OPHTHALMIC INSTRUMENTATION

UNIT 4: Ophthalmic Diagnostic Procedures

Visual Acuity

Definition: Visual Acuity or Acuity of Vision is defined as the ability of eye to determine the
precise shape and details of the object.

What is 20/20 or 6/6 Vision?

• 20/20 or 6/6 vision is a term used to express normal visual acuity (the clarity or
sharpness of vision) measured at a distance of 20 feet.

• If you have 20/20 vision, you can see clearly at 20 feet what should normally be seen at
that distance.

• If you have 20/100 vision, it means that you must be as close as 20 feet to see what a
person with normal vision can see at 100 feet.

Test for Visual Acuity

• Acuity of vision is tested for distant vision as well near vision. If there is any difficulty in
seeing the distant object or near object, the defect is known as error of refraction.

Distant Vision

• Snellen chart is used to test the acuity of vision for distant vision in the diagnosis of
refractive errors of the eye.

Near Vision

• Jaeger Chart is used to test the visual acuity for near vision.

Purpose of the test:

• You may need an eye exam if you feel you’re experiencing a vision problem or your
vision has changed. A visual acuity test is one part of a comprehensive eye exam.

• Children frequently take visual acuity tests. Early testing and detection of vision
problems can prevent issues from getting worse.

• Optometrists, driver’s license bureaus, and many other organizations use this test to
check your ability to see.
Snellen chart for Distant Vision Acuity Test:

• The fact that two distant points can be visible as separate only when they subtend an
angle of 1 minute at the nodal point of the eye, forms the basis of Snellen’s test-types.

• It consists of a series of black capital letters on a white board, arranged in lines, each
progressively diminishing in size. The lines comprising the letters have such a breadth
that they will subtend an angle of 1 min at the nodal point.

• Each letter of the chart is so designed that it fits in a square, the sides of which are five
times the breadth of the constituent lines. Thus, at the given distance, each letter
subtends an angle of 5 min at the nodal point of the eye.

• The letters of the top line of Snellen’s chart should be read clearly at a distance of 60 m.

• Similarly, the letters in the subsequent lines should be read from a distance of 36, 24,
18, 12, 9, 6, 5 and 4m, respectively.
Principle of Snellen’s chart test:

Procedure for Test:

• For testing distant visual acuity, the patient is seated at a distance of 6m or 20 feet from
the Snellen’s chart, so that the rays of light are practically parallel and the patient exerts
minimal accommodation. The chart should be properly illuminated (not less than 20 ft
candles).

• The patient is asked to read the chart with each eye separately and the visual acuity is
recorded as a fraction, the numerator being the distance of the patient from the letters,
and the denominator being the smallest letters accurately read. When the patient is
able to read up to 6 m line, the visual acuity is recorded as 6/6, which is normal.

• Similarly, depending upon the smallest line which the patient can read from the distance
of 6 m, his vision is recorded as 6/9, 6/12, 6/18, 6/24, 6/36 and 6/60, respectively.

• If he cannot see the top line from 6 m, he is asked to slowly walk towards the chart till
he can read the top line. Depending upon the distance at which he can read the top line,
his vision is recorded as 5/60, 4/60, 3/60, 2/60 and 1/60, respectively.

• If the patient is unable to read the top line even from 1 m, he is asked to count fingers
(CF) of the examiner. His vision is recorded as CF-3’, CF-2’, CF-1’ or CF close to face,
depending upon the distance at which the patient is able to count fingers.

• When the patient fails to count fingers, the examiner moves his hand close to the
patient’s face. If he can appreciate the hand movements (HM), visual acuity is recorded
as HM positive.

• When the patient cannot distinguish the hand movements, he is taken into the dark
room and a light is focused on his eye and he is asked to say when the light is on and
 when it is off. If he succeeds in doing this, V= PL (the examiner notes whether the
patient can perceive light (PL) or not). If yes, vision is recorded as PL +ve and if not it is
recorded as PL –ve.

• Also when examiner throws light, he may be able to give some indication of the four
directions from which the light is directed—up, down, right and left. This is recorded as
projection of light, accurate or inaccurate in each quadrant. If he fails to see the light the
vision is recorded as V=no Projection of light.

E chart or tumbling E chart test:

• This chart is designed for those people who don’t know the English alphabet.
• There are also charts with all numbers
• This test is especially for children who don’t know the alphabets.
• The patient indicates which way the legs of the “E” point
• Children can be asked to hold up three fingers and to point with the fingers which way
the “E” points
Broken ring chart or Landolt ‘C’ chart:

This is the broken ring chart. It is similar to the “E” chart. The patient indicates where the break
in the ring is (up, down, right, and left)

Measuring Visual Acuity that is worse than 20/200 or 20/400

Some eyes will not be able to see the big “E” on the Snellen chart at 20 feet. If this is the case
then following sequence of procedures should be followed:

Count Fingers (CF): Hold up fingers, starting at 4 feet away, & move your hand closer until the
number of fingers being held up can be identified. For example, if the eye can see to count
fingers at 2 feet, then the visual acuity is recorded as “CF @ 2 ft”

Hand Motion (HM): If the eye cannot count fingers, then wave your hand in front of the eye. If
the eye can see hand motion, then the visual acuity is recorded as “HM”

Light Perception (LP): If the eye cannot see the hand motion, then use a pen light, or muscle
light & shine it into the pupil. If the light can be seen, then determine if the eye can tell what
direction the light is coming from (left, right, up & down). If the eye can tell what direction then
record visual acuity as “LP with projection”. If the eye can see light, but cannot tell which
direction it is coming from, then record visual acuity as “LP without projection”

No Light Perception (NLP): Light perception is a very important measurement. If the eye cannot
see the light, then there is very little or no hope for improvement. You can be sure of no light
perception if you use a very bright light, such as the light from an indirect ophthalmoscope. If
no light can be seen then record visual acuity as “NLP”
 ERG (Electroretinogram)

What is ERG?

ERG is a diagnostic test that measures the electrical activity generated by neural and non-neural
cells of retina in response to a light stimulus.

ERG is recording of changes in resting potential of retina stimulated by light stimulus.

Components of ERG

Electrodes:

Three electrodes required to acquire electrical potential generated by retina. Electrical

potentials are picked up from the surface of cornea.

Three electrodes used are:

Active Electrode

Classified mainly into two types:

1) Corneal Electrode
(1) Burial Allen Electrode
(2) Jet Electrode
2) Non-Corneal Electrode
(1) DTL (Dawson Trick Litzkow) fiber Electrode
(2) Gold Foil Electrode
(3) LVP Zari Electrode

Reference or Inactive Electrode: Placed on patient forehead

Ground Electrode: Placed on patient ear lobe

Light Stimulation for ERG:

Several methods of stimulating the eye (particularly retina)

Source of light stimulating are:

1) Strobe Lamp: Strobe lamp is mobile and can be easily placed in front of a person
whether sitting or reclining
2) GANZFELD: ERG is recorded using GANZFELD which is integrating sphere used to deliver
light stimuli
3) Grass Xenon Arc Photo Stimulator: It can also be used for stimulating light

Procedure:

 There are many ways of recording ERG from patients

 Some laboratories record the light adapted state first and others dark adapted first
 Dark adapt the eye for 30 to 45 min
 Anesthetize subject’s cornea
 Dilate iris

Recording of ERG:

Attach Electrodes:
 Forehead (Negative Reference Electrode)
 Cornea (Positive Burial Allen Electrode using Non viscous coupler)
 Behind Ear (Ground Electrode)

Patient is made to sit in front of the Ganzfeld Stimulator

ERG Waveform:

a- wave:
 Sometimes called the “late receptor potential”
 It is the first negative wave
 It reflects the general physiological health of the photoreceptors (rods & cones)
in the outer retina

b- wave:
 It is a large positive wave
 It reflects the health of the inner layers of the retina including the ON bipolar
cells & Muller cells
c- wave:
 It indicates pigment epithelial layer

d- wave:
 It reflects OFF bipolar cells of retina

Measurement of ERG Component:

Two principal measures of the ERG waveform are:

1) The Amplitude
 a- wave amplitude is from the baseline to the negative trough of the a- wave
 b- wave amplitude is measured from the trough of the a- wave to the peak of the
b-wave
 2) The Time (t)
 Latency: Time interval between onset o f stimulus and beginning of a-wave
response , normally it is 2 ms
 Implicit Time: Time from the onset of light stimulus until the maximum a-wave &
b-wave response

Types of ERG:
What is Multifocal ERG (mfERG)?

 This technique is developed by Bearse & Sutter

 The response is recorded from many regions of retina
 Response is recorded to a scaled hexagonal reversal stimulus in photopic condition
 It allows assessment of focal retinal function

What is Pattern Electroretinogram (PERG)?

 The Pattern Electroretinogram (PERG) assesses the retinal response to a structured non-
luminance stimulus such as reversing a black & white check board
 It provides useful information in the distinction between optic nerve disease & macular
diseases in patients with poor central visual acuity
Why obtain an ERG? Or Need of ERG

 To evaluate retinal function in the obscured fundus

 To confirm a clinical diagnosis of retinal dysfunction or specific diseases
 To evaluate progression of retinal disease or toxicity

Color Blindness

What is Color blindness?

Color blindness is a vision defect wherein the eye perceives some colors differently than others.
This condition may be hereditary or may be caused by a disease of the optic nerve or retina.

Color blindness, or color vision deficiency, is the inability or decreased ability to see color,
or perceive color differences, under normal lighting conditions. Color blindness affects a
significant percentage of the population. There is no actual blindness but there is a deficiency of
color vision. The most usual cause is a fault in the development of one or more sets
of retinal cones that perceive color in light and transmit that information to the optic nerve.
This type of color blindness is usually a sex-linked condition. The genes that produce photo
pigments are carried on the X chromosome; if some of these genes are missing or damaged,
color blindness will be expressed in males with a higher probability than in females because
males only have one X chromosome, whereas females have two and a functional gene on only
one of the X chromosomes is sufficient to yield the necessary photo pigments.
Color blindness can also be produced by physical or chemical damage to the eye, the optic
nerve, or parts of the brain. For example, people with achromatopsia suffer from a completely
different disorder, but are nevertheless unable to see colors.
Color blindness is usually classified as a mild disability. There are occasional circumstances
where it is an advantage: some studies conclude that color blind people are better at
penetrating certain color camouflages. Such findings may give an evolutionary reason for the
high prevalence of red–green color blindness. There is also a study suggesting that people with
some types of color blindness can distinguish colors that people with normal color vision are
not able to distinguish
Causes for Acquired Color Blindness:

1. Trauma
Injury to eye due to accidents or strokes results in color blindness.

2. Chronic Diseases
Color blindness is caused by chronic diseases such as:
 Glaucoma
 Degeneration of macula of eye
 Retinitis
 Sickle cell anemia
 Leukemia
 Diabetes
 Liver diseases
 Parkinson disease
 Alzheimer disease
 Multiple sclerosis.

3. Drugs
Frequent use of some drugs leads to color blindness:

4. Toxins

Industrial toxins or strong chemicals cause color blindness. Common substances causing
color Blindness is:

 Fertilizers
 Carbon monoxide
 Carbon disulfide
 Chemicals with high lead content.

5. Alcoholism
 Chronic alcoholism results in color blindness.

6. Aging
 Color blindness can occur after 60 years of age due to various changes in eye.

Classification of Color Blindness:

Based on Young-Helmholtz trichromatic theory, color blindness is classified into three types

1. Monochromatism
Monochromatism is the condition characterized by total inability to perceive color. It is also
called total color blindness or achromatopsia. Monochromatism is very rare. Persons with
monochromatism are called monochromats. Retina of monochromats is totally insensitive to
color and they see the whole spectrum in only black, white and different shades of grey. So,
their vision is similar to black and white photography.

Monochromatism is divided into two types:

Rod Monochromatism

Rod monochromatism is the condition in which cones are functionless and the vision depends
purely on rods. So, rod monochramats are totally color blind. They are dazzled by light but
definitely are not blind during daylight. Their visual acuity is lowered and foveal vision is absent
which results in central scotoma. Central scotoma is the formation of big blind spot in fovea
centralis due to the non-functioning of cones. Rods are also absent in fovea.

Cone Monochromatism

Cone monochromatism is the condition in which vision depends upon one single type of cone.
Central scotoma does not occur in this condition.

2. Dichromatism

Dichromatism is the color blindness in which the subject can appreciate only two colors.
Persons with this defect are called dichromats. They can match entire spectrum of colors by
only two primary colors because the receptors for third color are defective. The defects are
classified into three groups:

Protanopia

Protanopia is the type of dichromatism caused by the defect in receptor of first primary color,
i.e. red. So, the red color cannot be appreciated. Persons having protanopia are called
protanopes. They use blue and green to match the colors. Thus, they confuse red with green.
Deuteranopia

Deuteranopia is the dichromatism caused by the defect in receptor of second primary color, i.e.
green. Deuteranopes use blue and red colors and they cannot appreciate green color.

Tritanopia

Tritanopia is the dichromatism caused by the defect in receptor of third primary color, i.e. blue.
Tritanopes use red and green colors and they cannot appreciate blue color.

3. Trichromatism

Trichromatism is the color blindness in which intensity of one of the primary colors cannot be
appreciated correctly though the affected persons are able to perceive all the three colors.
Persons with this defect are called trichromats. Even the dark shades of one particular color
look dull for them.

Trichromatism is classified into three types:

Protanomaly:

Protanomaly is the type of trichromatism in which the perception for red is weak. So to
appreciate red color, the person requires more intensity of red than a normal person.

Deuteranomaly

Deuteranomaly is the trichromatism in which the perception for green is weak.

Tritanomaly

Tritanomaly is the trichromatism with weak perception for blue.

Tests for Color Blindness:

1) By using Ishihara Color Charts

2) By using Holmgren colored wool
3) By using Edridge-Green Lanter
 Optical Coherence Tomography (OCT)

Definition: OCT is non-contact, non-invasive cross sectional study of retina. It is an imaging

technique generally used for imaging of living biological tissue. It is most commonly used for
imaging of retina

Two types of analysis can be done through OCT

1) Qualitative Analysis:
 Description by location
 Description by form & structure
 Identification of anomalous structure
 Observation of the reflective qualities of retina

2) Quantitative Analysis:
 Retinal thickness & volume
 Nerve fiber layer thickness

OCT Principle:

OCT works on the principle of “Interferometry”

 Low-coherence infra-red light coupled to a fiber-optic travels through a beam-splitter

and is directed through the ocular media to the retina and a reference mirror
 The distance between the beam-splitter and reference mirror is continuously varied
  When the distance between light source & retinal tissue = distance between light source
& reference mirror, the reflected light and the reference mirror interacts to produce an
interference pattern.
 Interference measured by a photo detector- produces a range of time delays for
comparison

OCT Setup:

Types of OCT:

Time Domain OCT (TD OCT) Fourier/Spectral Domain OCT (FD/SD OCT)
Reference Mirror moves Reference Mirror stationary
Interference not detected by special Interference not detected by special
interferogram interferogram
No Fourier transformation Interference pattern Fourier transformed
1 pixel at a time 2048 pixels at a time
Slow Rapid
Motion artifacts present No motion artifacts
Less sharp images Sharper and clear images

Scan Protocol Types:

1) Line: The "line" scan simply scans in a single, straight line. The length of the line can be
changed as well as the scan angle.
2) Circle: The "circle" scans in a circle instead of a line.
3) Radial: The "radial lines" scans 6 consecutive line scans in a star pattern
The OCT System:

• Fundus viewing unit

• Interferometric unit
• Computer display
• Control Panel
• Color inkjet printer

Procedure:

• Machine is activated
• Patients pupils are dilated
• Patient seated comfortably
• Asked to look into the target light in the ocular lens
• Discouraged to blink
• Protocol selected as per case requirement