-face, the braves
exacted an oath from him that she should die at the rising of the
planet of war.
His appearance before the guards was greeted with guttural
exclamations of triumph, and boldly the chief crossed the threshold
and startled the Squaw Spy with his voice.
“Artena ready to die?” he asked.
The spy looked around upon the occupants of the cave, and then
riveted her eyes upon the rebel.
“Ready,” she answered, seeing no pity in his dark eyes, for no doubt
he had at last reached the conclusion that she was the spy, declared
by his warriors.
“How would she die?”
As he spoke, the Indian held forth his hands, in one of which lay a
pistol, in the other a knife.
Artena’s eyes fell to the weapons, and the death of silence filled the
cavern.
“Reesa isn’t there!” said Kit South, with a groan, at this juncture.
“Where in the name of mercy is my child?”
“We’ll find out directly, Kit,” said McKay, without moving his eyes
from the scene in the cave. “Look! the girl takes the knife!”
Sure enough, the arm of the Squaw Spy had left her side, and was
pointing to the shining blade in Jack’s right hand.
The following moment the Modoc thrust the pistol in his belt, and
stepped forward with uplifted knife.
“Shall he kill her?” whispered Kit.
“No!” and McKay’s lips closed determinedly over the little
monosyllable.
“He is going to make the attempt.”
“Then the Modocs shall not boast of a chief to-morrow.”
The last speaker was Evan Harris, and his revolver, like Kit South’s
carbine, covered Captain Jack’s head.
“Hold your fire till I give the word,” said McKay, “and when you do
touch the trigger, mind that you don’t drop the gal.”
 CHAPTER XV.
NEW ARRIVALS AT DEVIL’S BRIDGE.
The three rangers held their breath, and kept their eyes upon the
striking tableau in the cave.
They waited for the further lifting of the knife that glittered in the
scarlet hand of the Modoc brigand; then they would drive their bullets
to his brain, and rescue Artena from “durance vile.”
The Indian guards had turned from their posts to witness the
execution, and a fierce smile of approval played with their lips.
“Artena goes to the Great Spirit now,” said Jack, suddenly breaking
the silence. “She will never—”
He was not permitted to finish the sentence, for, with a suddenness
that startled every one, the Squaw Spy sprung upon him and
wrested the knife from his hands.
He reeled backward with an exclamation of rage, and barely
escaped the blow she aimed at his heart.
Then Artena whirled upon the guards, who tried to seize her after
she had crossed the threshold of her prison!
“Catch her!” yelled Jack, as he recovered his equilibrium, and leaped
forward, revolver in hand.
But the guards had anticipated his commands, and were pursuing
the flying woman in the gloom, and over the loose rocks that strewed
the floor of the passage.
By and by the three guards returned—empty-handed.
“Where’s Artena?” asked the chief, angrily.
“The spirits of Wonemoc land took her off.”
Captain Jack’s lips curled with a contemptuous sneer.
“Dogs that will let a woman outrun them are not fit to live!” he cried,
and the next instant one of the guards dropped, with a bullet in his
brain.
The others looked to their weapons; but the murderer was too quick
for them; one fell before he could draw his weapon, the other with
the pistol in his hand.
“Thus I deal with dogs!” cried Jack, looking down upon his victims.
“The warriors shall hear that they freed Artena, and that I discovering
their treason, shot them. The traitors even will applaud me; the act
will help make us truer brothers.”
Then he sprung over the dead with the name of the Squaw Spy on
his lips, and the cave was untenanted by the living.
He knew where more than one red warrior lay, and he was
determined that Artena should not escape.
But where was the flying girl? Let us see:
Springing from the cave she ran into the arms of Donald McKay. She
would have shrieked, no doubt, but the ranger’s hand closed over
her mouth, and his lips touched her ear.
“’Tis Mack, girl,” he whispered, “and the boys are with him. Quick! to
the left,” and a moment later the Indians darted past.
The quartette found themselves in a corridor whose floor was devoid
of obstructions, and through the gloom they hurried with hasty feet.
“Hold!” suddenly cried Kit South, touching McKay’s arm.
The party halted.
“I want to know where my gal is?” said the scout. “Artena, what do
you know about her?”
Then, in low whispers, the Squaw Spy related the separating of
herself and Kit’s child by New York Harry.
“Where do you suppose he took her?”
“Artena does not know.”
For a moment the scout was silent.
“He does not mean to stay with Jack any longer, I’m satisfied of this,”
he said, then. “I know that Indian—the sharpest of all the Modocs.
He sees that Jack’s time is drawing to a close, and I’ll wager my rifle
that he’s going back to his old haunts with ’Reesa—back to the
Klamaths.”
“Then we must hunt him above ground,” said Evan Harris.
“Yes, and the sooner we get out o’ this the better.”
“We must cross the river, but where?”
“At the Devil’s Bridge,” answered the scout. “You won’t find an Indian
within a hundred yards of the spot. Why, several years ago, I couldn’t
get Cohoon to put his foot on it, and as we were compelled to cross
the stream, he plunged in, and I had to risk my life to save his.”
When Kit spoke the name of the Warm Spring spy, a hand fell softly
on his arm; but the owner thereof did not speak until he had finished.
“Speak gently of Cohoon,” said a voice in the darkness. “He is dead.”
“Who killed him?”
“The Modocs; they shot him full of holes as he jumped into the river.”
The gritting of teeth was heard in the corridor.
“If ever we git out o’ this, girl, we’ll pay the Indians for those shots,”
said the scout; “but we’ve got to be going. This hall leads to the river
—I know it by the rough walls.”
Then the march was commenced, Donald McKay in the van, and
admirable progress was made until the ranger suddenly brought up
against a stone wall.
“Perdition!” he hissed, turning upon his followers, “the corridor ends
here.”
“Then we’re lost!”
“Yes. In the gloom, I have turned from the true trail. But, hark! we are
near the river! I hear the water dashing over the rocks.”
Then every voice grew still, and the party listened to the sound of the
underground river.
“There must be an outlet to the river,” said young Harris, breaking
the silence. “I believe that a path leads from this cavern straightway
to its brink.”
The walls of the little cavern were examined, but not a single
indenture rewarded the searchers.
“We must get out of here,” McKay said, with stern determination.
“We are not twenty rods from Devil’s Bridge, and once across it, we
are safe. The ceiling may be perforated.”
“True! Lucky thought!” cried Kit South; and the next moment he was
running his tomahawk over the roof of the cave.
“Here is a hole,” he said, suddenly; “but I can barely reach it.”
“It leads up the river—I feel it,” said Harris; “but how can we reach
it?”
A way by which the hole in the ceiling could be utilized was soon
found.
Kit South, supported by McKay’s herculean shoulders, clambered
into the opening, and announced that he was in a corridor which led
to the river.
This was joyful news indeed, and he drew the young ranger and
Artena from the cavern. It then took the united strength of all to draw
the immense form of McKay into the corridor, and for a moment they
paused to recover breath.
A piercing shriek broke the silence, and startled every one.
“That was ’Reesa’s voice, by Heaven!” cried Kit South, springing
forward; but McKay held him back.
“The black path may be full of holes,” he said, admonishingly. “Wait!
we’ll light the way.”
“Then be quick about it, Mack. My gal’s in danger.”
The half-breed stripped his hunting-jacket from his burly form, and
wrapped one sleeve about a knife. A lucifer match ignited the
improvised torch, and, with a bright glare above his head, he started
forward.
All at once Donald McKay paused on the edge of the corridor, and
turned to his companions.
“Look!” he said, holding the torch in a position that enabled all to see
the Devil’s Bridge.
They did look and beheld two men—Indians—struggling like demons
on the rocky arch, which, every second, they threatened to desert for
the blackish water.
“Let ’em fight it out,” said the ranger chief, “then we’ll cross the river.”
But the next instant a cry pealed from Artena’s lips, and her slender
hand pointed forward.
“See!” she cried. “Cohoon is on the bridge! He not dead after all.
See! see!”
“By my heart! she’s right,” exclaimed McKay, “and the other Indian is
—”
“New York Harry! My gal is not far off either. By Heaven! Cohoon
shan’t kill him; he’s for me!”
And drawing a pistol, he took as steady aim as the flickering light of
the torch would allow, and fired. The traitor reeled, and being
released from the encircling arms of his astonished adversary, fell
forward on his face on the rocks.
“Cohoon!” said Kit, advancing toward the Indian. “Gods, we were’nt
looking for you. Where’s ’Reesa?”
“There,” and he pointed to where the insensible form of the girl had
been dropped by the abductor to grapple with his unseen foe.
A moment later she was in her father’s arms.
“Away!” cried Cohoon; “the Modocs rush up the river. The noise of
the pistol has reached their ears.”