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Ophthalmology
Ophthalmology
LEAD EDITORS FIFTH EDITION
Myron Yanoff, MD Jay S. Duker, MD
Chair Emeritus, Ophthalmology Director
Professor of Ophthalmology & Pathology New England Eye Center
Departments of Ophthalmology & Pathology Professor and Chairman
College of Medicine Department of Ophthalmology
Drexel University Tufts Medical Center
Philadelphia, PA, USA Tufts University School of Medicine
Boston, MA, USA

SECTION EDITORS
James J. Augsburger, MD Michael H. Goldstein, MD, MBA Alfredo A. Sadun, MD, PhD
Professor and Chairman Co-Director, Cornea and External Diseases Flora Thornton Chair, Doheny
Department of Ophthalmology Service Professor of Ophthalmology
University of Cincinnati College of Medicine New England Eye Center Vice-Chair of Ophthalmology, UCLA
Cincinnati, OH, USA Tufts Medical Center Los Angeles, CA, USA
Boston, MA, USA
Dimitri T. Azar, MD, MBA Joel S. Schuman, MD
Senior Director, Google Verily Life Sciences Narsing A. Rao, MD Professor and Chairman of Ophthalmology
Distinguished University Professor and B.A. Professor of Ophthalmology and Pathology Director, NYU Eye Center
Field Chair of Ophthalmic Research USC Roski Eye Institute Professor of Neuroscience and Physiology
Professor of Ophthalmology, Pharmacology, and Department of Ophthalmology Neuroscience Institute
Bioengineering University of Southern California NYU School of Medicine
University of Illinois at Chicago Los Angeles, CA, USA Professor of Electrical and Computer
Chicago, IL, USA Engineering
Shira L. Robbins, MD NYU Tandon School of Engineering
Sophie J. Bakri, MD Clinical Professor of Ophthalmology
Professor of Neural Science
Professor of Ophthalmology Ratner Children’s Eye Center at the Shiley Eye
Center for Neural Science, NYU
Vitreoretinal Diseases & Surgery Institute
New York, NY, USA
Mayo Clinic University of California San Diego
Rochester, MN, USA La Jolla, CA, USA Janey L. Wiggs, MD, PhD
Paul Austin Chandler Professor of
Scott E. Brodie, MD, PhD Emanuel S. Rosen, MD, FRCS, Ophthalmology
Professor of Ophthalmology FRCOphth Harvard Medical School
NYU School of Medicine Private Practice Boston, MA, USA
New York, NY, USA Case Reports Editor for Journal of Cataract &
Jonathan J. Dutton, MD, PhD Refractive Surgery
Professor Emeritus Manchester, UK
Department of Ophthalmology
University of North Carolina
Chapel Hill, NC, USA
For additional online content visit ExpertConsult.com

Edinburgh London New York Oxford Philadelphia St Louis Sydney 2019

© 2019, Elsevier Inc. All rights reserved.

First edition 1999

Second edition 2004
Third edition 2009
Fourth edition 2014

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).

Chapter 4.29: “Endothelial Keratoplasty: Targeted Treatment for Corneal Endothelial Dysfunction” by
Marianne O. Price, Francis W. Price, Jr.
Marianne O. Price and Francis W. Price, Jr. retain copyright of the video accompanying this chapter.

Chapter 6.5: “Contact B-Scan Ultrasonography” by Yale L. Fisher, Dov B. Sebrow

Yale L. Fisher retains copyright of the video accompanying this chapter. The remainder of this lecture as
well as additional lectures on ophthalmology can be found at www.OphthalmicEdge.org.

Chapter 7.2: “Mechanisms of Uveitis” by Igal Gery, Chi-Chao Chan

This chapter is in the Public Domain.

Chapter 7.23: “Masquerade Syndromes: Neoplasms” by Nirali Bhatt, Chi-Chao Chan, H. Nida Sen
This chapter is in the Public Domain.

Chapter 11.8: “Torsional Strabismus” by Scott K. McClatchey, Linda R. Dagi

This chapter is in the Public Domain.

Chapter 12.16: “Aesthetic Fillers and Botulinum Toxin for Wrinkle Reduction” by Jean Carruthers,
Alastair Carruthers
Jean Carruthers retains copyright of Figures 12.16.1 & 12.16.6.

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds or experiments described herein. Because of
rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug
dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier,
authors, editors or contributors for any injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.

ISBN: 978-0-323-52819-1
E-ISBN: 978-0-323-52821-4
ISBN: 978-0-323-52820-7

Content Strategist: Russell Gabbedy

Content Development Specialist: Sharon Nash
Content Coordinator: Joshua Mearns
Project Manager: Joanna Souch
Design: Brian Salisbury
Illustration Manager: Karen Giacomucci
Illustrator: Richard Tibbitts
Marketing Manager: Claire McKenzie

Printed in China

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

 User Guide

User Guide
COLOR CODING
Ophthalmology is organized into 12 parts, which are color-coded as follows
for quick and easy reference:

Part 1: Genetics

Part 2: Optics and Refraction

Part 3: Refractive Surgery

Part 4: Cornea and Ocular Surface Diseases

Part 5: The Lens

Part 6: Retina and Vitreous

Part 7: Uveitis and Other Intraocular Inflammations

Part 8: Intraocular Tumors

Part 9: Neuro-Ophthalmology

Part 10: Glaucoma

Part 11: Pediatric and Adult Strabismus

Part 12: Orbit and Oculoplastics

EXPERTCONSULT WEBSITE
n Full searchable text and downloadable image gallery
n Full reference lists for each chapter
n Additional online content including text, figures, & video clips

v
 Video Contents Video available at
Video Contents
ExpertConsult.com

Part 3: Refractive Surgery Chapter 6.25 Coats’ Disease and Retinal Telangiectasia
Chapter 3.4 LASIK 6.25.1 Pars Plana Vitrectomy and Subretinal Fluid and Exudate Drainage Performed
for a Severe Exudative Retinal Detachment
3.4.1 iLASIK
Chapter 6.32 Macular Hole
Chapter 3.5 Small Incision Lenticule Extraction (SMILE)
6.32.1 Macular Hole Surgery
3.5.1 SMILE Instructional Video
Chapter 6.33 Epiretinal Membrane
Chapter 3.7 Phakic Intraocular Lenses
6.33.1 Epiretinal Membrane Removal
3.7.1 Cachet Lens
3.7.2 Artisan/Verisyse Lens Implantation for Hyperopia After Radial Keratotomy Chapter 6.34 Vitreomacular Traction
3.7.3 Toric Artiflex Phakic Intraocular Lens in a Patient With High Myopia and
6.34.1 Vitreomacular Traction Syndrome
Astigmatism After Deep Anterior Lamellar Keratoplasty
3.7.4 Toric Artiflex Lens Implantation in a Patient With a Previous Intracorneal Chapter 6.39 Rhegmatogenous Retinal Detachment
Ring for Keratoconus 6.39.1 Internal Limiting Membrane (ILM) Peeling for Primary Rhegmatogenous
3.7.5 ICL Implantation Repair to Reduce Postoperative Macular Pucker
3.7.6 ICL Exchange
Chapter 6.41 Choroidal Hemorrhage
Part 4: Cornea and Ocular Surface Diseases 6.41.1 Transconjunctival Trocar/Cannula Drainage of Suprachoroidal Fluid
Chapter 4.17 Noninfectious Keratitis
Chapter 6.43 Posterior Segment Ocular Trauma
4.17.1 Patient With Lax Eyelids Recommended for Sleep Study
6.43.1 Intraocular Foreign Body Removal
Chapter 4.29 Endothelial Keratoplasty: Targeted Treatment for Corneal 6.43.2 Intraocular Foreign Body Removal With Rare Earth Magnet
Endothelial Dysfunction
Part 9: Neuro-Ophthalmology
4.29.1 DSEK Pull-Through
4.29.2 DMEK Donor Preparation Chapter 9.19 Nystagmus, Saccadic Intrusions, and Oscillations
4.29.3 Descemet’s Membrane Endothelial Keratoplasty (DMEK) 9.19.1 Congenital Nystagmus
9.19.2 Oculocutaneous Albinism With Associated Nystagmus
Part 5: The Lens 9.19.3 Latent Nystagmus
Chapter 5.8 Anesthesia for Cataract Surgery 9.19.4 Spasmus Nutans
5.8.1 Standard Technique for Sub-Tenon’s Anesthesia 9.19.5 Right Internuclear Ophthalmoplegia
5.8.2 “Incisionless” Technique for Sub-Tenon’s Anesthesia 9.19.6 Convergence Retraction Nystagmus in Parinaud’s Syndrome

Chapter 5.9 Phacoemulsification Part 10: Glaucoma

5.9.1 Two Examples of “Sculpting” Using Low Flow and Vacuum but Higher Chapter 10.7 Optic Nerve Analysis
Power/Amplitude 10.7.1 Three-Dimensional Imaging of the Optic Nerve Head
5.9.2 Two Examples of Using Higher Flow and Vacuum for Nucleus Fragment
Removal Chapter 10.28 Minimally Invasive and Microincisional Glaucoma Surgeries
Chapter 5.11 Small Incision and Femtosecond Laser-Assisted 10.28.1 iStent G1 Implantation
Cataract Surgery 10.28.2 Key Steps in Trabectome Surgery
5.11.1 Unexpected Subluxation Chapter 10.29 Trabeculectomy
5.11.2 Microincision Phaco 10.29.1 Bleb Leak Detection Using Concentrated Fluorescein Dye
5.11.3 Microincision Refractive Lens Exchange 10.29.2 Trabeculectomy With Mitomycin C
5.11.4 700µ Phaco 10.29.3 5-Fluorouracil Subconjunctival Injection
Chapter 5.13 Combined Procedures Chapter 10.32 Complications of Glaucoma Surgery and Their Management
5.13.1 Combined Phacoemulsification Cataract Surgery and Descemet’s Stripping 10.32.1 Small Pupil Cataract Surgery With Use of Pupil Expansion Ring (I-Ring;
Automated Endothelial Keratoplasty (DSAEK) Beaver Visitec, Waltham, MA) and Trypan Blue Capsular Staining
5.13.2 Combined Phacovitrectomy 10.32.2 Repair of Bleb Leak
Chapter 5.16 Complications of Cataract Surgery
Part 11: Pediatric and Adult Strabismus
5.16.1 Artisan Implantation
Chapter 11.3 Examination of Ocular Alignment and Eye Movements
Part 6: Retina and Vitreous 11.3.1 Strabismus Exam Elements
Chapter 6.3 Retinal and Choroidal Circulation 11.3.2 Cover/Uncover Test
11.3.3 Exotropia
6.3.1 Fluorescein and Indocyanine Green (ICG) Video Angiogram 11.3.4 Esotropia
Chapter 6.5 Contact B-Scan Ultrasonography 11.3.5 Hypertropia
11.3.6 Prism Alternate Cover Test
6.5.1 Examination Techniques for Contact B-Scan Ultrasonography
11.3.7 Simultaneous Prism Cover Test
Chapter 6.11 Scleral Buckling Surgery 11.3.8 Exophoria
11.3.9 Alternate or Cross Cover Test
6.11.1 Scleral Buckle
6.11.2 Suture Total running time approximately 2 hours and 34 minutes
6.11.3 Drain
Chapter 6.12 Vitrectomy
6.12.1 Vitrectomy for Nonclearing Vitreous Hemorrhage

vi
 Preface
Preface

It’s been 20 years since the first edition of Ophthalmology was published. Ophthalmology was never intended to be encyclopedic, but with each
We are delighted that our textbook now has gone to a fifth edition. The lon- edition we strived to make it quite comprehensive, readable, and easy to
gevity of this title reflects the uniqueness and utility of its format; the hard access. Like the fourth edition, this edition is thoroughly revised, with new
work of our authors, editors, and publishers; and the pressing need in our section editors and many new authors. Chapters have been rewritten and
field for updated, clinically relevant information. We continue to recognize restricted to reflect the new way diseases are diagnosed, categorized, and
the advantage of a complete textbook of ophthalmology in a single volume treated. We have discarded out-of-date material and have added numerous
rather than multiple volumes. The basic visual science is admixed with new items. Extra references and other material have been moved online to
clinical information throughout, and we have maintained an entire sepa- keep the book itself as one volume.
rate section dedicated to genetics and the eye.

xii
 Preface to First Edition

Preface to First Edition

Over the past 30 years, enormous technologic advances have occurred in To achieve the same continuity of presentation in the figures as well
many different areas of medicine—lasers, molecular genetics, and immu- as in the text, all of the artworks have been redesigned from the authors’
nology to name a few. This progress has fueled similar advances in almost originals, maximizing their accessibility for the reader. Each section is
every aspect of ophthalmic practice. The assimilation and integration of color coded for easy cross-referencing and navigation through the book.
so much new information makes narrower and more focused ophthalmic Despite the extensive use of color in artworks and photographs through-
practices a necessity. As a direct consequence, many subspecialty textbooks out, the cost of this comprehensive book has been kept to a fraction of the
with extremely narrow focus are now available, covering every aspect of multivolume sets. We hope to make this volume more accessible to more
ophthalmic practice. Concurrently, several excellent multivolume textbooks practitioners throughout the world.
detailing all aspects of ophthalmic practice have been developed. Yet there Although comprehensive, Ophthalmology is not intended to be encyclo-
remains a need for a complete single-volume textbook of ophthalmology pedic. In particular, in dealing with surgery, we do not stress specific tech-
for trainees, nonophthalmologists, and those general ophthalmologists niques or describe rarer ones in meticulous detail. The rapidly changing
(and perhaps specialists) who need an update in specific areas in which nature of surgical aspects of ophthalmic practice is such that the reader
they do not have expertise. Ophthalmology was created to fill this void will need to refer to one or more of the plethora of excellent books that
between the multivolume and narrow subspecialty book. cover specific current techniques in depth. We concentrate instead on
This book is an entirely new, comprehensive, clinically relevant, sin- the areas that are less volatile but, nevertheless, vital surgical indications,
gle-volume textbook of ophthalmology, with a new approach to content and general principles of surgical technique, and complications. The approach
presentation that allows the reader to access key information quickly. Our to referencing is parallel to this: For every topic, all the key references are
approach, from the outset, has been to use templates to maintain a uniform listed, but with the aim of avoiding pages of redundant references where a
chapter structure throughout the book so that the material is presented in smaller number of recent classic reviews will suffice. The overall emphasis
a logical, consistent manner, without repetition. The majority of chapters of Ophthalmology is current information that is relevant to clinical practice
in the book follow one of three templates: the disease-oriented template, superimposed on the broad framework that comprises ophthalmology as
the surgical procedure template, or the diagnostic testing template. Metic- a subspecialty.
ulous planning went into the content, sectioning, and chapter organization Essential to the realization of this ambitious project is the ream of
of the book, with the aim of presenting ophthalmology as it is practiced, Section Editors, each bringing unique insight and expertise to the book.
rather than as a collection of artificially divided aspects. Thus, pediatric They have coordinated their efforts in shaping the contents list, finding
ophthalmology is not in a separate section but is integrated into relevant contributors, and editing chapters to produce a book that we hope will
sections across the book. The basic visual science and clinical information, make a great contribution to ophthalmology.
including systemic manifestations, is integrated throughout, with only two We are grateful to the editors and authors who have contributed to
exceptions. We dedicated an entire section to genetics and the eye, in rec- Ophthalmology and to the superb, dedicated team at Mosby.
ognition of the increasing importance of genetics in ophthalmology. Optics Myron Yanoff
and refraction are included in a single section as well because an under- Jay S. Duker
standing of these subjects is fundamental to all of ophthalmology. July 1998

xiii
 List of Contributors
List of Contributors

The editor(s) would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition
would not have been possible.

Erika C. Acera, OC(C) Ferhina S. Ali, MD, MPH Steve A. Arshinoff, MD, FRCSC Nicole Balducci, MD
Clinical Orthoptist Vitreoretinal Surgery Fellow Associate Professor Consultant
Department of Ophthalmology Wills Eye Hospital University of Toronto Ophthalmology Division
Anne F. and Abraham Ratner Retina Service Department of Ophthalmology and Studio Oculistico d’Azeglio
Children’s Eye Center Mid Atlantic Retina Visual Sciences Bologna, Italy
Shiley Eye Institute Philadelphia, PA, USA Toronto, ON, Canada
University of California San Diego Piero Barboni, MD
La Jolla, CA, USA Jorge L. Alió, MD, PhD Penny A. Asbell, MD, FACS, FARVO Consultant
Professor of Ophthalmology Professor of Ophthalmology Neuro-Ophthalmology
Natalie A. Afshari, MD Miguel Hernandez University, Vissum Icahn School of Medicine at Mount Scientific Institute San Raffaele
Stuart I. Brown MD Chair in Alicante, Spain Sinai Milan, Italy
Ophthalmology in Memory of New York, NY, USA Studio Oculistico d’Azeglio
Donald P. Shiley Norma Allemann, MD Bologna, Italy
Professor of Ophthalmology Adjunct Professor Kerry K. Assil, MD
Chief of Cornea and Refractive Surgery Department of Ophthalmology and Corneal, Cataract and Refractive Cullen J. Barnett, COT, CRA, OCT-C,
Vice Chair of Education Visual Sciences Surgeon CDOS
Shiley Eye Institute University of Illinois at Chicago Medical Director Clinical Supervisor of Ophthalmology
University of California San Diego Chicago, IL, USA The Assil Eye Institute Roski Eye Institute
La Jolla, CA, USA Adjunct Professor Beverly Hills, CA, USA Keck Medicine USC
Department of Ophthalmology and Los Angeles, CA, USA
Anita Agarwal, MD Visual Sciences Neal H. Atebara, MD, FACS
Adjoint Professor of Ophthalmology Escola Paulista de Medicina (EPM) Associate Professor Soumyava Basu, MS
Vanderbilt Eye Institute Universidade Federal de São Paulo Department of Surgery Head of Uveitis Services
West Coast Retina (UNIFESP) University of Hawaii LVPEI Network
Vanderbilt University Medical Center São Paulo, SP, Brazil John A. Burns School of Medicine L V Prasad Eye Institute
San Francisco, CA, USA Honolulu, HI, USA Bhubaneswar, Odisha, India
David Allen, BSc, MB, BS, FRCS,
Joshua S. Agranat, MD FRCOphth James J. Augsburger, MD Priti Batta, MD
Resident Physician Consultant Ophthalmologist (Cataract) Professor of Ophthalmology Assistant Professor of Ophthalmology
Department of Ophthalmology Cataract Treatment Centre Dr. E. Vernon & Eloise C. Smith Chair Director of Medical Student Education
Massachusetts Eye and Ear Sunderland Eye Infirmary of Ophthalmology New York Eye and Ear Infirmary of
Harvard Medical School Sunderland, Tyne & Wear, UK College of Medicine, University of Mount Sinai
Boston, MA, USA Cincinnati New York, NY, USA
Keith G. Allman, MBChB, MD, FRCA Founding Director, Ocular Oncology &
Radwan S. Ajlan, MBBCh, FRCS(C), Consultant Anaesthetist Diagnostic Ultrasonography Service, Caroline R. Baumal, MD, FRCSC
FICO, DABO West of England Eye Unit University of Cincinnati Medical Associate Professor of Ophthalmology
Assistant Professor Royal Devon and Exeter NHS Trust Center Director ROP Service
Retina and Vitreous Exeter, Devon, UK Attending Surgeon, University of Vitreoretinal Surgery
Department of Ophthalmology Cincinnati Medical Center New England Eye Center
University of Kansas School of Nishat P. Alvi, MD Consulting Surgeon, Cincinnati Tufts University
Medicine Medical Director of Ophthalmology Children’s Hospital Medical Center School of Medicine
Kansas City, KS, USA The Vision Institute of Illinois Cincinnati, OH, USA Boston, MA, USA
Elgin, IL, USA
Anam Akhlaq, MBBS G. William Aylward, FRCS, FRCOphth, Srilaxmi Bearelly, MD, MHS
Postdoctoral Fellow Leonard P.K. Ang, MBBS, MD, FRCS, MD Assistant Professor of Ophthalmology
Center for Translational Ocular MRCOphth, MMed, FAMS Consultant Ophthalmologist Ophthalmology
Immunology Associate Professor of Ophthalmology London, UK Columbia University Medical Center
Department of Ophthalmology Medical Director, Lang Eye Centre New York, NY, USA
Tufts Medical Center Singapore Dimitri T. Azar, MD, MBA
Senior Director, Google Verily Life Jesse L. Berry, MD
Boston, MA, USA David J. Apple, MD †
Associate Director, Ocular Oncology
Sciences
Thomas A. Albini, MD Formerly Professor of Ophthalmology Distinguished University Professor Service
Associate Professor of Ophthalmology and Pathology and B.A. Field Chair of Ophthalmic Associate Residency Program Director
Department of Ophthalmology Director, Laboratories for Ophthalmic Research for Ophthalmology
Bascom Palmer Eye Institute Devices Research Professor of Ophthalmology, USC Roski Eye Institute
University of Miami John A. Moran Eye Center Pharmacology, and Bioengineering Keck School of Medicine, University of
Miami, FL, USA University of Utah University of Illinois at Chicago Illinois Southern California
Salt Lake City, UT, USA College of Medicine Attending Surgeon, Children’s Hospital
Ahmed Al-Ghoul, MD, MBA, FRCSC, Chicago, IL, USA of Los Angeles
DipABO Maria Cecilia D. Aquino, MD, MMED, Los Angeles, CA, USA
Clinical Lecturer (Ophthalmology) Sophie J. Bakri, MD
Division of Ophthalmology Resident Physician II Professor of Ophthalmology Angela P. Bessette, MD
Department of Surgery Ophthalmology/Glaucoma Vitreoretinal Diseases & Surgery Assistant Professor
University of Calgary National University Hospital Mayo Clinic Department of Ophthalmology
Calgary, AB, Canada National University Health System Rochester, MN, USA Flaum Eye Institute
Singapore University of Rochester
Laura J. Balcer, MD, MSCE Rochester, NY, USA
Anthony C. Arnold, MD Professor of Neurology
Professor and Chief Vice-Chair, Neurology
Neuro-Ophthalmology Division New York University
xiv UCLA Stein Eye Institute
Los Angeles, CA, USA
School of Medicine
†
Deceased New York, NY, USA
Nirali Bhatt, MD Igor I. Bussel, MS, MHA Chi-Chao Chan, MD Abbot (Abe) Clark, PhD, FARVO
Assistant Professor Doris Duke Clinical Research Fellow Scientist Emeritus Regents Professor of Pharmacology

List of Contributors
Department of Ophthalmology Department of Ophthalmology Laboratory of Immunology and Neuroscience
University of Pennsylvania University of Pittsburgh School of National Eye Institute Executive Director, North Texas Eye
Perelman School of Medicine Medicine National Institutes of Health Research Institute
Philadelphia, PA, USA Pittsburgh, PA, USA Bethesda, MD, USA University of North Texas Health
Visiting Professor Science Center
Orry C. Birdsong, MD Louis B. Cantor, MD Zhongshan Ophthalmic Center Fort Worth, TX, USA
Clinical Fellow Jay C. and Lucile L. Kahn Professor Sun Yat-Sen University
Ophthalmology and Chair China Jonathan C.K. Clarke, MD, FRCOphth
Hoopes Vision Department of Ophthalmology Consultant Ophthalmologist
Draper, UT, USA Indiana University Melinda Y. Chang, MD NIHR Moorfields Biomedical Research
School of Medicine Assistant Professor of Ophthalmology Centre
Jyotirmay Biswas, MS, FMRF, FNAMS, Indianapolis, IN, USA USC Roski Eye Institute and Children’s Moorfields Eye Hospital
FIC, Path, FAICO Hospital Los Angeles UCL Institute of Ophthalmology
Director Hilda Capó, MD Keck School of Medicine of the London, UK
Uveitis and Ocular Pathology Professor of Clinical Ophthalmology University of Southern California
Department Bascom Palmer Eye Institute Los Angeles, CA, USA François Codère, MD
Sankara Nethralaya Division Chief Pediatric Associate Professor
Chennai, Tamil Nadu, India Ophthalmology and Adult Stanley Chang, MD Ophthalmology/Oculoplastic and
Strabismus KK Tse and KT Ying Professor of Orbital Surgery Section
Bahram Bodaghi, MD, PhD, FEBOphth Miller School of Medicine Ophthalmology Université de Montréal
Professor of Ophthalmology John T. Flynn Professor of Department of Ophthalmology Montréal, QC, Canada
DHU ViewRestore Ophthalmology Chair Columbia University
APHP, UPMC, Sorbonne University University of Miami New York, NY, USA Ian P. Conner, MD, PhD
Paris, France Miami, FL, USA Assistant Professor
Victoria S. Chang, MD Ophthalmology
Swaraj Bose, MD Antonio Capone, Jr., MD Assistant Professor of Clinical UPMC Eye Center
Associate Professor of Ophthalmology Professor Ophthalmology Pittsburgh, PA, USA
UCI and Attending Physician Department of Ophthalmology Ophthalmology, Cornea and External
Cedars Sinai Medical Center Oakland University Disease Peter Coombs, MD
Los Angeles, CA, USA William Beaumont Hospital Bascom Palmer Eye Institute Vitreoretinal Physician and Surgeon
School of Medicine University of Miami Utah Eye Centers
Charles S. Bouchard, MD, MA Salt Lake City, UT, USA
Professor and Chairman of Auburn HIlls, MI, USA Naples, FL, USA
Ophthalmology Alastair Carruthers, MA, BM, BCh, David G. Charteris, MD, FRCS(Ed), Zélia M. Corrêa, MD, PhD
Loyola University Health System FRCP(Lon), FRCPC FRCOphth Tom Clancy Endowed Professor of
Maywood, IL, USA Clinical Professor Professor Ophthalmology
Department of Dermatology and Skin Vitreoretinal Unit Head of Ocular Oncology and
Michael E. Boulton, PhD Echography
Susan and Dowd Ritter/RPB Endowed Science Moorfields Eye Hospital
University of British Columbia London, UK Retina Service, Wilmer Eye Institute
Chair of Ophthalmology Johns Hopkins University School of
University of Alabama Birmingham Vancouver, BC, Canada
Soon-Phaik Chee, MD Medicine
Birmingham, AL, USA Jean Carruthers, MD, FRCSC, Professor Baltimore, MD, USA
James D. Brandt, MD FRC(OPHTH) Cataract Service, Ocular Inflammation
Clinical Professor & Immunology Service Steven M. Couch, MD, FACS
Professor Assistant Professor
Department of Ophthalmology & Department of Ophthalmology Singapore National Eye Centre
University of British Columbia Singapore Department of Ophthalmology &
Vision Science Visual Sciences
Vice-Chair for International Programs Fellow
American Society for Ophthalmic John J. Chen, MD, PhD Washington University in St Louis
and New Techology Assistant Professor St Louis, MO, USA
Director - Glaucoma Service Plastic and Reconstructive Surgery
Vancouver, BC, Canada Department of Ophthalmology and
University of California Davis Neurology Stuart G. Coupland, PhD
Sacramento, CA, USA Keith D. Carter, MD, FACS Mayo Clinic Associate Professor
Lillian C. O’Brien and Dr. C.S. O’Brien Rochester, MN, USA Department of Ophthalmology
Scott E. Brodie, MD, PhD University of Ottawa
Professor of Ophthalmology Chair in Ophthalmology
Professor and Chair Xuejing Chen, MD, MS Ottawa, ON, Canada
NYU School of Medicine Clinical Fellow
New York, NY, USA Department of Ophthalmology & Claude L. Cowan, Jr., MD, MPH
Visual Sciences Retina
Ophthalmic Consultants of Boston Clinical Professor of Ophthalmology
Michael C. Brodsky, MD Carver College of Medicine Georgetown University Medical Center
Professor of Ophthalmology and University of Iowa New England Eye Center at Tufts
Medical Center Washington, DC, USA
Neurology Iowa City, IA, USA Staff Physician
Knights Templar Research Professor of Boston, MA, USA
Rafael C. Caruso, MD Surgical Service
Ophthalmology Paul T.K. Chew, MMed, FRCOphth Veterans Affairs Medical Center
Mayo Clinic Staff Clinician
National Eye Institute Director Glaucoma Division Washington, DC, USA
Rochester, MN, USA Ophthalmology/Glaucoma
National Institutes of Health E. Randy Craven, MD
Cassandra C. Brooks, MD Bethesda, MD, USA National University Hospital Singapore
Singapore Associate Professor, Glaucoma
Resident in Ophthalmology Johns Hopkins University
Duke Eye Center Harinderpal S. Chahal, MD
Oculofacial Plastic and Reconstructive Bing Chiu, MD Baltimore, MD, USA
Duke University School of Medicine Ophthalmology Resident
Durham, NC, USA Surgery Catherine A. Cukras, MD, PhD
Eye Medical Center New York University
New York, NY, USA Director, Medical Retina Fellowship
Matthew V. Brumm, MD Fresno, CA, USA Program
Ophthalmologist Clement C. Chow, MD National Eye Institute
Cataract and Refractive Surgery Wallace Chamon, MD
Adjunct Professor Partner Physician National Institutes of Health
Brumm Eye Center Retinal Diagnostic Center Bethesda, MD, USA
Omaha, NE, USA Department of Ophthalmology and
Visual Sciences Campbell, CA, USA
Linda R. Dagi, MD
Donald L. Budenz, MD, MPH University of Illinois at Chicago Mortimer M. Civan, MD Director of Adult Strabismus
Kittner Family Distinguished Professor Chicago, IL, USA Professor of Physiology and Professor Boston Children’s Hospital
and Chairman Adjunct Professor of Medicine Associate Professor of Ophthalmology
Department of Ophthalmology Department of Ophthalmology and Department of Physiology Director of Quality Assurance
University of North Carolina at Chapel Visual Sciences University of Pennsylvania Department of Ophthalmology
Hill Escola Paulista de Medicina (EPM) Perelman School of Medicine Children’s Hospital Ophthalmology
Chapel Hill, NC, USA Universidade Federal de São Paulo Philadelphia, PA, USA Foundation Chair
(UNIFESP) Harvard Medical School
São Paulo, SP, Brazil Boston, MA, USA
xv
 Elie Dahan, MD, MMed, (Ophth)† Gary R. Diamond, MD† Bryan Edgington, MD Ayad A. Farjo, MD
Formerly Senior Consultant Pediatric Formerly Professor of Ophthalmology Associate Professor, Cornea Division President & Director
List of Contributors
Ophthalmology and Glaucoma and Pediatrics Casey Eye Institute Brighton Vision Center
Department of Ophthalmology Drexel University School of Medicine Oregon Health Sciences University Brighton, MI, USA
Ein Tal Eye Hospital Philadelphia, PA, USA Staff Ophthalmologist
Tel Aviv, Israel Veterans Health Administration Eric Feinstein, MD
Daniel Diniz, MD Portland Health Care System Surgical Retina Fellow
Iben Bach Damgaard, MD Surgical Optics Fellow Portland, OR, USA Department of Ophthalmology
PhD Fellow Department of Ophthalmology & Rocky Mountain Lions Eye Institute
Department of Ophthalmology Visual Sciences Howard M. Eggers, MD University of Colorado
Aarhus University Hospital Federal University of São Paulo Professor of Clinical Ophthalmology School of Medicine
Aarhus, Denmark (UNIFESP) Harkness Eye Institute Denver, CO, USA
São Paulo, SP, Brazil New York, NY, USA
Karim F. Damji, MD, FRCSC, MBA Karen B. Fernandez, MD
Professor Diana V. Do, MD Dean Eliott, MD Consultant
Department of Ophthalmology & Professor of Ophthalmology Stelios Evangelos Gragoudas Associate Department of Ophthalmology
Visual Sciences Byers Eye Institute Professor of Ophthalmology The Medical City
University of Alberta Stanford University Harvard Medical School Pasig City, Metro Manila, Philippines
Edmonton, AL, Canada School of Medicine Associate Director, Retina Service
Palo Alto, CA, USA Massachusetts Eye & Ear Yale L. Fisher, MD
Dipankar Das, MD Boston, MA, USA Voluntary Clinical Professor
Senior Consultant & Ocular Pathologist Peter J. Dolman, MD, FRCSC Department of Ophthalmology
Uveitis, Ocular Pathology and Neuro- Clinical Professor George S. Ellis, Jr., MD, FAAP, FAAO, Bascom Palmer Eye Institute
ophthalmology Services Division Head of Oculoplastics and FACS Miami, FL, USA
Sri Sankaradeva Nethralaya Orbital Surgery Director Ophthalmology Voluntary Clinical Professor
Guwahati, Assam, India Fellowship Director Children’s Hospital New Orleans Department of Ophthalmology
Department of Ophthalmology & Associate Clinical Professor of Weill Cornell Medical Center
Adam DeBusk, DO, MS Visual Sciences Ophthalmology and Pediatrics New York, NY, USA
Instructor Division of Oculoplastics and Orbit Tulane University
Department of Ophthalmology University of British Columbia Associate Clinical Professor of Gerald A. Fishman, MD
Wills Eye Hospital Vancouver General Hospital Ophthalmology and Pediatrics Director
Sidney Kimmel Medical College Vancouver, BC, Canada Louisiana State Universities Schools of The Pangere Center for Inherited
Thomas Jefferson University Medicine Retinal Diseases
Philadelphia, PA, USA Sean P. Donahue, MD, PhD New Orleans, LA, USA The Chicago Lighthouse
Professor Professor Emeritus of Ophthalmology
Jose de la Cruz, MD, MSc Department of Ophthalmology & Michael Engelbert, MD, PhD Department of Ophthalmology &
Assistant Professor Visual Sciences Research Assistant Professor Visual Sciences
Ophthalmology, Cornea Refractive Vanderbilt University Department of Ophthalmology University of Illinois at Chicago
Surgery Service Nashville, TN, USA NYU/VRMNY College of Medicine
University of Illinois Eye and Ear New York, NY, USA Chicago, IL, USA
Infirmary Richard K. Dortzbach, MD
Chicago, IL, USA Professor Emeritus Miriam Englander, MD Jorge A. Fortun, MD
Department of Ophthalmology and Attending Surgeon Associate Professor of Ophthalmology
Joseph L. Demer, MD, PhD Visual Sciences Vitreo-Retinal Surgery Vitreoretinal Diseases and Surgery
Arthur L. Rosenbaum Chair in University of Wisconsin Ophthalmic Consultants of Boston Medical Director of Bascom Palmer
Pediatric Ophthalmology School of Medicine and Public Health Boston, MA, USA Eye Institute
Professor of Neurology Madison, WI, USA Palm Beach Gardens Bascom Palmer
Chief, Pediatric Ophthalmology and Bita Esmaeli, MD, FACS Eye Institute
Strabismus Division Kimberly A. Drenser, MD, PhD Professor of Ophthalmology University of Miami Miller School of
Director, Ocular Motility Laboratories Associated Retinal Consultants, PC Director, Ophthalmic Plastic & Medicine
Chair, EyeSTAR Residency/PhD and Department of Ophthalmology Reconstructive Surgery Fellowship Miami, FL, USA
Post-doctoral Fellowship Program in Oakland University Program, Department of Plastic
Ophthalmology and Visual Science William Beaumont Hospital School of Surgery Veronica Vargas Fragoso, MD
Member, Neuroscience Medicine Chair, Graduate Medical Education Refractive Surgery Fellow
Interdepartmental Program Royal Oak, MI, USA Committee Vissum Corporation
Member, Bioengineering University of Texas MD Anderson Alicante, Spain
Interdepartmental Program Jacob S. Duker, MD Cancer Center
University of California Los Angeles Resident Physician Houston, TX, USA Nicola Freeman, MBChB, FCOphth,
Los Angeles, CA, USA Department of Ophthalmology MMed
Bascom Palmer Eye Institute Joshua W. Evans, MD Senior Specialist
Shilpa J. Desai, MD University of Miami Assistant Professor of Ophthalmology Department of Pediatric
Assistant Professor Miami, FL, USA Division of Glaucoma Ophthalmology
Department of Ophthalmology University of Kentucky Red Cross Children’s Hospital
Tufts University Jay S. Duker, MD Lexington, KY, USA Cape Town, Western Province, South
School of Medicine Director Africa
Boston, MA, USA New England Eye Center Monica Evans, MD
Professor and Chairman Ophthalmology David S. Friedman, MD, MPH, PhD
Deepinder K. Dhaliwal, MD, L.Ac Department of Ophthalmology San Jose, Costa Rica Director, Dana Center for Preventive
Professor of Ophthalmology, University Tufts Medical Center Ophthalmology
of Pittsburgh School of Medicine Tufts University School of Medicine Daoud S. Fahd, MD Professor of Ophthalmology, Wilmer/
Director, Cornea and Refractive Boston, MA, USA Clinical Assistant Professor Glaucoma
Surgery Services Department of Ophthalmology Johns Hopkins University
Director and Founder, Center for Vikram D. Durairaj, MD, FACS Ophthalmic Consultants of Beirut Baltimore, MD, USA
Integrative Eye Care ASOPRS Fellowship Director and Jal el Dib, Metn, Lebanon
Co-Director, Cornea and Refractive Managing Partner Deborah I. Friedman, MD, MPH
Oculoplastic and Orbital Surgery Lisa J. Faia, MD Professor
Surgery Fellowship Partner, Associated Retinal Consultants
Associate Medical Director, Charles TOC Eye and Face Department of Neurology
Austin, TX, USA Associate Professor & Neurotherapeutics and
T. Campbell Ocular Microbiology Oakland University
Laboratory Ophthalmology
Jonathan J. Dutton, MD, PhD William Beaumont School of Medicine University of Texas
Medical Director, UPMC Laser Vision Professor Emeritus Ophthalmology - Retina
Center Southwestern Medical Center
Department of Ophthalmology Royal Oak, MI, USA Dallas, TX, USA
University of Pittsburgh Medical University of North Carolina
Center Chapel Hill, NC, USA Katherine A. Fallano, MD Neil J. Friedman, MD
Pittsburgh, PA, USA Department of Ophthalmology Adjunct Clinical Associate Professor
University of Pittsburgh School of Department of Ophthalmology
Medicine Stanford University School of Medicine
Pittsburgh, PA, USA
xvi †
Stanford, CA, USA
Deceased
Nicoletta Fynn-Thompson, MD Jeffrey L. Goldberg, MD, PhD Jason R. Guercio, MD, MBA Joshua H. Hou, MD
Partner Professor and Chairman Senior Resident in Anesthesiology Assistant Professor

List of Contributors
Cornea, Cataract and Refractive Surgery Department of Ophthalmology Department of Anesthesiology Department of Ophthalmology &
Ophthalmic Consultants of Boston Byers Eye Institute at Stanford Duke University Medical Center Visual Neurosciences
Boston, MA, USA University Durham, NC, USA University of Minnesota
Palo Alto, CA, USA Minneapolis, MN, USA
Neha Gadaria-Rathod, MD Julie Gueudry, MD
Assistant Clinical Instructor Debra A. Goldstein, MD, FRCSC Senior Consultant Odette M. Houghton, MD
Department of Ophthalmology Magerstadt Professor of Ophthalmology Senior Associate Consultant
SUNY Downstate Medical Center Ophthalmology Charles Nicolle University Hospital Ophthalmology
New York, NY, USA Director Uveitis Service Rouen, France Mayo Clinic
Northwestern University Scottsdale, AZ, USA
Debora E. Garcia-Zalisnak, MD Feinberg School of Medicine Ahmet Kaan Gündüz, MD
Cornea Fellow Chicago, IL, USA Professor of Ophthalmology Kourtney Houser, MD
Department of Ophthalmology Ankara University Assistant Professor
University of Illinois at Chicago Michael H. Goldstein, MD, MBA Faculty of Medicine Ophthalmology
Chicago, IL, USA Co-Director, Cornea and External Ankara, Turkey University of Tennessee
Diseases Service Health Science Center
Gregg S. Gayre, MD New England Eye Center Joelle A. Hallak, PhD Memphis, TN, USA
Chief of Eye Care Services Tufts Medical Center Assistant Professor, Executive Director
Department of Ophthalmology Boston, MA, USA Ophthalmic Clinical Trials & Frank W. Howes, MBChB, MMed, FCS,
Kaiser Permanente Translational Center FRCS, FRCOphth, FRANZCO
San Rafael, CA, USA John A. Gonzales, MD Department of Ophthalmology & Associate Professor
Assistant Professor Visual Sciences Bond University
Steven J. Gedde, MD Francis I. Proctor Foundation and University of Illinois at Chicago Company and Clinical Director
Professor of Ophthalmology, John Department of Ophthalmology Chicago, IL, USA Cataract Refractive & Glaucoma
G. Clarkson Chair, Vice Chair of University of California San Francisco Surgery
Education San Francisco, CA, USA Julia A. Haller, MD Eye & Laser Centre
Bascom Palmer Eye Institute Ophthalmologist-in-Chief, Wills Eye Gold Coast, QLD, Australia
University of Miami Miller David B. Granet, MD, FACS, FAAp Hospital
School of Medicine Anne F. Ratner Chair of Pediatric William Tasman, MD Endowed Chair Jason Hsu, MD
Miami, FL, USA Ophthalmology Professor and Chair of Ophthalmology Co-Director of Retina Research
Professor of Ophthalmology & Sidney Kimmel Medical College at Retina Service of Wills Eye Hospital
Igal Gery, PhD Pediatrics Thomas Jefferson University Associate Professor of Ophthalmology
Scientist Emerita Director of the Ratner Children’s Eye Philadelphia, PA, USA Thomas Jefferson University
Laboratory of Immunology Center at the Shiley Eye Institute Mid Atlantic Retina
National Eye Institute University of California San Diego Pedram Hamrah, MD, FACS Philadelphia, PA, USA
National Institutes of Health La Jolla, CA, USA Director of Clinical Research
Bethesda, MD, USA Director, Center for Translational Jeffrey J. Hurwitz, MD, FRCS(C)
Matthew J. Gray, MD Ocular Immunology Professsor, Ophthalmology
Ramon C. Ghanem, MD, PhD Assistant Professor Cornea and Associate Professor, Ophthalmology University of Toronto
Director External Disease Tufts Medical Center Oculoplastic Specialist
Cornea and Refractive Surgery Department of Ophthalmology Tufts University Mount Sinai Hospital
Department University of Florida School of Medicine Toronto, ON, Canada
Sadalla Amin Ghanem Eye Hospital Gainesville, FL, USA Boston, MA, USA
Joinville, SC, Brazil Francisco Irochima, PhD
Kyle M. Green, BA David R. Hardten, MD Professor, Biotechnology
Vinícius C. Ghanem, MD, PhD Medical Student Researcher Director of Refractive Surgery Universidade Potiguar
Ophthalmologist, Medical Director Ophthalmology Department of Ophthalmology Natal, Rio Grande do Norte, Brazil
Department of Ophthalmology University of Southern California Minnesota Eye Consultants
Sadalla Amin Ghanem Eye Hospital Roski Eye Institute Minnetonka, MN, USA Jihad Isteitiya, MD
Joinville, SC, Brazil Los Angeles, CA, USA Cornea Fellow, Ophthalmology
Alon Harris, MS, PhD, FARVO Icahn School of Medicine at Mount
Saurabh Ghosh, MBBS, DipOphth, Craig M. Greven, MD Professor of Ophthalmology Sinai
MRCOphth, FRCOphth Richard G. Weaver Professor and Letzter Endowed Chair in New York, NY, USA
Consultant Ophthalmologist Chairman Ophthalmology
Cornea, Cataract, External Eye Disease Department of Ophthalmology Director of Clinical Research Andrea M. Izak, MD
Sunderland Eye Infirmary Wake Forest University Eugene and Marilyn Glick Eye Institute Post-Doctoral Fellow
Sunderland, Tyne & Wear, UK School of Medicine Indiana University Storm Eye Institute
Winston-Salem, NC, USA School of Medicine Medical University of South Carolina
Allister Gibbons, MD Charleston, SC, USA
Assistant Professor Indianapolis, IN, USA
Margaret A. Greven, MD
Bascom Palmer Eye Institute Assistant Professor Jeffrey S. Heier, MD Deborah S. Jacobs, MD
University of Miami Ophthalmology Co-President and Medical Director Associate Professor of Ophthalmology
Miami, FL, USA Wake Forest University Director, Vitreoretinal Service Harvard Medical School
School of Medicine Ophthalmic Consultants of Boston Medical Director
James W. Gigantelli, MD, FACS BostonSight
Professor Winston-Salem, NC, USA Boston, MA, USA
Needham, MA, USA
Department Ophthalmology & Visual Josh C. Gross, MD Leon W. Herndon, Jr., MD
Sciences Clinical Research Fellow Professor, Ophthalmology Sandeep Jain, MD
University of Nebraska Medical Center Ophthalmology Duke University Eye Center Associate Professor, Ophthalmology
Omaha, NE, USA Eugene and Marilyn Glick Eye Institute Durham, NC, USA University of Illinois at Chicago
Indiana School of Medicine Chicago, IL, USA
Pushpanjali Giri, BA Allen C. Ho, MD
Research Specialist Indianapolis, IN, USA Henry D. Jampel, MD, MHS
Wills Eye Hospital Director of Retina
Department of Ophthalmology Ronald L. Gross, MD Research Odd Fellows Professor of
University of Illinois at Chicago Professor and Jane McDermott Schott Retina Service Ophthalmology
College of Medicine Chair Wills Eye Hospital Wilmer Eye Institute
Chicago, IL, USA Chairman, Department of Philadelphia, PA, USA Johns Hopkins University
Ophthalmology School of Medicine
Ivan Goldberg, AM, MB, BS, FRANZCO, Christopher T. Hood, MD Baltimore, MD, USA
FRACS West Virginia University
Morgantown, WV, USA Clinical Assistant Professor
Clinical Professor Michigan Medicine Ophthalmology Lee M. Jampol, MD
University of Sydney Sandeep Grover, MD Cornea and Refractive Surgery Clinic Louis Feinberg Professor of
Head of Discipline of Ophthalmology Associate Professor & Associate Chair W.K. Kellogg Eye Center Ophthalmology
and Glaucoma Unit of Ophthalmology Ann Arbor, MI, USA Feinberg School of Medicine
Sydney Eye Hospital University of Florida Northwestern University
Director Jacksonville, FL, USA Chicago, IL, USA
Eye Associates xvii
Sydney, NSW, Australia
 Aliza Jap, FRCS(G), FRCOphth, FRCS Kevin Kaplowitz, MD Jeremy D. Keenan, MD, MPH Victor T.C. Koh, MBBS, MMed(Oph),
(Ed) Assistant Professor Associate Professor of Ophthalmology FAMS
List of Contributors
Senior Consultant Ophthalmologist Ophthalmology, VA Loma Linda Francis I. Proctor Foundation and Associate Consultant, Ophthalmology
Division of Ophthalmology Loma Linda University Department of Ophthalmology National University Hospital
Changi General Hospital, Singapore Loma Linda, CA, USA University of California San Francisco Singapore
Singapore National Eye Centre San Francisco, CA, USA
Singapore Michael A. Kapusta, MD, FRCSC Thomas Kohnen, MD, PhD, FEBO
Associate Professor Kenneth R. Kenyon, MD Professor and Director
Chris A. Johnson, PhD, DSc Director of Retina and Vitreous Surgery Clinical Professor, Ophthalmology Department of Ophthalmology
Professor Department of Ophthalmology Tufts University University Clinic Frankfurt
Department of Ophthalmology & Jewish General Hospital School of Medicine Goethe University
Visual Sciences McGill University Harvard Medical School Frankfurt am Main
University of Iowa Hospitals and Montreal, QC, Canada Schepens Eye Research Institute Germany
Clinics Boston, MA, USA
Iowa City, IA, USA Rustum Karanjia, MD, PhD, FRCSC Andrew Koustenis, BS
Assistant Professor, Ophthalmology Sir Peng Tee Khaw, PhD, FRCS, FRCP, Medical Student
Mark W. Johnson, MD University of Ottawa FRCOphth, FRCPath, FRSB, FCOptom Clinical Ophthalmology Research
Professor, Chief of Retina Section Ottawa Hospital Research Institute (Hon), DSc, FARVO, FMedSci Internship
Department of Ophthalmology & The Ottawa Hospital Professor of Glaucoma and Ocular Department of Ophthalmology
Visual Sciences Ottawa, ON, Canada Healing Eugene and Marilyn Glick Eye Institute
University of Michigan Doheny Eye Institute Consultant Ophthalmic Surgeon Indiana University
Ann Arbor, MI, USA Doheny Eye Centers Director, National Institute for Health School of Medicine
UCLA, David Geffen School of Research, Biomedical Research Indianapolis, IN, USA
T. Mark Johnson, MD, FRCS(C) Medicine Centre for Ophthalmology
Attending Surgeon, Vitreo-Retinal Los Angeles, CA, USA Moorfields Eye Hospital Stephen S. Lane, MD
Surgery UCL Institute of Ophthalmology Medical Director
Retina Group of Washington Randy H. Kardon, MD, PhD London, UK Adjunct Clinical Professor
Rockville, MD, USA Professor and Director of Neuro- Chief Medical Officer and Head Global
ophthalmology and Pomerantz Gene Kim, MD Franchise Clinical Strategy
Mark M. Kaehr, MD Family Chair in Ophthalmology Assistant Professor and Residency Associated Eye Care
Partner Ophthalmology/Neuro-ophthalmology Program Director University of Minnesota, Alcon
Associated Vitreoretinal and Uveitis Director of the Iowa City VA Center Department of Ophthalmology & Minneapolis, MN, USA
Consultants for the Prevention and Treatment of Visual Science at McGovern Medical
Assistant Clinical Professor of Visual Loss School at UTHealth Patrick J.M. Lavin, MB, MRCPI
Ophthalmology University of Iowa and Iowa City VA Houston, TX, USA Prof. Neurology and Ophthalmology
Indiana University Medical Center Neurology, Ophthalmology and Visual
Associated Vitreoretinal and Uveitis Iowa City, IA, USA Ivana K. Kim, MD Science
Consultants Associate Professor of Ophthalmology Vanderbilt University Medical Center
Indiana University Carol L. Karp, MD Retina Service, Massachusetts Eye and Nashville, TN, USA
School Of Medicine Professor of Ophthalmology Ear
Indianapolis, IN, USA Richard K. Forster Chair in Harvard Medical School Fabio Lavinsky, MD, PhD, MBA
Ophthalmology Boston, MA, USA Research Fellow
Malik Y. Kahook, MD Bascom Palmer Eye Institute NYU Langone Eye Center
The Slater Family Endowed Chair in University of Miami Alan E. Kimura, MD, MPH NYU School of Medicine
Ophthalmology Miller School of Medicine Clinical Associate Professor New York, NY, USA
Vice Chair of Clinical & Translational Miami, FL, USA Department of Ophthalmology Director, Ophthalmic Imaging
Research University of Colorado Department
Professor of Ophthalmology & Chief of Amir H. Kashani, MD, PhD Health Sciences Center Lavinsky Eye Institute
Glaucoma Service Assistant Professor of Clinical Aurora, CO, USA Porto Alegre, Brazil
Director of Glaucoma Fellowship Ophthalmology
University of Colorado University of Southern California Michael Kinori, MD Andrew W. Lawton, MD
School of Medicine Roski Eye Institute Senior Physician Director, Neuro-Ophthalmology
Aurora, CO, USA Los Angeles, CA, USA The Goldschleger Eye Institute Division
Sheba Medical Center, Tel Hashomer Ochsner Health Services
Peter K. Kaiser, MD Michael A. Kass, MD Ramat Gan, Israel New Orleans, LA, USA
Chaney Family Endowed Chair in Bernard Becker Professor,
Ophthalmology Research Ophthalmology and Visual Science Caitriona Kirwan, FRCSI(Ophth) Bryan S. Lee, MD, JD
Professor of Ophthalmology Washington University Consultant Ophthalmic Surgeon Private Practitioner
Cleveland Clinic School of Medicine Mater Private Hospital Altos Eye Physicians
Cole Eye Institute St Louis, MO, USA Dublin, Ireland Los Altos, CA, USA
Cleveland, OH, USA Adjunct Clinical Assistant Professor of
Paula Kataguiri, MD Szilárd Kiss, MD Ophthalmology
Sachin P. Kalarn, MD Research Fellow Chief, Retina Service Director Stanford University
Resident Physician Department of Ophthalmology and Clinical Research Director Stanford, CA, USA
Department of Ophthalmology & Center for Translational Ocular Tele-Ophthalmology Director
Visual Sciences Immunology Compliance Associate Professor of Daniel Lee, MD
University of Maryland Tufts Medical Center Ophthalmology Clinical Instructor, Glaucoma Service
Baltimore, MD, USA New England Eye Center Weill Cornell Medical College Wills Eye Hospital
Boston, MA, USA New York, NY, USA Philadelphia, PA, USA
Ananda Kalevar, MD, FRCSC, DABO PhD Candidate
Associate Professor, Department of John W. Kitchens, MD Gregory D. Lee, MD
Department of Ophthalmology Retina Surgeon, Partner Assistant Professor, Ophthalmology/
Ophthalmology Universidade Federal de São Paulo
University of Sherbrooke Co-Fellowship Director Retina
(UNIFESP) Retina Associates of Kentucky New York University
Sherbrooke, QC, Canada São Paulo, SP, Brazil Lexington, KY, USA New York, NY, USA
Steven Kane, MD L. Jay Katz, MD
Cornea, Cataract, and Refractive Kendra Klein, MD Olivia L. Lee, MD
Director, Glaucoma Service Faculty Physician Assistant Professor of Ophthalmology
Surgery Specialist Wills Eye Hospital
Eye Institute of West Florida Department of Ophthalmology David Geffen School of Medicine
Philadelphia, PA, USA University of Arizona University of California Los Angeles
Largo, FL, USA
Paul L. Kaufman, MD Associated Retina Consultants Los Angeles, CA, USA
Elliott M. Kanner, MD, PhD Ernst H. Bárány Professor of Ocular Phoenix, AZ, USA Associate Medical Director
Chief, Glaucoma Service Pharmacology Doheny Image Reading Center
Hamilton Eye Institute Douglas D. Koch, MD Doheny Eye Institute
Department Chair Emeritus Professor and Allen, Mosbacher, and
University of Tennessee Department of Ophthalmology & Los Angeles, CA, USA
Health Science Center Law Chair in Ophthalmology
Visual Sciences Cullen Eye Institute
Memphis, TN, USA University of Wisconsin-Madison Baylor College of Medicine
xviii School of Medicine & Public Health Houston, TX, USA
Madison, WI, USA
Paul P. Lee, MD, JD Pedro F. Lopez, MD Jodhbir S. Mehta, BSc, MD, MBBS, Majid Moshirfar, MD, FACS
F. Bruce Fralick Professor and Chair Professor and Founding Chair FRCS(Ed), FRCOphth, FAMS Professor of Ophthalmology

List of Contributors
Director W.K. Kellogg Eye Center Department of Ophthalmology Associate Professor, Cornea and Hoopes Vision and John A. Moran Eye
Department of Ophthalmology & Herbert Wertheim College of Medicine External Disease Center
Visual Sciences Florida International University Singapore National Eye Centre Draper, UT, USA
University of Michigan Director of Vitreoretina and Macular Singapore
Heather E. Moss, MD, PhD
Ann Arbor, MI, USA Division
Luis J. Mejico, MD Assistant Professor
Center for Excellence in Eye Care
Richard M.H. Lee, MSc, FRCOphth Professor and Chair of Neurology Departments of Ophthalmology and
Miami, FL, USA
Clinical Fellow Professor of Ophthalmology Neurology & Neurological Sciences
Department of Glaucoma Mats Lundström, MD, PhD SUNY Upstate Medical University Stanford University
Moorfields Eye Hospital Adjunct Professor Emeritus Syracuse, NY, USA Palo Alto, CA, USA
London, UK Department of Clinical Sciences,
Carolina L. Mercado, MD Mark L. Moster, MD
Ophthalmology
Dawn K.A. Lim, MBBS, MRCP, Clinical Research Fellow, Director, Neuro-Ophthalmology
Faculty of Medicine
MMed(Int, Med), MMed(Ophth), FAMS Ophthalmology Fellowship
Lund University
Consultant, Ophthalmology/Glaucoma Bascom Palmer Eye Institute Professor, Neurology and
Lund, Region Skåne, Sweden
National University Hospital Miami, FL, USA Ophthalmology
Singapore Robi N. Maamari, MD Wills Eye Hospital
Ophthalmology Resident Shahzad I. Mian, MD Sidney Kimmel Medical College of
Jennifer I. Lim, MD, FARVO Department of Ophthalmology & Associate Chair, Terry J. Bergstrom Thomas Jefferson University
Marion H. Schenk Esq. Chair in Visual Sciences Professor Philadelphia, PA, USA
Ophthalmology for Research of the Washington University School of Associate Professor, Ophthalmology &
Aging Eye Visual Sciences Kelly W. Muir, MD, MHSc
Medicine in St Louis
Professor of Ophthalmology University of Michigan Associate Professor of Ophthalmology,
St Louis, MO, USA
Director of the Retina Service Ann Arbor, MI, USA Glaucoma Division
University of Illinois at Chicago Assumpta Madu, MD, MBA, PharmD Duke University
Illinois Eye and Ear Infirmary Vice Chair, Operations William F. Mieler, MD, FACS School of Medicine
Chicago, IL, USA Associate Clinical Professor of Cless Family Professor of Durham, NC, USA
Ophthalmology Ophthalmology
Ridia Lim, MBBS, MPH, FRANZCO Vice-Chairman of Education Ann G. Neff, MD
NYU School of Medicine
Ophthalmic Surgeon Illinois Eye and Ear Infirmary Dermatology Associates
NYU Langone Medical Center
Glaucoma Service University of Illinois at Chicago Sarasota, FL, USA
New York, NY, USA
Sydney Eye Hospital College of Medicine Jeffrey A. Nerad, MD
Sydney, NSW, Australia Maya H. Maloney, MD Chicago, IL, USA Oculoplastic & Reconstructive Surgery
Consultant, Medical Retina
Tony K.Y. Lin, MD, FRCSC David Miller, MD Cincinnati Eye Institute
Mayo Clinic
Assistant Professor Associate Clinical Professor of Volunteer Professor, Ophthalmology
Rochester, MN, USA
Department of Ophthalmology Ophthalmology University of Cincinnati
Schulich School of Medicine and Naresh Mandava, MD Harvard Medical School Cincinnati, OH, USA
Dentistry Professor and Chair Boston, MA, USA Neda Nikpoor, MD
Western University Department of Ophthalmology
Clinical Instructor, Ophthalmology
London, ON, Canada University of Colorado Kyle E. Miller, MD
Byers Eye Institute
School of Medicine Assistant Professor, Ophthalmology
Stanford University
John T. Lind, MD, MS Denver, CO, USA Naval Medical Center Portsmouth
Palo Alto, CA, USA
Associate Professor Portsmouth, VA, USA
Michael F. Marmor, MD
Department of Ophthalmology & Robert J. Noecker, MD, MBA
Professor Tatsuya Mimura, MD, PhD
Visual Sciences Director of Glaucoma
Department of Ophthamology Tokyo Womens Medical University
Washington University in St Louis Ophthalmic Consultants of
Byers Eye Institute Medical Center East
St Louis, MO, USA Connecticut
Stanford University Tokyo, Japan
Fairfield, CT, USA
Yao Liu, MD School of Medicine
Assistant Professor Palo Alto, CA, USA Rukhsana G. Mirza, MD Ricardo Nosé, MD
Department of Ophthalmology & Associate Professor Clinical Research Fellow
Jeevan R. Mathura, Jr., MD Department of Ophthalmology
Visual Sciences New England Eye Center
Private Practitioner and Owner Northwestern University
University of Wisconsin-Madison Tufts Medical Center
Diabetic Eye and Macular Disease Feinberg School of Medicine
Madison, WI, USA Boston, MA, USA
Specialists, LLC Chicago, IL, USA
Sidath E. Liyanage, MBBS, FRCOphth, Washington, DC, USA Annabelle A. Okada, MD, DMSc
PhD Mihai Mititelu, MD, MPH Professor of Ophthalmology
Cynthia Mattox, MD Assistant Professor
Consultant Ophthalmologist Kyorin University
Associate Professor, Ophthalmology Department of Ophthalmology &
Bristol Eye Hospital School of Medicine
Tufts University Visual Sciences
Bristol, UK School of Medicine Tokyo, Japan
University of Wisconsin-Madison
Alastair J. Lockwood, BM, BCh, Boston, MA, USA School of Medicine and Public Health Michael O’Keefe, FRCS
FRCOphth, PhD Madison, WI, USA Professor, Ophthalmology
Scott K. McClatchey, MD
Consultant, Ophthalmology Mater Private Hospital
Associate Professor, Ophthalmology Ramana S. Moorthy, MD
Queen Alexandra Hospital Dublin, Ireland
Naval Medical Center Clinical Associate Professor,
Portsmouth, Hampshire, UK San Diego, CA, USA Jeffrey L. Olson, MD
Ophthalmology
Nils A. Loewen, MD, PhD Indiana University Associate Professor
Stephen D. McLeod, MD
Associate Professor of Ophthalmology School of Medicine Department of Ophthalmology
Theresa M. and Wayne M. Caygill
Vice Chair of Electronic Health Founding Partner and CEO University of Colorado
Distinguished Professor and Chair,
Records in Ophthalmology Associated Vitreoretinal and Uveitis School of Medicine
Ophthalmology
University of Pittsburgh Consultants Denver, CO, USA
University of California San Francisco
Pittsburgh, PA, USA San Francisco, CA, USA Indianapolis, IN, USA Jane M. Olver, MB, BS, BSc, FRCS,
Reid A. Longmuir, MD Andrew A. Moshfeghi, MD, MBA FRCOphth
Brian D. McMillan, MD
Assistant Professor Director, Vitreoretinal Fellowship Consultant Ophthalmologist
Assistant Professor of Ophthalmology
Department of Ophthalmology & Associate Professor of Clinical Eye Department
WVU Eye Institute
Visual Sciences Ophthalmology Clinica London
West Virginia University
Vanderbilt University University of Southern California London, UK
School of Medicine
Nashville, TN, USA Morgantown, WV, USA Roski Eye Institute Yvonne A.V. Opalinski, BSc, MD, BFA,
Keck School of Medicine MFA
Alan A. McNab, DMedSc, FRANZCO, Los Angeles, CA, USA Clinical Associate Cardiovascular
FRCOphth
Surgery
Associate Professor and Director
Department of Cardiovascular Surgery
Orbital Plastic and Lacrimal Clinic
Royal Victorian Eye and Ear Hospital Trillium Health Partners xix
Toronto, ON, Canada
Melbourne, VIC, Australia
 Faruk H. Örge, MD Alfio P. Piva, MD P. Kumar Rao, MD Damien C. Rodger, MD, PhD
William R. and Margaret E. Althans Professor of Neurosurgery and Professor of Ophthalmology and Visual Assistant Professor of Clinical
List of Contributors
Chair and Professor Ophthalmology Science Ophthalmology
Director, Center for Pediatric University of Costa Rica Washington University Research Assistant Professor of
Ophthalmology and Adult San Jose, Costa Rica St Louis, MO, USA Biomedical Engineering
Strabismus USC Roski Eye Institute and Viterbi
Rainbow Babies, Children’s Hospital, Dominik W. Podbielski, HonBSc, MSc, Rajesh C. Rao, MD School of Engineering
UH Eye Institute MD, FRCSC Leslie H. and Abigail S. Wexner University of Southern California
Cleveland Medical Center Staff Physician, Ophthalmology Emerging Scholar Los Angeles, CA, USA
Cleveland, OH, USA Prism Eye Institute Assistant Professor, Retina Service
North Toronto Eye Care Department of Ophthalmology & Miin Roh, MD, PhD
Mark Packer, MD, FACS, CPI Toronto, ON, Canada Visual Sciences Vitreoretina Surgery Clinical Fellow
President W.K. Kellogg Eye Center Department of Ophthalmology/Retina
Mark Packer MD Consulting, Inc. Nicolas J. Pondelis, BA University of Michigan Service
Boulder, CO, USA Ophthalmic Photographer and VA Ann Arbor Health System Massachusetts Eye and Ear
Research Assistant Ann Arbor, MI, USA Boston, MA, USA
Suresh K. Pandey, MD Tufts Medical Center
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displaced, and appears between the lips of the vulva, resting on the
inferior commissure, and forming a mass the size of an orange.
Eversion cannot occur unless the ligaments of the bladder have
become relaxed, stretched or ruptured. Expulsive efforts and the
pressure of the intestinal mass complete the process, the peritoneum
and peri-vasicular layers of connective tissue being torn.
Diagnosis. The diagnosis of eversion of the bladder presents no
difficulty. The everted mass appears to have a narrow neck opposite
the meatus, and is seen to form a reddish, unctuous mass. The
mucous membrane now forms the external coat and appears covered
with mucus so long as inflammation does not occur.
The urine continually escapes from the ureters (which open on the
surface of the mucous membrane) as it is formed, and flows away by
the lower commissure of the vulva. The vulva is half open, and the
prominence formed by the bladder projects beyond it.
Prognosis. The prognosis is grave, because reduction is difficult,
and may be accompanied by rupture of the organ; also because even
in favourable cases it is invariably followed by acute cystitis.
Treatment. Treatment is confined to reduction. Before
attempting this, measures must be adopted to prevent straining,
either by passing a rope round the animal’s body, thus causing it to
flex the vertebral column, or by puncturing the rumen or performing
tracheotomy. The open hand is then applied to the surface of the
swelling, which is gently compressed and thrust in turn through the
meatus and urethra. The portions nearest to the urethra should first
be returned. It is sometimes necessary to use both hands, and even
to employ a catheter with a large round head, to reduce the eversion
effectually. After reduction a truss or vulval clamp should be applied.
Subsequent treatment consists in the administration of sedatives—
e.g., laudanum, mucilaginous drinks, barley-water, pellitory, etc.

HÆMATURIA.

Hæmaturia, i.e., the passage of blood-stained urine, is in itself only

a symptom, which may accompany very varying conditions, such as
the congestion peculiar to the early stages of nephritis, traumatic
lesions of the kidneys, ulceration of the uriniferous tubules, or of the
pelvis of the kidney, lesions of the ureters, bladder, etc., etc. The
term, therefore, does not indicate a disease, but nevertheless in
bovine practice the term hæmaturia has acquired a special
significance.
This hæmaturia of bovine animals is clinically indicated by the
presence of blood in the urine; anatomically by lesions of the
bladder, sometimes also of the ureters. It is probable that some
forms at least of the condition will ultimately be proved to be due to
the piroplasmata, but in the present state of our knowledge the
disease can only be described from the clinical standpoint. The
reader is recommended to refer to the article on “Bovine
Piroplasmosis,” ante.
Pichon in 1863 and Sinoir in 1864 introduced the name
“hæmaturia” in the course of their remarkable investigations
concerning the disease. Vigney in 1845 and Gillet in 1862 had
previously described it, and it has since formed the subject of
constant researches.
Detroye in 1891 termed it “essential hæmaturia,” and Galtier in
1892 gave it the name of “hæmorrhagic cystitis.” Boudeaud in 1894
also used the term “hæmaturia of bovine animals.” In Germany the
disease is known as “stallroth” (stable-red).
Geographical distribution. Hæmaturia is a perfect scourge in
certain countries. It seems to have made its appearance in the
departments of the West of France, the Mayenne and the Sarthe,
afterwards spreading into the Maine-et-Loire and the Indre. At the
present day, it inflicts great ravages in the Creuze, the Corrèze, Haut-
Vienne, Cantal and Haute-Loire districts. It has been described in
Germany, Belgium, and Italy. These forms are probably due to
Piroplasma bigeminum.
Causation. The most varying opinions have been advanced
regarding its cause. Pichon believed its appearance was due to
changes in cultivation, which between 1830 and 1860 completely
altered the general appearance of the country and the conditions of
breeding in the old province of Maine. Land reclamations and the
use of lime dressings have been mentioned, as well as the
introduction of the Durham breed of cattle. Sinoir practically adopts
the latter view, for he considers that the crossing with the Durham
breed, while increasing the precocity, has diminished the powers of
resistance of the indigenous cattle.
But in course of time these ideas have become modified, and
investigation has taken a new direction. Detroye regarded the disease
as a microbic and easily transmissible disorder, while Galtier in the
following year described it as merely a chronic hæmorrhagic cystitis,
produced by the consumption of irritant plants in animals previously
suffering from distomatosis. In Germany, Arnold attributed
“stallroth” to coccidia developing in the epithelium of the vesical
mucous membrane.
Cruzel considered the disease to be due entirely to poor feeding.
Boudeaud thought the same. He says that hæmaturia affected one-
tenth of the whole of the oxen in the south of the Indre and the north
of the Creuze, in parts where the arable soil is thin and poor in
phosphoric acid. Furthermore, he suggests that dressings with lime
and phosphates would result in the disappearance of hæmaturia.
We cannot admit that poor forage and feeding alone are sufficient
to produce hæmaturia, for one frequently sees poorly nourished
animals pass through all the stages of wasting and most profound
cachexia without ever showing signs of this particular ailment.
Besides, hæmaturia may attack animals in good condition.
Detroye’s early opinion as to the infectious or microbic nature of
the disease seems scarcely more acceptable, for it now appears
certain that the organism originally described is incapable of
producing the disease.
Galtier’s theory is still less admissible. According to the Lyons
professor, hæmaturia occurs only in animals suffering from
distomatosis. The liver, he says, being affected by the growth of liver
flukes, no longer performs its proper work of destroying toxins, and
if under these conditions the animals eat improper food containing
ranunculaceæ, sedges, rushes, etc., the toxic principles of these
plants are absorbed. Then, he adds, these principles being no longer
destroyed, are eliminated by the kidneys, their stay in the bladder
causes irritation, and hæmorrhagic cystitis is set up, this being
afterwards maintained by microbic agents in the bladder.
This very specious theory, all the points in which may readily be
refuted, in our opinion falls to the ground before the simple fact that
hæmaturia occurs in animals which present no trace of distomatosis
on post-mortem examination, and that, furthermore, it is not seen in
the lower regions of the departments of the Nord, the Pas-de-Calais
and the Somme, where ranunculaceæ and other irritant plants are
common and distomatosis rages.
Moussu states that he has proved that hæmaturia is very rare in
young animals and is exceptional before the age of two and a half
years or three years; that it attacks oxen as often as cows; that it is
particularly common in low regions; and that it is scarcely ever seen
above a height of 800 yards. Careful investigation, moreover, shows
that the passage of blood occurs just as frequently in winter, when
the animals are housed, as in spring, when at pasture.
Lesions. The lesions of hæmaturia are to be found in the bladder,
though in exceptional cases they may also affect the ureters and
kidneys. They have been described by Pichon and Sinoir, but as these
observers regarded the condition as a disease of the blood due to
poor feeding, etc., they did not attach much importance to them.
Detroye has described the different appearances very well, though
Moussu states that he has never met with the “blisters” which he
mentions.
The first period is accompanied simply by abnormal vascularity of
the bladder, which appears in the form of true varicosities of the
submucous vessels and intra-mucous capillaries. But if this lesion is
primary, it does not correspond to the period during which blood-
stained urine is passed, and is not sufficient to explain it. It always
appears in the form of a more or less abundant hæmorrhagic intra-
mucous, sub-epithelial spotting.
Over the hæmorrhagic area, which may be of very varied
dimensions, ranging from those of a small pin’s head to those of a
lentil, the epithelium is swollen and loosened, and so separated from
the surrounding parts as to have lost its vitality. This patch of
separated epithelium soon falls away, leaving an epithelial ulceration
of the mucous membrane. The subjacent clot rapidly breaks up in
contact with the liquid in the bladder, and is replaced by a small
ulceration which becomes the seat of continual capillary
hæmorrhage. Nevertheless, the neighbouring tissues react, and the
process of repair may end either in true cicatrisation, which appears
to be rare, or more frequently in the formation of exuberant
granulations, which are also of the nature of a soft, bleeding
vegetation. This vegetation is either sessile or pedunculated, and is of
very varying size.
The wall of the bladder also reacts, becoming sclerosed and
thickened beneath the granulations, so that, in animals which have
long suffered from hæmaturia, it may entirely have lost its
dilatability.
When the disease has existed for a certain time, sub-epithelial
hæmorrhages, ulcerations, vegetations and points of sclerosis may all
co-exist, a fact which shows that the disease does not develop all at
once, but that, on the contrary, every little lesion develops separately
and continuously. This fact also explains the length of time for which
blood may be passed, despite the presence of old or healed lesions.
Finally, in very old standing cases dating from several years back
(Moussu saw an animal aged twenty-eight years which had suffered
from this disease for more than twenty years, but in a very
intermittent fashion), it is not exceptional to find numerous
papilliform vegetations 1 or 2 inches in length, either with a fine
pedicle or largely sessile, invading one-half or two-thirds of the
internal surface of the bladder.
These vegetations sometimes, though rarely, invade the ureters.
When they occur towards the point where these conduits enter the
bladder, they obstruct the passage of urine, and lead to the
development of hydro-nephrosis or pyelo-nephritis.
Symptoms. The early symptoms often escape notice, because
general disturbance is rare. The first appreciable signs are cystitis
and frequent urination.
The urine passed is turbid, particularly towards the end of the act
of urination; then it is of a pink or red colour, and all intermediate
shades between a pale pink and a bright arterial red colour may be
observed.
The patients sometimes seem to pass unaltered blood in the urine,
but on microscopic examination this blood is found to be extremely
diluted. Provided the bladder is not gravely infected by the
(secondary) penetration of germs into its cavity the blood corpuscles
remain normal, or are scarcely changed. As soon as the bladder,
however, becomes secondarily infected an almost immediate change
takes place; the red blood corpuscles become crenated, broken up
and dissociated; the hæmoglobin is also partly dissolved and
modified, and at this stage the urine is red-brown or coffee-coloured,
according to the length of time it has been retained in the bladder.
In other cases, chiefly when hæmaturia has existed for some time,
the extravasated blood coagulates in the bladder, and the urine
passed contains filamentous clots the size of a man’s thumb, a
pigeon’s egg, or more. If the clots formed are too large to be passed,
which is often the case in the ox, they may obstruct the urethra,
causing retention of urine and all the accidents which accompany
this condition, even including rupture of the bladder. This, in the ox,
is a frequent termination. In the cow the dilatability and shortness of
the urethra render retention of urine much rarer. It is certainly
possible, however, and it is not exceptional, to find from 4 to 6 lbs. of
clotted matter in the distended bladder. All these conditions can be
detected by rectal exploration, and by attention to the symptoms of
obstruction of the urethra.
Whenever there is retention of clots dysuria is extremely marked
and, so to speak, permanent, the animals having continual tenesmus.
Hæmaturia observes a slow, progressive course, which, in time,
ends in death by exhaustion, though this is not invariably the case.
Hæmaturia is frequently intermittent, and, after having been very
marked for weeks or months, may suddenly or gradually cease, and
only reappear a long time afterwards. This fact is explained by a
study of the development of the lesions. When ulceration occurs the
sub-epithelial vessels of the mucous membrane, which have
contributed to the formation of the hæmorrhagic spot, are widely
open, and a capillary hæmorrhage results; but as soon as a small clot
forms in this position, or local capillary thrombosis occurs, the
hæmorrhage ceases, with the result that the hæmaturia disappears.
Unfortunately, however, the obliterating clots are not permanent,
any more than the local thrombosis—or, in the event of their proving
permanent, another small lesion develops at a different point, and
this lesion may at any time cause the reappearance of the hæmaturia;
the process goes on until the animal succumbs. Should the lesions
heal successively, spontaneous recovery may take place, but such
recovery is exceptional.
 The animals may not appear to suffer from the passage of blood
for weeks or even months, but after a time they become less capable
of replacing the loss. They become anæmic, the number of corpuscles
falls from the normal figure of from six to seven millions of red
corpuscles per cubic millimètre to three millions, two millions, one
million, and even to five hundred or eight hundred thousand.
The richness in hæmoglobin simultaneously diminishes; wasting
progresses to the point of cachexia, and the appetite diminishes
while diarrhœa appears; swellings are noticeable about certain parts
of the body; and the animals, continuing to pass blood, die in a state
of absolute exhaustion, without apparent suffering.
This termination is the most common, unless slaughter is
determined on, and is very different from the premature end which
follows the formation of clots and obstruction of the urethra.
Externally the patients only show feebleness, pallor of the visible
mucous membranes, and difficulty in urination. The bunch of hair at
the lower commissure of the vulva is always soiled with blood-
stained urine or little clots.
Hæmaturia may cause death by exhaustion in from six weeks to
two months, but not infrequently it lasts for months or even years.
Diagnosis. The diagnosis presents no difficulty when the urine
can be examined; but in the periods of intermittence no opinion can
be advanced. These intermittences are so frequent that in parts of the
country ravaged by this disease it is a usual custom, when selling, to
grant or refuse guarantees for a longer or shorter term.
The condition can be distinguished from parasitic hæmoglobinuria
(piroplasmosis) or from Brou’s disease (a febrile disease of rapid
development) by simply examining the urine or blood.
Prognosis. The prognosis is extremely grave, for, up to the
present, no really efficacious treatment has been discovered, and
although some animals may live for years without their lives being in
any way endangered, this cannot possibly be foreseen, and there is
no economic advantage in keeping them.
Treatment. No curative treatment is known.
It is true that iron salts, tonics, Rabel’s liquid, decoctions of certain
plants, such as plantain, have been recommended, but apart from the
fact that they are of doubtful efficacy, they cannot be used over long
periods. All these preparations also tend to increase the coagulability
of the blood; but considering that the disease is beyond question of a
parasitic character, good results cannot always be expected of them.
Preventive treatment appears more hopeful, although even in this
connection, the best informed appear to have considerable doubts.
All those who have studied the question agree in recommending
drainage of the pasturages, and their improvement by the use of
various manures, particularly superphosphates and lime. These
improvements alter the character of the pasture, render the soil
healthier, and may perhaps prove sufficient to diminish or prevent
the local growth of the germs. Under such conditions, Boudeaud
declares that he has seen hæmaturia disappear from farms where it
had previously been in permanent possession. It has also been
recommended that the affected cattle should be sent elsewhere to
places where the disease does not exist, and experience shows that
spontaneous recovery is more frequent under such conditions.
It is probable that, during attacks of hæmaturia in a contaminated
country, successive parasitic infestations occur, which would explain
the persistence with which blood is passed, a symptom which does
not occur in a healthy country. This view, however, is still only an
hypothesis.
 CHAPTER III.
DISEASES OF THE KIDNEYS.

CONGESTION OF THE KIDNEYS.

Congestion of the kidneys is not a morbid condition in the strict

sense of the term, for it is merely the forerunner of nephritis caused
by infectious diseases or intoxications (primary active congestions)
or the final consequence of other diseases, such as diseases of the
heart or liver, mechanical compression of the vena cava or renal
veins (secondary passive congestion, cardiac kidney).
Nevertheless, under certain circumstances the development of
nephritis may be arrested at the primary congestive stage, and it is
only then that an opportunity occurs of studying it as a definite
complaint.
Causation. All infections accompanied by lesions of the kidneys,
and these are numerous (gangrenous coryza, anthrax, parasitic
hæmoglobinuria), produce congestion of the kidneys.
Cold also acts directly under certain conditions, as do large doses
of diuretics, irritant foods the principles of which are eliminated
through the urine (fermenting or putrid sugar-pulp, for example),
and foods rich in resins, essential oils, various glucosides, tannin, etc.
(young shoots of trees during the spring-time).
Symptoms. The symptoms are difficult to define accurately, and
the diagnosis can only be arrived at with the aid of the history.
Renal congestion produces pain, indicated by dull colic and
repeated and ineffectual attempts to urinate, suggesting acute
cystitis. The patients lose appetite, and present all the general
symptoms of marked visceral inflammation, viz., fever, acceleration
of breathing, somewhat tumultuous action of the heart, etc.
 External or internal examination of the kidneys reveals abnormal
sensitiveness. The urine is of a dark or bright-red tint, owing to the
presence of red blood corpuscles. These blood corpuscles are
precipitated on placing the fluid in a tall glass, and can be detected,
together with renal epithelium, by microscopic examination.
The diagnosis is somewhat difficult, and it requires very careful
attention to distinguish between congestion of the kidney and true
nephritis.
The prognosis should always be reserved until it is certain that
acute nephritis will not ultimately develop.
The treatment consists in removing the cause of the congestion;
rich foods, or foods containing irritant principles, should, therefore,
be avoided, as also the administration of diuretics, etc.
Otherwise, the treatment is similar to that employed in all visceral
inflammations: bleeding to the extent of two to four quarts,
according to the size of the animals, warm poultices to the loins and
flanks, dry friction, mucilaginous drinks and emollient decoctions of
barley or pellitory. The animals should be kept in a warm place.
In cases of passive and secondary congestion, treatment must be
directed towards improving the condition of the organ primarily
affected, whether it be the heart, liver, or lymphatic glands.

ACUTE NEPHRITIS.

The term nephritis applies to inflammation of the renal tissues.

Clinically, two forms only can be distinguished, the acute and the
chronic.
As regards its pathological anatomy, the inflammation may
principally affect either the interstitial tissue or the epithelial
parenchyma, a fact which has suggested the division of the condition
into epithelial nephritis, interstitial nephritis, and mixed nephritis.
Clinically, such distinctions are impossible; and in reality all forms of
nephritis are to a varying degree mixed, the lesions predominating in
one or other of the constituent tissues. These lesions depend on the
extent, intensity, and duration of the inflammatory attack, whatever
the primary causes. All the constituent tissues of the kidney may be
affected, simultaneously or individually: the Malpighian corpuscles,
the convoluted tubules, the collecting tubules, or the interstitial
connective tissue.
Causation. Cold seems to be an important factor. All acute or
chronic intoxications in which the toxic principles are eliminated by
the kidneys, such as poisoning by cantharides, fermented beet pulp,
young shoots of trees or toxic plants, may cause acute nephritis.
Infectious diseases, such as gangrenous coryza, hæmoglobinuria,
tuberculosis and post-partum infections, also play an important part,
whether the nephritis be direct, that is to say, the result of the
infecting agent itself, or indirect, i.e., produced by toxins generated
in the body. In female animals gestation is an often unsuspected
cause. Moussu believes that albuminuria is frequent during
gestation, and although in most cases it is only of moderate degree,
he thinks it is often associated with subacute nephritis, which might
be aggravated by an accidental cause.
Many forms of nephritis are overlooked in consequence of their
slight character.
Symptoms. The early symptoms are similar to those of
congestion of the kidney, viz., dull colic, excessive sensitiveness over
the region of the loins, passage of pink urine, loss of appetite, and
fever. At a later stage, in cases of acute nephritis due to cold, the
animal stands with the limbs close together and remains stationary,
arching the loins and back, which are held stiffly. The animal
obstinately refuses to move in consequence of the pain produced by
so doing.
The general condition becomes grave, respiration is rapid, the
pulse frequent, the artery tense, the muzzle dry, the accessible
mucous membranes are injected, and appetite is almost entirely lost.
Urine is frequently passed, but the act causes pain, and the
quantity is small. Absolute anuria is rare, and does not last long.
The urine is generally sanguinolent, at least at first, but to a very
varying extent. It is always albuminous, the quantity of albumen
varying enormously, and on microscopic examination, is usually
found to contain red and white blood corpuscles, epithelium from
the kidney hyaline or epithelial cylinders, and, towards the end, pus
corpuscles.
 Œdema or anasarca, though common in mankind, does not occur
in a very marked form, except in intense acute nephritis. Epistaxis is
also rare.
Diagnosis. The diagnosis requires some care, because unless the
urine be examined the symptoms might lead to error. Nevertheless,
it is always possible to distinguish between this condition and
hæmaturia or accidental renal hæmorrhage.
Prognosis. The prognosis is grave, because absolute recovery is
rare, and because the condition is very apt to become chronic.
The degree of anuria and the respiratory difficulty are of great
service in confirming the prognosis. As soon as urine is freely passed
the prognosis becomes more favourable.
Treatment. Among the most effective methods of treatment must
be included bleeding, which always produces some improvement.
Dry friction over the kidneys and flanks, hot moist applications, and
the application of a sheep-skin to the loins are also of service.
Internally, mucilaginous drinks, diuretic decoctions and milk give
the best results. The proportion of albumen rapidly diminishes,
dysuria becomes less marked, urine is passed in greater quantities,
and in from eight to ten days all the alarming symptoms disappear.
Bicarbonate of soda may then be given for a fortnight.
In very grave cases camphor, bromide of camphor, injections of
camphorated oil (1 to 2½ drachms internally, or 1 to 1¼ drachms in
subcutaneous injections) give excellent results in modifying the pain
and moderating the inflammation.
From ½ to 1 drachm of digitalis in powder, or better still an
injection of from 5 milligrammes to 1 centigramme of digitalin may
also be given when dyspnœa is very great and is accompanied by
anasarca. Medicines such as oil of turpentine and considerable doses
of nitrate of potash, however, are contra-indicated.

CHRONIC NEPHRITIS

True chronic nephritis, i.e., a condition strictly limited to the renal

tissue, and unaccompanied by pyelitis, is still little known among our
domestic animals. The symptoms characterising it have not always
been carefully noted, and the diagnosis is very often uncertain.
Nevertheless, one of the most common forms has been carefully
studied by Seuffert, viz., chronic hypertrophic nephritis.
Causation. Chronic nephritis is the common sequel to the acute
forms, whatever their origin, but it may also occur primarily from
repeated chills produced by such conditions as exposure to heavy
continued rain when at grass, chills contracted during cold nights
and the great variations in temperature in spring and autumn. The
conditions, however, thus produced are rather of the nature of
subacute nephritis than of chronic nephritis, properly so called.
These forms of chronic nephritis may also occur primarily in
consequence of chronic hepatic lesions with pressure on the
posterior vena cava, producing blood stasis in the kidneys. Finally,
they may represent the delayed effects of slight lesions which have
escaped notice and have developed during grave diseases or as a
consequence of repeated gestation.
From the anatomico-pathological standpoint, the only conditions
hitherto recognised are the chronic hypertrophic forms of nephritis
(large, white sclerotic kidney with lardaceous degeneration and
sometimes marbling). This is probably because the animals are
slaughtered as soon as they suffer in condition, but if they were kept
long enough they would undoubtedly suffer also from the atrophic
chronic forms of nephritis found in man and in the dog. In the case
of man observation has shown that these two forms only represent
different stages in the development of one disease, the large,
hypertrophied kidney of the early stages afterwards undergoing
marked progressive atrophy.
The symptoms are at first so vague that diagnosis would be
impossible on a single examination. Seuffert states that the condition
develops as follows:—
The first sign, loss of appetite, is soon followed by constipation and
dull colic, due to congestion of the kidney; the pain is often so great
as to cause intermittent groaning.
The urine passed is always turbid, and sometimes blood-stained,
but this staining rarely lasts longer than a week. The urine then
gradually resumes its normal appearance, is passed in small
quantities, and contains more or less albumen. The yield of milk
markedly and progressively diminishes.
If treatment is resorted to at this stage laxatives and diuretics
appear to effect a real improvement. Unfortunately, however, the
apparent improvement is but temporary; the kidneys become
hypertrophied, and the right soon occupies the whole of the
sublumbar space, its margin extending as far as the extremity of the
transverse processes near the anterior angle of the hollow of the
flank.
This hypertrophy and the extreme sensitiveness can be detected by
external palpation. Internal examination confirms the facts so
observed as regards both the kidneys.
The patients eat little and become thin, whatever treatment be
adopted. They progressively waste, and die after some months in a
state of marasmus, exhausted and intoxicated.
It is very probable that the digestive disturbances are complicated
by respiratory and cardiac trouble, as in man and the dog; but
neither cardiac nor uræmic disease of the kidney has been recorded.
Diagnosis. When the urine is analysed the diagnosis becomes
comparatively easy. Persistent albuminuria and hypertrophy of the
kidneys during the early stages are significant indications. There can
be little hesitation except in so far as pyelo-nephritis and hydro-
nephrosis are concerned, but the conditions are distinguished by the
character of the urine in the two latter cases, together with the
condition of the pelvis of the kidney, and of the ureters.
Prognosis. The prognosis is grave, and Seuffert believes that
recovery never occurs. This is also true, generally speaking, as
regards all forms of chronic nephritis.
Treatment. As the disease must be regarded as incurable there is
really no justification for treatment. Nevertheless, if for special
reasons the owner wishes to keep the animals for a certain time, as in
the case of a cow near its time of calving, recourse may be had to the
internal treatment suggested in acute nephritis, viz., mucilaginous
drinks, diuretic infusions, milk, bicarbonate of soda, stimulating
applications to the loins, etc.
 HYDRO-NEPHROSIS.

Hydro-nephrosis, i.e., retention of urine in the pelvis of the kidney

and in the collecting and secreting tubules, is a somewhat common
malady of the bovine species. It is usually confined to one kidney.
Causation.
Anything which
obstructs the
discharge of
urine through
the ureters may
cause hydro-
nephrosis.
Thus, vesical
tumours
pressing on the
orifices of the
ureters, calculi
which have
become fixed in
them, torsion or
“kinking” of the
ureters, may
bring about
hydro-
nephrosis. The
urine secreted
Fig. 228.—Hydro-nephrosis of the kidney. by the kidney
being unable to
escape,
accumulates in the pelvis of the kidney, in the ureter, and uriniferous
tubules, producing dull colic, which escapes observation, or the exact
cause of which is not discovered, because the second kidney
vicariously acts for the one affected, and urination continues
regularly. Secretion continuing in spite of the obstruction, that
portion of the ureter above the obstructed point, together with the
pelvis and the uriniferous tubules, gradually becomes dilated, until
the whole mass of the kidney is hypertrophied.
 The ureter sometimes becomes enlarged to the size of a man’s arm,
the kidney double, treble, or quadruple its normal side: the
interlobular divisions are lost, and each circumscribed lobule soon
forms a cystic cavity varying in size. The pressure due to the
accumulated urine causes the renal tissue, first the medullary
substance and afterwards the peripheral zone, to undergo atrophy.
The kidney is represented by a vast cystic cavity, and the lobules by
culs-de-sac; the cortical layer may become atrophied to such a degree
as to form merely a fibrous sheath, the primary constituent elements
of which are difficult to discover. From 20 to 40 pints of liquid may
sometimes be found in the cystic kidney.
Diagnosis. The condition is rarely diagnosed, because, as one of
the kidneys continues to act, no acute disturbance follows. Only in
cases where the cystic kidney projects into the flank are suspicions
aroused. Examination per rectum will then permit of the diagnosis
being made.
Prognosis. Hydro-nephrosis being, as a rule, unilateral, the
prognosis is not very grave as regards immediate danger. As the
condition is hopeless, however, the lesions being irreparable, the
animal should be prepared for slaughter.
Treatment. Practically there is no treatment. Puncture of the
cystic cavity or even the removal of the hydro-nephrotic kidney
certainly suggests itself, but, as such operations are usually opposed
to the interests of the owner, they are rarely or never practised.

INFECTIOUS PYELO-NEPHRITIS.
 Fig. 229.—Section of a kidney affected with hydro-nephrosis. The gland
substance is almost entirely atrophied, and each lobule shows marked
dilatation.

The term “infectious pyelo-nephritis” describes an inflammation

which may involve any portion of the mucous membrane of the
urinary tract, and which is produced by a special bacillus. As a rule,
this inflammation commences in the mucous membrane of the
calices and pelvis (pyelitis). It afterwards extends into the depths of
the uriniferous canaliculi (nephritis), but in grave and old-standing
cases the mucous membrane of the ureters and the bladder may also
be affected. The disease had long been known in France (Rossignol,
1848). It was afterwards described in Germany (Siedamgrotsky,
1875; Pflug, 1876), in Switzerland (Hess, 1888), and also in France
(Lucet, 1892; Masselin and Porcher, 1895).
Causation. Female animals are more frequently affected than
males, because the lesions are produced by an ascending infection,
originating very frequently in genital infection after delivery.
Nevertheless, calculus formation is also an important factor in
producing the disease.
Many different agents are capable of producing pyelo-nephritis.
Hofflich in 1891 described a bacillus about 2 to 8 micromillimètres in
length, which stained readily with aniline colours and with Gram
solution. Lucet in 1892 found a short bacillus which did not stain
with Gram, and later another thin bacillus which did. Kitt has
described cocci, but no other organisms. Masselin and Porcher
discovered a cocco-bacillus which stained with Gram and reproduced
the disease in an animal lent by Moussu, after a single intra-vesical
injection of the culture. Cadéac has met with staphylococci, and
Moussu has discovered various bacilli, some resembling the colon
bacillus, and pyogenic streptococci.
There is no doubt that many different organisms may produce
pyelo-nephritis by ascending infection. The most common seem to
be forms of paracoli, such as the Bacillus ureæ. Moussu nevertheless
believes that Hofflich’s bacillus, which was rediscovered by Porcher,
is that which produces typical pyelo-nephritis. It grows in the
bladder without producing cystitis, and is succeeded by an ascending
infection of the ureters without causing primary ureteritis, the local
inflammation occurring chiefly, it would seem, in the pelvis and the
kidney. All the other organisms which Moussu has tested have
caused lesions of cystitis and of ureteritis, together with those of
pyelo-nephritis.
In these latter cases the pyelo-nephritis assumes the acute form,
and is accompanied not infrequently by cellulitis and abscess
formation in the tissue around the kidney.
Symptoms. Pyelo-nephritis develops in one of two principal
forms, the slow chronic form, which is the most frequent, or an acute
or subacute form, much more rapid in its development.
The chronic form for a time escapes notice. There is no doubt that
at first some general disturbance occurs, such as diminution of
appetite, disturbed nutrition, unhealthy general appearance, staring
of the coat, tightness of the hide, wasting, etc., but such symptoms
are in no wise characteristic, being found in all grave diseases.
 The signs only become really significant from the clinical
standpoint when the urine appears modified in character, and such
modification does not occur until the pelvis of the kidney and the
kidneys themselves are already gravely diseased.
The urine is then turbid, of a brownish colour, and charged with
sediment, filaments of mucin, pus corpuscles, and earthy
phosphates. On analysis it is found to contain more or less albumen.
At a late stage it may even become glairy, blood-stained, or of the
colour of blood, and when the pelvis or the calices of the kidney are
ulcerated may, on standing, deposit considerable quantities of red
blood corpuscles.

Fig. 230.—Pyelo-nephritis with

hæmorrhagic pyo-nephrosis of one
side. One ureter is dilated and
blocked with a blood clot.
 Exposed to the air, the urine rapidly assumes a brown tint and
smells strongly of ammonia.
Percussion of the loins in the region of the kidneys causes pain, as
does external palpation by the flank. On rectal examination at this
period the ureters are found to be distended and hard, and they give
the impression of rigid or bosselated fibrous cords, sometimes as
large as a child’s arm. The corresponding kidney, often both kidneys,
are enlarged, sometimes to double or treble their normal volume,
and are painful on pressure and fluctuating, at least in the region of
the pelvis. On vaginal examination the meatus urinarius is usually
found to be inflamed, rough and turgid.
In this condition the animals rapidly lose flesh, the appetite
becomes irregular, the general condition gradually gets worse, and
they die as a result of continued uro-septic fever or uræmic troubles.
The acute form takes a much more rapid course, with fever, more
marked general disturbance, acceleration of pulse and breathing, the
passage of turbid and sometimes purulent urine with a strong
ammoniacal smell. Pyo-nephrosis is the most frequent and
characteristic end. Ordinary chronic pyelo-nephritis may also occur
in these cases, and the acute course may be determined simply by
accidental ascending infections.
Diagnosis. During the early stages diagnosis is extremely
difficult, unless a careful examination of the urine be made.
Afterwards it becomes easy, the appearance of the urine and the
indications furnished by rectal exploration being perfectly
characteristic. In very exceptional cases there may be some doubt, as
where the urine remains normal, in spite of hydro-nephrosis, or
where there is old-standing hæmaturia or renal tuberculosis. In
simple hæmaturia the lesions are confined to the bladder and
ureters, the kidneys not being affected, and in renal tuberculosis the
diagnosis can always be confirmed by the use of tuberculin.
Prognosis. The prognosis is extremely grave, for the lesions
produced are irreparable, and, moreover, local intervention is
impossible.
Treatment. There is no curative treatment. All that is possible is
palliative treatment with the object of facilitating the function of the
kidney and of disinfecting the urinary passages by administering
antiseptic substances which are excreted by the kidney. It is not
possible, however, to administer active drugs of this kind (e.g.,
combinations of carbolic acid). As the kidney acts badly it soon
ceases to eliminate such substances, and the condition would not be
improved, but aggravated.
Benzoate of soda in doses of 2 to 2½ drachms per day dissolved in
diuretic liquids is the most useful drug, and sometimes holds the
disease in check for a sufficient time to allow of the animals being
fattened.
Treatment also comprises certain prophylactic precautions. As the
infection which produces pyelo-nephritis originates in the genital
tract, it is desirable to protect all animals in a receptive condition
(those about to calve or having recently calved) from infection;
hence, when the disease is detected in a cow-shed, the patients
should be isolated, and the shed thoroughly disinfected.

SUPPURATIVE NEPHRITIS AND PERINEPHRITIS.

Suppuration of the kidney may occur under two conditions. In the

majority of cases such suppuration occurs as a complication of pyelo-
nephritis; less frequently it is the consequence of infection from
within or infection of adjacent parts, leading to the formation of an
abscess.
When it results from an ascending infection the kidney becomes
swollen, congested and inflamed, and soon displays localised minute
hæmorrhages. Pus then forms within the calices, in the large straight
tubes, and diffuse suppuration invades all the uriniferous tubules.
The enlarged kidney is yellowish, firm under the knife, and when
sections are compressed pus exudes from the openings of the tubular
canaliculi.
When suppurative nephritis has resulted from accidental infection
of internal origin, an abscess is found to have produced more or less
extensive atrophy of a portion of the kidney while not affecting the
rest of the organ.
It is only in those favourable cases where the renal abscess opens
into the pelvis that suppuration may invade the whole of the kidney,
producing diffuse suppurative nephritis by secondary infection of the
uriniferous tubules. Such complications are rare. Usually the abscess
empties through the pelvis, and recovery may occur.
More frequently suppurative pyelo-nephritis develops, together
with ureteritis, cystitis, dilatation of the ureters, dilatation of the
pelvis of the kidney, and dilatation of the collecting tubules of the
pyramids, the final stage resembling the lesions of pyo-nephrosis.
Perinephritis and perinephritic cellulitis, i.e., inflammation with or
without abscess formation in the connective tissue and adipose layer
surrounding the kidney, always occur in cases of suppurative
nephritis or pyelo-nephritis. Such inflammations may also, in
exceptional cases, follow direct mechanical injury, but they almost
invariably represent complications, the organisms infecting the
kidney passing through the tissues and the layer of fibrous tissue, or
extending by the lymphatic paths, finally attaining the fatty tissue
surrounding the kidney and there undergoing multiplication. The
fatty tissue is infiltrated with reddish serosity, is inflamed, and may
become the seat of large abscesses communicating with or separate
from the abscesses of the kidney itself.
Symptoms. Suppurative nephritis is characterised by fever, loss
of appetite, arrest of rumination, and frequent attempts to urinate.
These attempts are painful, are accompanied by groaning, and end in
the passage of an insignificant quantity of blood-stained and
purulent urine.
Palpation, more especially palpation of the right flank, percussion
over the region of the loins, and examination of the kidneys through
the rectum are painful. Wasting is rapid.
If the suppurative nephritis develops rapidly, and particularly if it
be accompanied by perinephritis, the patients refuse to rise and
appear to be suffering from paraplegia, although not really so, both
sensation and motor power persisting in a greater or less degree.
Probably the condition is accompanied by reflex pain and irritation
of the nerve trunks of the lumbo-pubic plexus.
On the other hand, when suppurative nephritis tends to develop
slowly and assume a chronic form, lesions of pyo-nephrosis
gradually develop, and are identical in appearance with those of
hydro-nephrosis, except that the ureters, the pelvis and the
dilatations corresponding to the lobules, are filled with pus.
Fig. 231.—Leaf lard around kidney of pig.

Diagnosis. The diagnosis is not very difficult. The urinary trouble

and the composition of the urine itself always arouse suspicion. The
diagnosis is confirmed by careful and methodical examination per
rectum; the inflammation of the fatty tissue surrounding the kidney
can usually be detected.
Prognosis. The prognosis is extremely grave, and almost always
fatal, particularly in cases of diffuse nephritis.
Treatment. No curative treatment can be absolutely relied on.
Treatment, if attempted, is limited to the methods suggested for
pyelo-nephritis. Mucilaginous, emollient, and diuretic drinks, and
daily doses of 2 to 3 drachms of benzoate of soda given in the
drinking water, cause some improvement.
Stimulation of the region of the loins also undoubtedly has a
favourable effect, and should always be practised, particularly where
perinephritis is developing. It may check the course of the disease
and prevent the formation of abscesses. On slaughtering animals
suffering as above described the layer of tissue surrounding the
kidney is found to be lardaceous and fibro-fatty.
Any treatment through the bladder is contra-indicated, for even
the passage of a catheter may cause severe injury of the urethra or
the vesical mucous membrane and produce a fatal aggravation.
If these conditions are diagnosed early, while the function of the
kidney is more or less preserved, and if the animal is still in good
condition, it should be slaughtered.

THE KIDNEY WORM (SCLEROSTOMA

PINGUICOLA) OF SWINE.[7]

7. From Report of the U.S.A. Bureau of Animal Industry,

1899, p. 612. (Louise Taylor.)
In the United States of America a worm is
frequently found in the fat surrounding the kidneys
of pigs, and is supposed by farmers to be the cause of
paralysis of the hind limbs.
This so-called kidney worm of hogs (Sclerostoma
pinguicola) should not be confounded with the
kidney worm (Dioctophyme viscerale) of dogs and
man. Both of these parasites belong to the same
zoological family (Strongylidæ), but to different
subfamilies and genera. The kidney worm of dogs
grows to a length of 1 to 3 feet. The kidney worm of
hogs is much smaller, attaining at most something
less than 2 inches in length.
Fig. 232.—
Sclerostoma
pinguicola.
External view
of female. a,
Male, natural
size; b,
female,
natural size;
c, mouth; d,
buccal cavity;
e,
œsophagus;
f, intestine; g,
anus; h,
genital
opening; i,
 genital tract;
k, cephalic
gland.
(Louise
Taylor,
Annual
Report,
Bureau of
Animal
Industry,
1899, p. 614.)

Fig. 233.—Embryos of Sclerostoma pinguicola. (Louise

Taylor, Annual Report, U.S.A. Bureau of Animal Industry,
1899, p. 634.)

The body of the worm is plump, mottled in color—red, yellow,

white, black—according to the organs visible beneath. The average
female is about 37 mm. and the average male 32 mm. in length. The
worms seem to occur in pairs, usually in cysts or canals; thus, upon
the examination of two kidneys with their surrounding fat, fifteen
specimens were found, seven males and eight females. The
connective tissue layers between the fat were found to be the most
general seat of infection, and the cysts were numerous and closely
packed together. Although a cyst usually contained two worms, a
male and a female, sometimes three were found together, two
females and one male, or just as often one female and two males. The
cysts contained pus, which bathed the parasites, and in which were
thousands of eggs in the segmentation stage. Still, other cysts, upon
being cut into, were found without parasites and in a necrotic
condition.
It will be noticed that Sclerostoma pinguicola is colloquially
known as the kidney worm. In no case, however, has Miss Taylor
found it in the kidney substance, but only in the tissue surrounding
this organ; the lard appears to be its normal habitat, at least.
Just how the eggs leave the kidney fat or enter the bodies of fresh
hogs has not been demonstrated, but it does not seem unreasonable
to suppose that they eventually find their way out with the urine.
Indeed, Dean reports eggs found in the urine. From analogy one is
led to believe that no intermediate host is required, but that in all
probability the embryos develop for a short time in water, casting
several skins, and they eventually gain access to the hogs either
through contaminated drinking water or food.
Because of the hog’s habits, it is difficult to see any practical
measures which can be adopted to prevent infection. Feeding from
troughs and supplying plenty of pure drinking water will decrease
but not exclude the disease. Leuckart’s advice to the Germans,
“Swine should be kept in a less swine-like manner,” holds good in all
countries and in connection with all diseases. It is equally impossible
to suggest practical methods of treatment. This is all the more true
because it seems probable that a number of distinct complaints are
popularly grouped together by the farmer as kidney-worm disease.
 CHAPTER IV
GENITAL APPARATUS.

Semiology. The examination of the genital apparatus properly so

called is easy in animals of large size, whether male or female, but is
more delicate and difficult, and is sometimes partially impossible, in
small creatures.
In male animals it comprises the examination of the testicles by
inspection and palpation, of the vas deferens, and of the intra-pelvic
genital organs (vesiculæ seminales, prostate, etc.).
Inspection and palpation of the scrotum reveals hypertrophy,
atrophy, œdematous or sanguineous infiltrations, inflammation of
the tunica vaginalis, and tumours of the testicle. Intra-pelvic
examination partly covers the same ground as examination of the
pelvic portion of the urethra, and, provided the anatomical
relationships of the different organs encountered are known, there is
no difficulty in detecting the position of possible lesions (Fig. 226).
In small male animals, such as he-goats and rams, rectal
exploration is confined to the use of one or two fingers.
In female animals examination comprises inspection, intra-vaginal
examination, and rectal examination.
Inspection reveals lesions of the vulva and clitoris.
Vaginal examination with the hand establishes the condition of the
walls of the vagina, the neck of the uterus, and the vaginal culs-de-
sac.
If a lesion is detected, its character can easily be ascertained by
means of a speculum, which exposes the base of the vagina, the
prominence formed by the uterus, or any particular part of the
vagina itself. Examination with the speculum is the only useful
method in young female animals, heifers in particular, on account of
the narrowness of the genital tract.
 In small female animals, such as she-goats, ewes and sows, the
fingers alone can be employed.
As regards examination of the uterus, the direct method gives little
exact information, and examination by the rectum is to be preferred.
By passing the arm into the rectum and gently pressing downwards
towards the base of the pelvis, the hand can be brought in contact
with the body of the uterus, which can be moved and displaced from
right to left; the horns of the uterus can be felt and followed from the
body of the uterus as far as the Fallopian tubes and the ovaries. By
this means the state of the uterus, its degree of sensitiveness and
mobility, as well as the state of the Fallopian tubes and of the ovaries,
can all be ascertained. The examination also reveals the existence or
non-existence of gestation, during which the uterus becomes
hypertrophied and is displaced in a forward direction towards the
right flank, at the same time descending in front from the base of the
pelvis over the abdominal wall and under the mass of the intestinal
convolutions.
 Fig. 234.—Genital organs in a cow, showing the
anatomical relations. R, Rectum; Gr, meso-rectal
lymphatic glands; U, ureter; LL, broad ligament;
Va, vagina; V, bladder; Cu, uterine cornu; O, ovary;
F, Fallopian tube.

VAGINITIS.

Inflammation of the vaginal conduit may be primary or secondary.

It usually follows difficult parturition, but may occur under various
circumstances. From the clinical standpoint three varieties are
distinguished: simple or contagious acute vaginitis; croupal vaginitis;
and chronic vaginitis.

ACUTE VAGINITIS.