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Global Optometry Resources
Clinical Optometric Procedures 2

CLINICAL OPTOMETRIC PROCEDURES 2
STUDENT MANUAL
PRIMARY AUTHOR
Luigi Bilotto: Brien Holden Vision Institute
CONTRIBUTING AUTHORS
Mark Dunbar: Bascom Palmer Eye Institute, University of Miami
Sarah McGowan: Mzuzu University
Daniel Palanker: Department of Ophthalmology and Hansen Experimental Physics Laboratory, Stanford University
PEER REVIEWERS
Benoit Tousignant: Université de Montréal, School of Optometry
James Loughman: Dublin Institute of Technology
Dr Cédric Yansouni: McGill University
Patricia Hrynchak: University of Waterloo
Timothy Wingert, University of the Incarnate Word Rosenberg School of Optometry
Maureen Hanley, The New England College of Optometry
Meng Meng Xu, The New England College of Optometry
Iqbal Ike Ahmed, MD, FRCS

University of Toronto, Toronto, Ontario, Canada
Trillium Health Partners, Mississauga, Ontario, Canada
Credit Valley EyeCare, Mississauga, Ontario, Canada
Graham Belovay, MD
Jean-Sébastien Dufour: University of Montreal
John Pula: NorthShore University Health System, Pritzker School of Medicine Clinician Educator, University of
Chicago
EDITORS AND GRAPHICS
Brien Holden Vision Institute Staff – Public Health Division

Brien Holden Vision Institute Foundation (formerly ICEE) is a Public Health division of Brien Holden Vision Institute
DISCLAIMER:
DISCLAIMER
The material and tools provided in this publication are provided for purposes of general information only. Brien Holden Vision Institute is not providing specific advice concerning the clinical
management of any case or condition that may be mentioned in this publication, and the information must not be used as a substitute for specific advice from a qualified professional.
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COPYRIGHT © 2014 Brien Holden Vision Institute. All rights reserved.
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a licence, please visit: education.brienholdenvision.org.
COURSE OUTLINE
COURSE AIM
This course aims to build on and advance the student’s theoretical knowledge of the various clinical procedures used
in the practice of optometry to determine an individual's visual and ocular status.
COURSE OBJECTIVES
By the end of the module students should be able to use the knowledge gained to perform a wider set of diagnostic
procedures necessary to provide more comprehensive eye care.
By the end of the module the student should be able to:

• describe the purpose and methodology of standard diagnostic procedures in eye care
• differentiate normal from abnormal ocular clinical findings
• integrate all clinical procedures into a comprehensive eye exam
• apply formal chart keeping modalities to eye care
COURSE CONTENT
The topics covered in this course include:
STANDARD OCULAR HEALTH ASSESSMENT

• Sphygmomanometry
• Biomicroscopy common findings of the anterior segment
• Fundus methods
• Gonioscopy
VISUAL FIELDS ASSESSMENT AND INTERPRETATION

• Introduction to visual fields
• Testing the visual field
• Campimetry
• Perimetry
• Anatomical correlation of visual field defects
ANCILLARY PROCEDURES
• Corneal procedures
• Eyelid procedures
• Carotid artery and orbital auscultation
• Brightness & color comparison; photostress recovery
• Deceptive testing
• Contrast sensitivity function
• Glare Evaluation and potential acuity testing
• Ocular coherence tomography
• Ultrasonography (ocular echography)
• Fluorescein angiography
• Electrodiagnostic tests
• Radiological examination of the visual system
• Ophthalmic laser therapy
COURSE DELIVERY
This module is designed to be delivered over 1 semester. Total delivery time for Clinical Optometric Procedures 2 is
56 hours of lectures.
Learning and Teaching Methods & Resources

The suggested teaching methods for this course include: PowerPoint presentations, discussions, practical sessions,
clinical attachments, question and answer sessions, and general observation.
Suggested equipment for teaching includes:

• Computer & projector
• White board
• Handouts
• Standard optometric clinical equipment
RECOMMENDED ASSESSMENT
• Written examination
• Laboratory assignments
• Clinical attachments
TEXT BOOKS
Prescribed texts
• Brien Holden Vision Institute Global Optometric Resources: http://www.brienholdenvision.org/education/optometry-
resources.html
• Alexander LJ. Primary Care of the Posterior Segment. 3rd Edition. Norwalk: MacGraw-Hill Companies, Inc. 2002.
• Alward WLM, Longmuir RA and American Academy of Ophthalmology. Color atlas of gonioscopy. San Francisco:
American Academy of Ophthalmology. 2008.
• Carlson NB and Kurtz D. Clinical procedures for ocular examination. 3rd Edition. USA: MacGraw-Hill Companies,
Inc. 2004.
• Casser L, Fingeret M and Woodcome HT. Atlas of Primary Eyecare Procedures. USA: Appleton and Lange.
1997.
• Catania LJ. Primary Care of the Anterior Segment. 2nd Edition. Conneticut: Appleton and Lange. 1995.
• Elliott DB. Clinical procedures in primary eye care. 3rd Edition. Oxford: Elsevier. 2008.
• Eskridge JB, Amos Jfand Bartlett JD. Clinical Procedures in Optometry, Philadelphia: J.B.Lippincott Company.
1991.
• Jones W. Peripheral Ocular Fundus. 3rd Edition. St Louis: Butterworth-Heinemann, 2007.
Recommended texts
• American Academy of Ophthalmology, Basic and Clinical Science Course CD, The Foundation of American
Academy Ophthalmology. 2005
• Anderson DR. Patella VM, Automated Static Perimetry, 2nd Edition. Mobsy, St. Louis, 1999.
• Anderson, D., Testing The Field of Vision, The C.V. Mosby Company, St-Louis, MI, 1982.
• Bajandas, FJ, Kline LB. Neuro Opthalmology Review Manual. 6/e. Slack Inc.: Thorofare, NJ, 2008
• Bell FC., Stenstrom WJ., Atlas of the Peripheral Retina, W.B. Saunders Company, 1983.
• Benjamin W, Borish's Clinical Refraction, Butterworth-Heinnemann, 2007
• Bennett AG and Rabbetts RB, Clinical Visual Optics 4/e. Butterworth Heinemann. London, 2007
• Bennett ES, Fiscella RG, Jaanus SD, Rowsey JJ. Ophthalmic Drug Facts, Facts & Comparisons, 21/e, Woulter
Kluwer, St-Louis, Missouri, 2009
• Brien Holden Vision Institute Global Optometric Resources: http://www.brienholdenvision.org/education/optometry-
resources.html
• Caloroso, E.E. and Rouse, M.W. Clinical Management of Strabismus. Butterworth-Heinemann: Boston. 1993
• Ehlers JP, Shah CP, Fenton GL, Hoskins EN, Shelsta HN, Friedberg MA, Rapuano CJ. The Wills Eye Manual:
Office and Emergency Room Diagnosis & Treatment of Eye Disease, 5/e, J.B. Lippincott Company, Philadelphia,
PA, 2008.
• Fingeret M, Casser L, Woodcome HT. Atlas of Primary Eyecare Procedures. Norwalk, CT: Appleton & Lange;
1997.
• Fisch BM, Gonioscopy and the Glaucomas. Butterworth-Heinemann, 1993.
• Haley MJ., The Field Analyzer Primer, 2nd ed., Allergan Humphrey, San Leandro, California, 1986.
• Harrington DO, Drake MV, The Visual Fields: Text & Atlas of Clinical Perimetry, C.V. Mosby, 1990.
• Heijl A, Patella VM. Essential Perimetry: the Field Analyser Primer, 3rd Edition, Carl Zeiss Meditec, Dublin, CA,
2002.
• Humphrey Field Analyzer II, User’s Guide, Humphrey Instruments Inc., 1994.
• Humphrey Field Analyzer, Capabilities & Applications, Allergan Humphrey, 1989.
• Lewis TL, Fingeret M, Primary Care of the Glaucomas, Norwalk, CT: Appleton & Lange; 2001.
• Milder B, Rubin ML, The Fine Art of Prescribing Glasses Without Making a Spectacle of Yourself, 3/e, Gainesville,
Fla. : Triad Pub. Co., 2004.
• Scheiman M, Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye
Movement Disorders. 3rd Ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.
• Zadnik K, Lampert R. The Ocular Examination: Measurements and findings, WB Saunders 1997
TABLE OF CONTENTS
STUDENT MANUAL

1. Sphygmomanometry
2. Biomicroscopy common findings of the anterior segment
3. Fundus methods
4. Gonioscopy

5. Introduction to visual fields
6. Testing the visual field
7. Campimetry
8. Perimetry
9. Anatomical correlation of visual field defects
10. Corneal procedures
11. Eyelid procedures
12. Carotid artery and orbital auscultation
13. Brightness & color comparison; photostress recovery
14. Deceptive testing
15. Contrast sensitivity function
16. Glare Evaluation and potential acuity testing
17. Ocular coherence tomography
18. Ultrasonography (ocular echography)
19. Fluorescein angiography
20. Electrodiagnostic tests
21. Radiological examination of the visual system
22. Ophthalmic laser therapy
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Copyright © 2015 Brien Holden Vision Institute

CLINICAL OPTOMETRIC PROCEDURES 2
RECOMMENDED DELIVERY TIME OF LECTURES

1. Sphygmomanometry 1.5
2. Biomicroscopy common findings of the anterior segment 5.0
3. Fundus methods 4.0
4. Gonioscopy 3.0

5. Introduction to visual fields 1.0
6. Testing the visual field 4.0
7. Campimetry 1.5
8. Perimetry 7.5
9. Anatomical correlation of visual field defects 4.0
10. Corneal procedures 3.0
11. Eyelid procedures 3.0
12. Carotid artery and orbital auscultation 1.0
13. Brightness & color comparison; photostress recovery 1.0
14. Deceptive testing 1.0
15. Contrast sensitivity function 1.0
16. Glare Evaluation and potential acuity testing 1.0
17. Ocular coherence tomography 3.0
18. Ultrasonography (ocular echography) 2.0
19. Fluorescein angiography 2.0
20. Electrodiagnostic tests 2.5
21. Radiological examination of the visual system 1.5
22. Ophthalmic laser therapy 2.5
56.0
SPHYGMOMANOMETRY
(BLOOD PRESSURE)
AUTHOR
PEER REVIEWER
Dr Cédric Yansouni: McGill University
Sphygmomanometry, the measurement of blood pressure (BP), is a useful complementary test of an optometric
assessment. The BP measurement serves as a screening method for the frequently asymptomatic patient with
suspected or poorly controlled hypertension and cardiovascular disease. A BP assessment may also be valuable
when pharmacological agents are used in eye care as some medication may have potentially deleterious side
effects in people with severe hypertension or cardiovascular problems. Finally, because the eye is an important
target organ of many vascular diseases, blood pressure measurement is useful in the diagnosis and management of
both ocular and systemic diseases, some of which can be sight-threatening or even fatal (Table 1.1).
• Chronic open angle glaucoma

• Low tension glaucoma
• Repeated spontaneous subconjunctival hemorrhages
• Hypertensive retinopathy
• Retinal embolic phenomena
• Transient ischemic attacks
• Amaurosis fugax
• Headache
• Papilledema
Table 1.1: Clinical conditions where BP Measurement complements the clinical diagnosis
THEORY
Arterial pressure varies during the cardiac cycle. At the end of the ventricular contraction, when the ventricle finishes
pumping blood into the aorta, the arterial pressure within the vascular system reaches the maximal systolic pressure.
As the ejected blood is distributed throughout the vascular system during the relaxation phase of the ventricle,
arterial pressure gradually decreases to reach the minimal diastolic pressure.
Systolic and diastolic pressure can be measured directly by inserting a catheter into a major artery that is connected
to a manometer or electronic recording device. This is an invasive method used principally in critical care settings or
in animals for experimental purposes.
2013 Clinical Optometric Procedures 2, Chapter 1-1

Sphygmomanometry (Blood Pressure)
Pressure in the arterial system during single cardiac cycle
125 Systolic pressure
mmHg Mean pressure
75 Diastolic pressure
Figure 1.1: Pressure in the arterial system during a single cardiac cycle
Clinically, blood pressure is usually evaluated indirectly by wrapping an inflatable bladder around the arm to oppose
the pressure in the brachial artery and listening to the resulting Korotkoff sounds. The Korotkoff sounds are
produced by the blood opening and swirling through the brachial artery when the outside pressure compresses it.
Normally, no Korotkoff sound is heard when the artery is either fully shut or fully opened. Sounds are only heard
when the blood forces open the artery and swirls between the vessel walls against a certain resistance.
Consider an air-filled bladder wrapped around the upper arm, where the brachial artery runs. In addition to being
easily accessible and compressible, the brachial artery also offers the key benefit of being located near level of the
heart, an important fact to obtain an accurate blood pressure measurement. If the pressure in the bladder is
increased until its pressure is higher than the highest arterial pressure (systolic pressure), the brachial artery will
collapse and blood flow will cease, at which time no Korotkoff sound will be heard. As the bladder pressure is
decreased by releasing air from an adjustable valve, blood in the brachial artery will first flow when the pressure
within the artery is slightly greater than the pressure compressing it (systolic pressure ≈ bladder pressure). At this
point, a first Korotkoff sound will be heard.
During the relaxation phase of the artery, however, the pressure within the artery will gradually fall reaching a point
below the bladder pressure at which point the artery will collapse again, until the next systolic contraction. This cycle
will continue if the bladder pressure is kept constant. However, if the bladder is further deflated, the pressure within
the artery will exceed the bladder pressure and open the brachial artery for a longer segment of the cardiac cycle. A
point is eventually reached where the bladder pressure is too low to ever compress the artery against even the
lowest pressure within the vessel (diastolic pressure ≈ bladder pressure). At this point, the Korotkoff sound will
cease.
The Korotkoff sounds vary in loudness throughout the cardiac cycle. The intensity of sound throughout the cardiac
cycle is depicted in Figure 1.2. The systolic and diastolic pressure correspond to the first and the last Korotkoff
sounds respectively (stage I & V) (Fig. 1.2).

Figure 1.2: Set up and phases of a blood pressure measurement
Inspired by Raffery EB: The Methodology of blood pressure recording. Br. J Pharmacol 1978; 6: 193-201
INSTRUMENTATION
Using the above principle, the arterial pressure is measured with a sphygmomanometer and a stethoscope.
The sphygmomanometer or blood pressure meter is a device composed of an inflatable bladder inside an unyielding
cuff that can be wrapped and tied around the arm and inflated with a bulb. The bladder is connected to a measuring
device, usually a mercury column, an electronic or mechanical manometer, that indicates the pressure within the bag
in millimeters of Mercury (mmHg). The column of Mercury is the standard by which pressure measurements are
denoted.
Pressure cuffs are available in various sizes for the newborn, infant, child, adult, and large adult. In many clinical
settings, an adult size is used as an all-purpose measuring cuff. The clinician must however bear in mind that the
use of an inadequately sized BP cuff will yield significant errors in the measurements. The ideal bladder width should
cover 40% of the arm circumference (2.5 X the width = arm circumference). Conveniently, most bladders are 2X
their width; the proper length of the inflatable bladder should therefore cover approximately 80% of the arm’s
circumference.
The stethoscope, an instrument used to amplify the Korotkoff sounds, generally consists of earpieces, binaural,
rubber tubing and a chest piece. The chest piece can be composed of a single flat base surface (diaphragm) used to
capture higher frequency sounds or include 1 to 3 bells used to capture low frequency noises. Although debatable,
the diaphragm is recommended for blood pressure measurement (Fig. 1.3).
Figure 1.3: Instrumentation used for blood pressure measurement
PROCEDURE
• If not your own, clean earpieces of the stethoscope with alcohol

• Sit and rest the patient comfortably for at least 5 minutes
• Free the arm of clothing insuring that the rolled up sleeves do not compress the arm. If absolutely necessary, the
BP can be evaluated through a thin layer of clothing
• The arm is then extended, slightly bent and rested on the chair arm (or held) with the palm facing upward
• Locate the brachial artery by palpating the inner aspect of the biceps muscle just above the level of the
antecubital crease (elbow fold)
• Wrap the cuff securely but not too tight around the upper arm ~ 2,5 cm above the crease
• Insure proper alignment of the middle of the cuff above the artery
• Palpate the radial pulse with the index & middle fingers; avoid using the thumb as it has a detectable pulse
• Before inflating the cuff, make sure the cuff is approximately at the level of the heart. If necessary, support the
patient’s elbow to ensure the patient’s arm remains relaxed
• Inflate the cuff at ~ 20-30 mmHg above the point at which the radial pulse disappears
• Place the stethoscope diaphragm firmly but gently over the brachial artery avoiding cuff contact
• Deflate the cuff by increments of 2-3 mmHg, listening for first (systolic) & last (diastolic) Korotkoff sounds
• Wait 1 minute; Repeat the procedure a second time and average the results
• If sounds are inaudible, consider elevating the arm during inflation of the bladder or after inflating it have the
patient open and close the fist.
SYSTOLIC / DIASTOLIC; ARM USED; PATIENT POSITION; TIME
E.g. 150/90 RAS 13:45

• Use R,L for right/left; A for arm; S for sitting, U for upright, L for lying
• If pertinent, note additional comments such as cuff size or abnormal conditions.
SOURCE OF ERRORS
• Diurnal Variation
• Interobserver variability
• Arm used
• Weak or inaudible Korotkoff sounds
• Orthostatic hypotension
Table 1.2: Possible Sources of Variability in BP Readings
Falsely Low Readings:

• Cuff too big (wide)
• Cuff deflated too rapidly
• Arm level above heart level
• Auscultatory gap*
• Placing chest piece under cuff
Falsely High Readings:

• Patient anxiety, fear emotional distress
• Cuff too small (narrow)
• Cuff too loose
• Cuff deflated too slowly (diastolic)
• Cuff deflated too rapidly (diastolic)
• Pseudohypertension (medial sclerosis and/or calcification of
arteries)
• Arm level below heart level
Table 1.3: Possible Sources of Error in BP Readings
*An auscultatory gap is a period of abnormal silence or diminished intensity during one of the Korotkov sound phases.

BP Range (mmHg) Category Recommended Follow-up
Adults (> 18)
≤ 95/60 Hypotension Routine unless symptomatic
Diastolic
< 85 Normal BP Recheck within 2 years

85-89 High-normal BP Recheck within 1 years
90-104 Light hypertension Confirm within 2 months
105-115 Moderate hypertension Obtain medical care within 2 weeks
≥ 115 Severe hypertension Obtain immediate medical care
Systolic (when diastolic < 90)
< 140 Normal BP Recheck within 2 years

140-159 Borderline isolated systolic HTN Confirm within 2 months
≥ 160 Isolated systolic HTN Confirm within 2 months
≥ 200 None given Obtain medical care within 2 weeks
Children
< 135/90 Ages 14-18 years Routine

< 110/75 Less than 6 years Routine
Table 1.4: BP classification with the Recommended Guidelines for medical follow-up based on initial readings. Specific medical
conditions may modify interpretation of blood pressure values
REFERENCE
• Eskridge, J.B., Clinical Procedures in Optometry, Lippincott Williams & Wilkins, January 1991.

BIOMICROSCOPY - COMMON FINDINGS
OF THE ANTERIOR SEGMENT
AUTHOR
PEER REVIEWER
In biomicroscopy, it is beneficial to adhere to a routine method of examination that will allow for effective recognition
of normal and abnormal findings. The following describes a systematic approach to Slit Lamp Examination (SLE)
that incorporates the techniques into a routinely performed sequence.
The logical approach in biomicroscopy is to examine the tissues from the most anterior structure to the most
posterior structure. The routine proceeds therefore from the lids & lashes to conjunctiva to sclera to cornea and
anterior chamber angle assessment, to iris to anterior chamber to lens and finally to anterior vitreous.
With the routine use of the biomicroscope, a “new world” of findings, normal & abnormal, opens to the eye care
practitioner. One must naturally establish an understanding of common anterior segment presentation prior to
developing the ability to recognize and manage “truly” abnormal presentations.
The SLE routine is therefore presented in combination to the common “normal” and “abnormal” appearances of the
anterior segment. This will render the use of the SLE more clinically relevant by directly relating the procedures to
their application with regards to clinical findings.
Additionally, the problem oriented SOAP system (SOAP = Subjective, Objective, Assessment and Plan) is used to
facilitate the presentation of findings & to familiarize the student with this useful clinical method of documentation.
Clinical Optometric Procedures 2, Chapter 2-1

2013
Common Anterior Segment Findings
LIDS & LASHES
METHOD OF OBSERVATION
The evaluation of lids and lashes is performed by using a direct diffuse illumination or a wide parallelepiped with low
to moderate magnification. Points to inspect include the tissue of the lids, lashes, caruncle and plica semilunaris, the
lid position and apposition to the globe, the lid margin including glands, tear prism and puncta and finally the integrity
of the lashes.
NORMAL
The lid tissue should be devoid of lumps, bumps, inflammation and unusual pigmentation or vascularization. The
position of the lid is such that it covers 1-3mm of the superior limbus /cornea adhering closely to the globe. The lid
margin should appear free of blocked glands, infection, inflammation and the tear prism should be 0.2-0.4mm in
height. The lashes should be clear of flaking or debris and each lash should arise separately from its respective
follicle as opposed to being matted together. Finally, as part of the lachrymal apparatus, both the superior and
inferior puncta should be visible and open upon eversion of the lids.
ABNORMAL
Blepharoptosis (ptosis):
Definition: A drooping or abnormally low position of the upper eyelid.
S: The patient usually has no complaints but they may have cosmetic concerns. The clinician must determine if
the ptosis is congenital or acquired. It is possible to confirm congenital diagnosis by history and/or old
photos. If the lid crease is absent, it is indicative of a long-standing ptosis. An acquired ptosis requires
further evaluation to determine cause. Must note a unilateral versus bilateral nature. Congenital ptosis is
usually bilateral and acquired is usually unilateral.
O: The presentation varies from a subtle difference between lid apertures to a total unilateral or bilateral closure
of the lid.
A: Both congenital & acquired ptosis have many etiologies or differential diagnosis including neurological,
aponeurotic, mechanical, myogenic, trauma, multiple sclerosis, myasthenia gravis, etc.
P: The management depends on the etiology of the ptosis. A referral may be necessary for evaluation of an
acquired ptosis.
Dermatochalasis
Definition: Protrusion of superior lid tissue secondary to attenuation or stretching of the orbital septum from aging.
S: The patient usually has no complaints but they may have cosmetic concerns. It presents in middle age to
elderly persons. It is usually bilateral and has a familial tendency.

2013
O: The draping of superior lid tissue over septum or lid margin causes a loose or redundant tissue fold. It may
have a puffy appearance due to fatty tissue herniation. The lid crease may become indistinct and produce a
pseudo-ptosis. It may cause a visual field deficit if it covers the pupil.
A: Primarily due to the aging process.
P: Surgery is indicated if the patient suffers a functional deficit ( e.g. visual field defect) or for cosmesis,
otherwise no treatment is required.
Hordeolum
Definition: An acute staphylococcal infection of the glands of Zeiss, Moll or Meibomian.
S: Hodeoli are usually seen as an acute presentation or within 24-48 hours of onset. The patient suffers either
generalized lid tenderness/soreness or distinct tenderness/pain with palpation. They may have a history of
chronic blepharitis.
O: 2 types:
External Hordeolum (“stye”) or an infection of the glands of Zeiss or Moll. There is a tender lump at lid
margin and the exudate “points” outward, either through a gland orifice or skin surface. Appearance is red
and swollen.
Internal hordeolum is an infection of a Meibomian gland. Because it is anatomically deeper, It is less

common and more painful than an external hordeolum. The “lump” may “point” in or out and diffuse redness
and swelling are noted.
A: The staphylococcal infection can be an isolated incident or associated with a chronic condition such as
blepharitis. As part of the differential diagnosis, the clinician must rule out the presence of preseptal cellulitis
which is an infection of the structures anterior to the septum. It is also recommended to palpate nodes to rule
out a viral etiology.
P: Most resolve spontaneously. Resolution may be promoted by hot compresses performed 15-20 minutes
QID. Antibiotics are commonly prescribed for hordeolum, but their usefulness is controversial. If it does not
resolve excision may be required.
Chalazion
Definition: Granuloma or nodule of granulized tissue occurring as a result of chronic inflammation of a Meibomian
or Zeiss gland. An internal chalazion is a granuloma of the meibomian gland and an external chalazion is a
granuloma of the Zeiss gland.
S: Painless lid bump (painless unless inflamed) that may stay the same size or progress. The patient may
report a recent hordeolum at same location.
O: Firm round or elongated mass. The external points outward and the internal points inward toward the
palpebral conjunctiva. Eversion of the lids is a must.

2013
A: Lipogranulomatous inflammation secondary to retention of sebum caused by obstruction of the duct of a

gland. Differential diagnosis includes preseptal cellulitis, sebaceous cell carcinoma(suspect in recurrent
chalazion) and pyogenic granuloma.
P: Chalazions will usually resolve by themselves however they may be treated with warm compresses. Often,
they require surgical excision or incision and curettage. If the chalazion is located near the lacrimal
apparatus, injection of steroids into the lesion may be considered rather than excision. Antibiotics are
commonly prescribed for chalazion but their usefulness is controversial.
Chronic Marginal Blepharitis
Definition: Chronic infection of lids and lashes.
S: Itching, burning, irritation, foreign body sensation, tearing, crusting on awaking, inflammation. Possible
history of frequent hordeoli, chalazia of chronic duration.
O: Thickened, rounded, ill-defined hypertrophic lid margins, telangiectatic blood vessels, moderate to abundant
flat yellowish crustations around base of lashes. May have madarosis, poliosis, trichiasis, hordeoli, chalazia,
SPK, or dry eye association. There are 2 main types: dry-seborrheic type which is associated with skin
problems and an infectious bacterial type.
A: The dry-seborrheic type is associated with acne rosacea and eczema and the chronic infectious type is
usually caused by staphylococcus.
P: Blepharitis is treated by routine & maintenance use (2 times/day) of warm compresses, lid scrubs and
artificial tears. This will remove the source of the inflammation/infection, lubricate the eyes and will provide
much relief to the patient.
Moderate to severe presentations with a high degree of pain may require more frequent compresses, lid scrubs and
artificial tear use. Antibiotic or antibiotic-steroid combinations are sometimes recommended. However, removing the
source of the inflammation with warm compresses and lid scrubs is the first line of defense and usually sufficient.
The treatment is always aimed at the underlying cause which may be infectious (staphylococcal origin) or seborrheic
(oily skin).
Meibomianitis (Meibomian Gland Dysfunction, Posterior Blepharitis)
Definition: Build up of fatty esters in meibomian glands which are frequently associated with seborrhea (oily skin)
and atopic allergic history.
S: Itching, burning, irritation, foreign body sensation, tearing, crusting on awaking, inflammation. Possible history
of frequent hordeoli, chalazia of chronic duration.
O: Mild to moderate inflammatory appearance to posterior lid margin congested orifices of multiple meibomian
glands in palpebral conjunctiva palpebral conjunctiva red, velvety if chronic: thickened, rounded lid margins
associations: almost always see a blepharoconjunctivitis (>inferior) - SPK possible tear film disturbances
(rapid tear break-up time, “frothy” tears) - DRY EYE.
A: Many causes of inflammation and congestion of these glands. Remember it is not an infectious organism but
rather a congestion and inflammation of the glands.

2013
P: MGD is treated by routine use of ocular massage, warm compresses, lid scrubs and artificial tears. Ocular
massage is performed by using rotary action of the fingers at the lid margins. This is a crucial part of the
therapy because simple MGD is not caused by an infectious organism. MGD is a congestion and
inflammation of the glands by sebum (sterol fatty esters). When the patient is in office it recommended to
express the meibomian glands. Depending on severity, home therapy is started on a frequent basis (TID or
QID) & decreased gradually to a maintenance therapy (BID, QD).
In more complex cases, MGD can be associated to seborrheic dermatitis, or acne rosacea in which case treatment
with topical or oral antibiotics & steroids or combinations of both may be indicated.
Ectropion
Definition: Inferior eyelid turning outward.
S: Eye/eye lid irritation , epiphora or patient may be asymptomatic.
O: Inferior lid margin is not in apposition with the globe; punctal ectropion occurs when the puncta is not in
apposition with the globe.
A: Lid atonia due to aging, chemical burn, surgery, lid laceration, 7th nerve palsy(Bell’s Palsy), also cicatricial
(scarring).
P: None / taping / surgical repair. If the cornea is compromised, lubricating agents, bandage soft CL, mild
antibiotic ointment.
Entropion
Definition: Inferior lid & lashes turning inward.
S: Excess tearing, lid spasms, corneal foreign body sensation, irritation, red eye.
O: Lids / lashes turned inward & rub against corneal surface which may result in corneal foreign body tracking,
SPK and conjunctival injection.
A: May be congenital (rare). Differential diagnosis includes spastic response on forced closure of lids, aging
(involutional), cicatricial, ocular pemphigoid, Stevens-Johnson, chemical burns, trauma, trachoma, surgical ,
blepharospasm.
P: Definitive treatment is usually surgical. Can also use bandage CL to protect cornea or complete epilation
(removal of lashes). Taping offers temporary relief.
Poliosis
Definition: Whitening of eyelashes.
S: Cosmetic complaint.

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O: Unilateral or bilateral, partial to complete, whitening of lashes of inferior or superior lashes.
A: Can be congenital in ocular albinism. The differential diagnosis for acquired causes includes staphylococcus
or chronic blepharitis, chronic uveitis, chemotherapy, Vogt Koyanagi Harada syndrome.
P: Treat underlying cause (e.g., treat staphyloccoccal infection).
Madarosis
Definition: Loss of eyelashes.
S: None. Usually a cosmetic concern.
O: Partial to complete loss of inferior or superior lashes. Unilateral or bilateral.
A: Congenital vs. acquired. The differential diagnosis includes toxic reaction to staphylococcus, systemic
relationships (medications, chemotherapy, other hair loss), or self-inflicted.
P: Aim treatment at the causative agent.
Papilloma
Definition: Benign epithelial tumor
S: None, usually a cosmetic concern. Generally seen in children associated with a virus and in older patients
without a viral association.
O: Epithelial overgrowth with a wide variation in size & shape. Presenting as singular or multiple masses, they
are amelanotic to black (black when they outgrow underlying blood supply and necrose). Often at
mucocutaneous borders of the eyelid, they can be anywhere. They are avascular with roughened (but not
eroded!) granulated surfaces due to redundant epithelial cell growth. The surface texture is different than the
surrounding skin.
A: Abnormal cell growth (benign tumor). The clinician must rule out neoplasm.
P: Must document size and appearance. Photodocument if lesion is questionable. If surgically removed, it is a
complete excision with biopsy.
Sebaceous Cyst
Definition: fatty, fibrous cyst of a sebaceous gland.
S: Cosmetic concern. The patient may report either recent onset or long-standing.
O: 2 types:

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Superficial: Superficial cysts range from 2-5 mm in size with a wide variation. There is a caseous
(“cheesy”) yellowish material in recently developed cysts covered by a thin, flattened epithelial layer. It
presents as an individual cyst or multiple cysts and is located commonly around the lids, especially at inner
and outer canthus.
Subcutaneous (deep): The deep cyst is an epidermal inclusion cyst. A slightly moveable lump, it is variable
in size ( 1- 20 mm or greater) and can be located anywhere on the body. The overlying skin is normal
but may show prominent blood vessels, telangiectasia, or venous congestion.
A: Results from a blockage of the gland and accumulation of material within it. Clinician must rule out
malignancy from the differential diagnosis.
P: None. Can be removed if desired.
Verrucae
Definition: Viral wart.
S: Usually a cosmetic concern. The patient may report a slow, insidious development and may report similar
lesions elsewhere (auto-innoculation tendency).
O: Single or multiple non-secreting wart(s). The coloration varies from gray-brown to yellowish-brown. They
present in various shapes such as planar - flat, or round. Vulgaris - is raised and irregular with a broad base.
Digitata - is cauliflower-like on narrow stalk. They have smooth surfaces with redundant tissue waves.
A: Verruca can resemble other lid bumps such as papilloma and neoplasm. Therefore the clinician must rule out
malignancies from the differential diagnosis.
P: Educate patient as to its contagious nature. Consider surgical removal for cosmesis concern.
Trichiasis
Definition: In-turning lash(es).
S: Frequent complain of hyper-lacrimation and epiphora or foreign body sensation.
O: Lash or lashes turning inward toward globe and irritating corneal surface. The inferior lid is more commonly
affeted than the superior. Foreign body tracking may be seen. Note that the lid position is normal as opposed
to entropion where it is turned inward.
A: Congenital or acquired. The differential diagnosis for acquired causes includes chronic staphylococcal
reaction/blepharitis, also scarring pemphigoid, chemical burns, trachoma, Stevens-Johnson syndrome.
P: Usual treatment is epilation; electrolysis or laser ablation may be used for multiple lashes.
Nevus

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Definition: Well circumscribed pigmented spot devoid of vasculature.
S: None; usually a cosmetic concern.

O: 3 basic types of nevi:
Dermal: Most common; deep form; raised or flat; rarely becomes malignant.
Junctional: Superficial; usually flat; may convert to malignancy.
Transitional: A mixed form that is pigmented (usually brown) to amelanotic. The spots on the skin surface
have well-defined borders and are usually < 8-10 mm. They may increase in size with age (can also
decrease) but may also increase in size or change pigmentation with hormonal changes.
A: Usually congenital or early onset ; if acquired, need to rule out malignancies from the differential.
P: Photo-documentation for most; referrals for suspicious lesions where there is a change in the presentation of
the lesion.
Xanthelasma
Definition: Cutaneous deposition of lipid material.
S: Cosmetic concern. Usually found in older patients, in females more than males. The patient may report a
history of atherosclerosis, hyperlipidemia, or a high risk cardiovascular history.
O: Flat, triangular, elevated areas (usually base in!). They are generally found at the inferior or superior inner
canthal lid sulcus. Color appears light brown to yellowish. Usually bilateral and symmetrical.
A: Deposition of lipid is chronic and is associated with raised blood cholesterol.
P: Cosmetic surgery is performed if it is desired by the patient. More importantly, the clinician must advise the
patient that a medical work-up may be necessary to rule out any serum cholesterol or lipid disorder.
CONJUNCTIVA
By using direct diffuse illumination, indirect illumination, or wide parallelepiped with low to moderate magnification,
examine the superior and inferior palpebral and bulbar conjunctiva with lid eversion. Also examine the medial and
temporal bulbar conjunctiva including the inner canthus. Evert inferior lids routinely and evert superior lids as
indicated by factors specific to the individual patient.
NORMAL
The palpebral conjunctiva should appear pink/healthy and devoid of papillae, follicles, discharge, infectious/
inflammatory membranes, filamentary strands, pinguecula and unusual injection of the blood vessels. The bulbar
conjunctiva should appear white/healthy and devoid of injection, cystic formation or unusual pigmentation.
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ABNORMAL
Calcium Concretions
Definition: Hard spots of calcium on palpebral conjunctiva.
S: Usually asympytomatic. Patients sometimes have complaints of corneal irritation or foreign body sensation. It
is commonly seen in the elderly.
O: Small, white to yellowish hard spots on palpebral conjunctiva usually located inferior or superior. They are
usually 1-3 mm and rarely > 5 mm, and can present as single or multiple lesions.
A: Simply an accumulation of calcium.
P: Usually no treatment necessary; may be “pried” off if causing irritation.
Inclusion Cyst
Definition: Clear to yellow fluid or caseous-filled cyst on conjunctiva.
S: Usually asymptomatic but their appearance may produce concern in patients.
O: Small to moderate size (2-5 mm) cystic formations, appear clear to yellowish in color. They have a variable
location usually at the fornices, palpebral conjunctiva most common. They frequently present in multiples.
A: Simply an accumulation of aqueous fluid.
P: Usually no treatment; may be surgically removed if cosmesis is a concern.
Lymphangiectasia
Definition: Clear fluid-filled cyst on bulbar conjunctiva.
S: None/cosmesis is a possible concern.

O: Clear cyst of variable size and shape that is usually 2-10 mm. They are focal or segmental dilations of thin-
walled lymphatic vessels. Present as single or multiple lesions and are always clear and transparent. In
comparison with inclusion cysts, the latter have thicker walls and thus yellowish appearance. Inclusions cysts
are also more common nasally and on the palpebral conjunctiva while Lymphangiectasia are more common
temporally.
A: Lymph filled cyst.
P: None needed; can be drained if necessary.
Telangiectasia
2013
Definition: Isolated, superficial, dilated or convoluted blood vessel (arteriole) on bulbar conjunctiva.
S: None / cosmesis is a possible concern and it occurs in any age group.
O: Vessel as described above and it may be simple convolution or sac-like. It is usually unilateral.
A: Most commonly idiopathic but possible systemic causes include: vascular disease, diabetes, and acne
rosacea.
P: None except for routine monitoring; may consider laser if cosmesis is a concern.
Conjunctival Melanosis
Definition: Pigment in the conjunctiva which can be congenital or acquired.
S: Congenital or acquired. Congenital are more common in dark races and they may increase with age.
Acquired are most common between 30-40 years of age and present more commonly in females.
O: 2 types:
Congenital: Flat, pigmented patches, usually at limbus which vary in size and shape. Coloration varies from
grayish-brown to black.
Acquired: Irregular, diffuse, flat patches of grayish-black conjunctival pigmentation that develop
spontaneously and may extend onto the palpebral conjunctiva. The pigmentation and shape may change
over time.
A: Accumulation of melanin. Must rule out malignancy from the differential diagnosis.
P: No Tx for congenital but careful monitoring with photo-documentation; possible referral for acquired.
Nevus
Definition: Localized area of pigmentation.
S: None/cosmetic concern. Usually congenital or develops early in life.
O: Smooth, flat surface lesion with well-demarcated pigment edges. They have variable degrees of
pigmentation, from almost amelanotic to very dark. They are usually superficial located on the bulbar or
palpebral conjunctiva and have a greater frequency of presentation at the inner canthus.
A: Accumulation of melanin.
P: Must provide photo-documentation and rule out neoplasm from the differential diagnosis.

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Pinguecula
Definition: Benign degenerative tumor of the bulbar conjunctiva.
S: Usually asymptomatic. Patient may note irritation or redness. Patient reports a frequent history of outdoor or
UV exposure.
O: Slightly raised, yellowish-white triangular (base toward limbus) thickening on either side of the cornea. It is
found on exposed lateral areas of bulbar conjunctiva (>nasal). They are commonly found bilaterally and may
become surrounded by hyperemic blood vessels.
A: Deposition of hyaline substance thought to be associated with wind and UV exposure.
P: Usually none. Recommend UV protection. Lubricants are sometimes used for symptomatic (inflamed)
presentations. Vasoconstrictors and cold packs may be used if hyperemic. They may be excised for
cosmetic purposes.
SCLERA
By using indirect illumination during evaluation of the conjunctiva, view the inferior, superior, medial and lateral
scleral tissues.
NORMAL
The sclera should appear white /quiet and devoid of injection, nodules, yellowing and abnormal pigmentation. A very
common normal entity is termed an Axenfeld loop. It is blue/black in presentation and is an extension of the ciliary
nerve loops on the surface of the sclera. They are usually located within a few millimetres of the limbus and are
more commonly located nasally. Sometimes the nerve loop is accompanied by an adjacent vessel loop.
ABNORMAL
Blue Sclera
Definition: Hereditary defect in which the sclera has a bluish appearance. The sclera is thinner than
normal and susceptible to rupture.
S: None / cosmesis may be a concern. Obvious presentation is seen in newborns which causes parent
concern.
O: Variable density, intensity and distribution of pale to dark blue coloration to white of eyes. It is common and
generally normal in infants with large globe size at birth there is a thin scleral tunic transmitting the choroid.
A: In children and elderly, mechanism is as described above. In adults and acquired cases, it can be related to
systemic or developmental conditions.
P: Reassure in case of children, elderly. Appropriate referral for acquired.

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CORNEA
By using direct diffuse, illumination, indirect illumination, parallelepiped, optic section, specular reflection of the
endothelium and scleral dispersion with medium to high magnification one can examine the clarity, uniformity and
various layers of the cornea.
NORMAL
The layer(s) being examined will vary depending on the method of observation. However, the cornea should appear
clear, intact and of uniform thickness. It should be clear of opacities, disruption of tissue components and edema. A
very common normal entity is the appearance of corneal nerves. The cornea has a rich supply of sensory nerves. It
includes ciliary nerve and the ophthalmic division of the 5th nerve which enters the middle and anterior stromal layers
of the cornea in a radial fashion. They are viewed as fine white lines in the corneal stroma and are more evident in
the peripheral cornea when using indirect illumination.
ABNORMAL
Arcus Senilis
Definition: Grayish-white ring (or part of ring) opacity occurring in periphery of cornea.
S: Asymptomatic finding found in 50% of persons by age 50 and near 100% of persons by age 80. More
common and pronounced on black individuals.
O: Broad (1-2 mm) whitish mid-peripheral ring of lipid substances. It is usually seen bilaterally. It is at the level
of Bowman’s layer and has a gradual development. The ring is separated from the limbus by zone of clear
cornea.
A: Due to lipoid infiltration of the corneal stroma. Aging process in older individuals, but in younger patients it is
associated with systemic disease such as hyperlipidemia and cardiovascular disease.
P: None usually. In young individual (< 40 y/o), the clinician must refer for serum cholesterol testing.
White Limbal Girdle of Vogt
Definition: Narrow band of fine crystal-like opacities lined up along nasal or temporal limbal borders.
S: Asymptomatic lesion most common in women over age 50 and presents bilaterally.
O: Semilunar opacity (subepithelial hyaline degeneration) without a clear separation from the limbus at the
interpalpebral limbus. Nasal affected twice as temporal.

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A: Age-related degeneration.
P: None.
Hudson-Stahli Line
Definition: Line of iron in cornea at level of Bowman’s layer.
S: Usually none.
O: Orange-brown line in band region of cornea where margins meet on blink. More common in males, the
frequency usually parallels the age (e.g., age 30=30%, age 40 = 40%, ...). There are three typical
presentations which are: faint segmented line, continuous distinct line, and line with surrounding opacities.
The Hudson-Stahli line is a frequent site of spontaneous or recurrent corneal erosions.
A: May be produced by migration of ions over time from blinking action.
P: None.
ANTERIOR CHAMBER ANGLE ASSESSMENT
Using the Van Herrick method which is an optic section at 60° with 16X or greater magnification, the examiner can
accurately assess the depth of the anterior chamber nasally, temporally, superiorly and inferiorly. This method
denotes the risk of angle closure.
NORMAL
Van Herrick Grade Dac/Dc Risk of Angle Closure Upon Dilation

0 ~0 Extremely narrow / closed
I < 1/4 Considerable risk
II = 1/4 Moderate risk
III 1/4 to 1/2 Rare
IV > 1/2 Rare
Dac = Depth anterior chamber Dc = Depth of the cornea
ABNORMAL
Iris Nevus
Definition: Iris freckle.

2013
S: None / possible concern.
O: Flat or raised hyperpigmented spot on the iris stroma that creates no distortion to the iris, pupil or pupil
dilation.
A: Accumulation of melanin. Must rule out melanoma from differential diagnosis.
P: Slight increased risk for melanoma. Clinician must photo-document & monitor for changes.
ANTERIOR CHAMBER CLARITY
After turning off the room lights use the conical beam to examine the superior, inferior, nasal and temporal aspects
of the anterior chamber with low and high magnifications.
NORMAL
Black and quiet appearance of empty space.
ABNORMAL
Presence of inflammation or uveitis (in the form of cells, flare or hypopion), cysts or hyphema (blood). There exists a
grading scale for the presence of inflammation, which will be covered elsewhere (pathology course). There are a
number of systemic associations to uveitis that must be considered and these will also be covered within the
pathology course.
NORMAL & ABNORMAL FINDINGS OF THE LENS
The examination of the lens is performed by using a direct illumination, parallelepiped, optic section, retro-
illumination and specular reflection with moderate magnification. When observing with parallelepiped and optic
section, one should scan from the anterior lens capsule to the posterior lens capsule both medially and laterally.
When observing the tissues with retro-illumination or specular reflection of the anterior lens surface, one must focus
at the plane of the iris. To observe specular reflection of the posterior lens surface, one must focus at the plane of
the posterior capsule.
NORMAL
The examiner is able to view the various layers of the lens using a parallelepiped and optic section. The layers
include the capsule, subcapsular space, cortex and nucleus. Anterior and posterior portions should appear clear and
free from opacities. The anterior erect Y suture and the posterior inverted Y suture are visible within the fetal
nucleus. By using retro-illumination the examiner will view the red reflex which should be devoid of opacification.

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During lens development, new fibers from the epithelial layer are produced continuously and migrate centrally
towards the cortex and nucleus. Due to this development, the lens increases in sagital width and the nucleus
becomes less flexible with increasing age.
The embryonic blood supply to the lens is the tunica vasculosa lentis and it is replaced during development.
Sometimes it does not completely atrophy. In this case there remains an embryological remnant attached to the
posterior capsule. It is termed a Mittendorf dot and it can be viewed by using an optic section or retro-illumination. It
is most commonly located inferior and nasal to the optic axis.
ABNORMAL
Cataracts
Cataract refers to the opacification of the lens. Cataract development is a major contributor to low vision and
blindness around the world. Cataracts are classified either as acquired or congenital and result from a variety of
etiologies:
Acquired Congential
Senile/Age-Related Maternal Infection
Traumatic Birth Trauma
Metabolic/Systemic Disease Metabolic/Systemic Disease
Genetic Disease Genetic Disease
Toxic Ocular Maldevelopment Syndromes
Intraocular Disease
Acquired Cataracts
Senile/Age Related Cataracts
S: Decreasing vision, glare, reduction in contrast sensitivity.
O: Yellowing or darkening of the lens as well as the formation of vacuoles and irregularities within the lens fibers.
To grade age-related changes of the lens in an objective manner, the Lens Opacification Classification
System III (LOCS III) is used. By adopting this system of classification, one can develop a standard routine
of examining and classifying senile changes within the lens. Utilization of a standard classification system will
reduce error introduced by subjective grading of lens opacities. This will also enhance the management of
lens opacities.
The most common forms of senile/ age related cataracts are:

• Nuclear (NUC), resulting in an increasing degree of opacification of the nucleus of the crystalline lens.
• Cortical (COR), involving the cortex from the periphery toward the centre with classical wedge-shaped radial
spokes.
• Posterior sub-capsular (PSC), developing distinct central or paracentral opacities on the posterior capsule.
In 2002, Thylefors et al. proposed a method for grading the presence and severity of different cataract types.

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Known as the World Health Organisation (WHO) simplified cataract grading system, it is designed to enable observers
using a slit-lamp to obtain comparable data across countries based on in-the-field assessment of the most common
forms of cataract.
The grading system is designed to:

• Facilitate epidemiological studies
• Increase the comparability of studies
• Estimate cases that are likely to be in need of surgery
The classification system employs three levels of progressive severity for grading nuclear, cortical and posterior sub-
capsular cataract.
Grading nuclear cataract
The WHO classification system for nuclear cataract is defined in terms of the opacification of the lens nucleus. The
examiner assigns a severity grade by comparing the degree of opacification in the slit-lamp appearance with three
standard photographs.
When grading the severity of any nuclear cataract, Thylefors proposes that only a specified grading region of the
nucleus should be examined with the slit-lamp. The anterior and posterior borders of this region are limited by the
anterior and posterior nuclear shells, respectively. The region contains bright features which include the anterior shell,
the anterior embryonal nucleus, the posterior embryonal nucleus, and the posterior shell.
Three nuclear cataract standard photographs are included, representing different severities:
• NUC Standard - 1 – The embryonal nuclei are more visible than normal but the central clear zone is still easily
distinguishable. Severe enough to be considered a “case” i.e. clinically significant nuclear cataract.
• NUC Standard - 2 – The nuclear zone is more uniformly opaque and the central clear zone is not clearly
visible. Moderately advanced progression.
• NUC Standard - 3 – The nuclear zone is densely opaque. Severity sufficient to consider surgery.
The examiner assigns a severity grade by comparing the degree of nuclear opacification observed using the slit-lamp
with the standard photographs.
Three nuclear cataract grades are included, representing different severities:

1. Grade NUC - 1 – Cataract equal to or greater than the NUC Standard - 1 but less than NUC Standard - 2.
2. Grade NUC - 2 – Cataract equal to or greater than the NUC Standard - 2 but less than NUC Standard - 3.
3. Grade NUC - 3 – Cataract equal to or greater than the NUC Standard - 3.
Fig 1: Grading cortical cataract photographs. left: NUC-1, middle: NUC-2, right: NUC-3

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The WHO classification system for cortical cataract seen on retro-illumination using the slit-lamp is defined in terms of
sharp and well-defined anterior and posterior cortical opacities.
Three cortical cataract grades are included, representing different severities:

1. Grade COR - 1 – Cataract involves one eighth, but less than one quarter, of the circumference.
2. Grade COR - 2 – Cataract involves a quarter, but less than one half, of the circumference.
3. Grade COR - 3 – Cataract involves half or more of the circumference
Thylefors recommends in cases of a dispersed cortical cataract (with several non-contiguous spoke opacities) that all
of the opacities should be aggregated for the purpose of grading the circumferential extent.
Progression of the cortical cataract toward the central optical zone is also graded as follows:
Grade CEN – Involvement of the central optical zone of 3 mm diameter (Yes / No)
Grading posterior sub-capsular cataract
The WHO classification system for posterior sub-capsular cataract seen on retro-illumination using the slit-lamp is
defined in terms of the vertical diameter (in mm) of the opacity.
Three posterior sub-capsular cataract grades are included, representing different severities:
1. Grade PSC - 1 – Cataract equal to or greater than 1.0 mm, but less than 2.0 mm. Severe enough to be
considered a “case”.
2. Grade PSC - 2 – Cataract equal to or greater than 2.0 mm, but less than 3.0 mm. Progression which may
require surgery.
3. Grade PSC - 3 – Cataract equal to or greater than 3.0 mm. Progression which usually requires surgery.
A: Lens fiber changes that result from aging processes and the accumulation of lens fibers within the capsular
bag as a result of continued cell growth throughout life.
P: Ultimately, surgery is required to remove the cataractous lens and replace it with an artificial lens. The
cataract is monitored until the decrease in visual function affects daily activity. Referral for surgery is based
on an individual patient basis.
Traumatic Cataract
S: Patients may report a history of penetrating injuries, concussion injuries, receiving radiation, glass blower’s
injury or electric shock.
O: Penetrating injuries display opacification in the area penetrated. Concussion may lead to a Vossius ring or
what is viewed as an imprinting of the iris pigment onto the anterior capsule.
Radiation & electric shock induced cataract vary in presentation. Glass blower cataract appears as
exfoliation.
A: Penetrating, Concussion, Radiation, Glassblower’s, Electric shock.
P: As any type of opacification, the cataract is monitored until the decrease in visual function affects daily
activity. Referral for surgery is based on an individual patient basis.

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Metabolic/Systemic Disease
S: Patient may report a history of Diabetes, Galactosaemia, Mannosidosis, Wilson’s disease, Hypocalcemia or
no reported disease.
O: Diabetic cataracts present in 2 forms. The first, termed “true” diabetic, is due to osmotic over-hydration of the
lens & appears as bilateral white punctate or “snowflake” or "rosette" opacities that are located either
anteriorly or posteriorly. The second, termed “senile” diabetic cataract, is similar to the common senile
changes discussed previously but occurs earlier in the diabetic.
Alpha Galactosidase A or Fabry's disease cataract has 2 different presentations. The first, sometimes
referred to as an “oil droplet” appears as a fine anterior subcapsular cataract that is cream colored &
feathery. The other, located in the posterior lens, is shaped like a star or cross.
Wilson’s syndrome cataract, called green “sunflower”, consists of central pigmented opacities with tapering
extensions. Because copper is deposited anteriorly & posteriorly within the lens, it takes on a yellow-green
appearance.
Hypocalcemia cataract consists of multicolored crystals or flecks. They are small white or polychromatic
crystals located in the anterior and posterior cortex just beneath the capsule. A clear zone separates this
zonular cortical cataract from the nucleus.
Mannosidosis cataract varies in presentation.
A: Diabetes, Alpha Galactosidase A, Wilson’s disease, Hypocalcemia, Mannosidosis.
P: As any type of opacification, the cataract is monitored until the decrease in visual acuity affects daily function.
Referral is based on an individual patient basis.
Genetic Disease
S: Patients may report a history of Myotonic dystrophy or Down’s syndrome.
O: Myotonic dystrophy causes a “Christmas tree” cataract, which is a stellate figure in the posterior subcapsular
area with or without multicolored dust-like opacities present in the cortex.
Down’s syndrome cataracts vary in appearance but generally have the potential to decrease VA. The more
common presentations consist of cortical flake opacities or arcuate opacities.
A: Myotonic dystrophy, Down’s syndrome.
Toxic
S: Use of steroids, anticholinesterases, arrhythmic agents or antipsychotics may be reported.

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O: Steroids have an association with posterior subcapsular cataracts following long term use of either topical or
systemic forms.
Phosphospholine iodide, an anticholinesterase, causes cataracts in the form of anterior subcapsular

vacuoles.
Amiodarone causes anterior subcapsular lens opacities.
A: Steroids, Anticholinesterases, Arrhythmic agents, Antipsychotics.
Intraocular Disease
S: Patient may have a history of chronic intraocular inflammation or infection, retinal disease, or vitreo-retinal
disease.
O: Uveitic cataracts appear as a colorful luster at the posterior pole of the lens as well as anterior and posterior
subcapsular opacities. If allowed to progress, a fibrovascular membrane may grow over the anterior lens
surface.
Retinal disease such as Retinitis Pigmentosa, Leber’s Hereditary Optic Neuropathy, Gyrate Atrophy or vitreo-
retinal diseases such as Stickler’s syndrome or Wagner’s syndrome produce posterior subcapsular lens
opacities.
“Glaukomflecken” present as fine whitish-gray anterior subcapsular opacities in the area of the pupil and
result from an acute angle closure attack.
A: Uveitis, Retinal disease, Vitreo-retinal disease.
Congenital Cataracts
Maternal Infection/Drug Ingestion
S: Patient reports that their biological mother had a history of Rubella(viral infection) or ingested medications
such as steroids or thalidomide during pregnancy.
O: Rubella infection during pregnancy produces congenital cataracts, which are present unilaterally or bilaterally.
They appear as either a diffuse opacity throughout the lens or a dense pearly nuclear cataract that is
surrounded by a less dense cortical opacity. Certain cases of rubella may exhibit microspherophakia.
Ingestion of medications during pregnancy produces cataracts, which vary in appearance according to the
medication taken. In particular, long-term use of steroids may yield posterior subcapsular cataracts.

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A: Rubella, Steroids, Thalidomide.
P: The severity of the opacification is assessed and referral for surgery is based on an individual basis with the
risk for amblyopia in mind.
Birth Trauma
S: Patient reports a history of trauma at birth.
O: Cataract appearance secondary to birth trauma depends on the type of trauma.
A: Trauma.
Metabolic/Systemic Disease
S: Patient reports a history of Alpha Galactosidase A or no related history of disease.
O: Alpha Galactosidase A cataract (refer to previous section on acquired cataracts related to metabolic/systemic
disease).
A: Alpha Galactosidase A.
Genetic
S: Patient reports a history of Lowe’s oculocerebrorenal syndrome, or Down’s syndrome or no systemic disease.
O: 100% of patients with Lowe’s present with a congenital cataract. The lens appears thin and small and is
referred to as microphakia. Opacities may be present in the capsule, cortex or nucleus.
Down’s syndrome is associated with various forms of cataracts. (Refer to previous section on acquired
cataracts related to genetic etiologies). The cataracts usually have the potential of causing decreased vision.
Congenital nuclear cataracts without systemic association may present in two forms. The first is termed the
Embryonal or nuclear cataract (cataracata centralis pulverulenta) which contains small star-shaped opacities
that are located in the embryonal nucleus. The fetal nucleus is not affected. This type of cataract has a
dominant inheritance pattern, is usually bilateral and does not affect vision adversely. The second is termed
the total nuclear cataract. This type of cataract affects both the embryonal and fetal nucleus and therefore
may affect vision adversely.
A: Lowe’s syndrome, Down’s syndrome.

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Ocular Maldevelopment
S: Patient reports a history of Peter’s Anomaly or no related anomaly.
O: The cataract associated to Peter's Anomaly appears in conjunction with a central corneal defect. which is in
apposition with the lens. The anomaly is referred to as keratolenticular strands.
A: Peter’s Anomaly.
Abnormalities in Lens Shape & Positioning
S: Patient may complain of blurry and/or monocular double vision. They may report a history of Lowe’s
syndrome, Weill-Marchesani syndrome, Marfan’s syndrome, Alport’s syndrome, Homocystinuria or
Hyperlysinaemia or Ehlers-Danlos.
O: Lowe’s - may display posterior lenticonus in which the posterior pole of the lens is conical. Spherophakia
may be present which is defined as an abnormally short lens radius of curvature.
Weill-Marchesani - may display spherophakia, subluxation of the lens due to defective lens zonules. After
subluxation, the lens may dislocate anteriorly.
Marfan’s - may present with microspherophakia. Due to defective lens zonules, 80% of patients present with
bilateral lens subluxation. The lens is usually displaced upward and this is referred to as Ectopia Lentis.
Alports - may present with an anterior lenticonus where the anterior pole of the lens is conical. Anterior
lenticonus produces irregular astigmatism as well.
Homocystinuria - may present with subluxation of the lens due to defective zonules. Lens is usually
displaced downward.
Hyperlysinaemia - may present with microspherophakia.
Ehlers-Danlos - may present with subluxation of the lens.
A: Lowe’s, Weill-Marchesani, Marfan’s, Alports, Homocystinuria, Hyperlysaemia, Ehlers-Danlos.
P: Treatment is dependent on anomaly and presentation.

2013
ANTERIOR VITREOUS
Performed by using a parallelepiped or optic section. Focus past the posterior capsule of the lens to view the
anterior vitreous and scan both the right and left portions. By having the patients look up and then straight ahead,
one can view the movement of the vitreous. This movement is referred to as the Ascension phenomenon of Vogt.
NORMAL
Anterior vitreous should appear black and free of debris, inflammation, pigment or blood.
ABNORMAL
Any presence of debris, inflammation (cells / flare), pigment or blood.
CHART NOTATIONS FOR SLE OBSERVATIONS
The chart notation for biomicroscopy is quite straightforward. A “Cl” is used to denote clear unremarkable findings
except for the A/C clarity where (-) C/F is used to denote the absence of cells & flare and the VH angle evaluation
where a roman numeral (0 - 4) is used to indicate the angle grade. Abnormal findings are either described verbally or
preferably drawn while the WHO system is used to describe cataracts.
CHART EXAMPLE: SLE SECTION

2013
METHODS FOR OBSERVATION
OF THE FUNDUS
AUTHOR
PEER REVIEWER
Patricia Hrynchak: University of Waterloo
INTRODUCTION
This chapter includes a review of:

 Fundus Biomicroscopy
 Binocular Indirect Ophthalmoscopy
 Monocular Indirect Ophthalmoscopy
FUNDUS BIOMICROSCOPY
Alternative names:
 Slit Lamp Indirect Ophthalmoscopy
 Biomicroscopic Indirect Ophthalmoscopy Auxiliary Lens Retinal Evaluation.
DESCRIPTION
Fundus biomicroscopy is a procedure used to examine the retina and posterior 2/3 of the vitreous using the
biomicroscope with auxiliary lenses. The auxiliary lenses bring the image of the fundus into focus. The
biomicroscope, with its illumination and observation systems, provides the binocularity, magnification, illumination
and coverage needed for optimal examination of the retina. The procedure is now the standard of practice for both
routine and problem specific detailed examination of the fundus. Fundus biomicroscopy is most often used to
examine the posterior pole but can also be used to examine the peripheral retina especially when a closer
assessment of findings is required. Its advantages are summarized in the following table.
 Binocular stereoscopic view  Undilated view possible

 Posterior pole and peripheral views  Available accessories (tints, reticules, holders)
 Wide field of view (lens dependant)  High resolution
 Variable illumination  Multiple lens options
 Variable magnification  Contact and non-contact versatility
Table 3.1: Advantages of fundus biomicroscopy

Fundus Methods
THEORY AND INSTRUMENTATION
Indirect Methods
The indirect method uses high plus auxiliary lenses to focus light from the retina to form an image in a plane
between the lens and the biomicroscope. The biomicroscope is used to view the image which is aerial, real,
reversed and inverted (Fig. 3.1). The main advantage over direct methods is the elimination of the pupil as a field
stop, therefore producing a wider field of view.
Figure 3.1: Image formation using an indirect method of examination
A number of indirect lenses are available both to be used in contact and non-contact procedures. Only the
mainstream ones will be discussed here.
The +60D, +78D, +90D are the most commonly used lenses. These lenses are double aspheric in design
to reduce reflections and produce a higher quality image. They are available clear or tinted yellow to improve
patient comfort. The yellow lens filters phototoxic blue and violet wavelengths but it will alter the perceived
color of fundus findings. Clear lenses are more widely used.
The SuperZoom 78/90 is simply a zooming telescopic lens that permits shifting from +78D to +90D optics
so that the examiner can draw from the advantages of both powers.
The SuperPupil XL is designed for use with small pupils such as when dilation is not indicated or is limited
(e.g., fixed miotic pupils). It is used in a similar way as the above mentioned lenses but it is held closer to the
eye. It allows an equator to equator view without changing the patient’s fixation. A special lens design allows
the biomicroscope illumination system to be 30° away from the observation system to reduce reflections. It
also comes with accessories such as a contact adapter (to maximize the view through small pupils), a lid and
a yellow filter adapter.
The Superfield NC is also a hand held non-contact high plus lens that
allows a wide field of view. It produces a magnification similar to the +90D
but increases the field of view. It also comes with a multitude of accessories
rendering it extremely versatile. A (+) lens adapter is available to decrease
its magnification and increase its field of view. A (-) lens adapter is provided
to produce the opposite effect to render it more like a +78D lens.
A reticule is available to facilitate measurement and grading fundus

observations. A (+) contact adapter is also available to give it the
advantages of contact fundus biomicroscopy by producing a sharper image, reducing reflections, increasing
field of view up to the ora and providing increased lid control.
A (-) contact adapter provides increased magnification for a detailed disc and macular view.
Several accessories are available to make the above lenses more versatile.
Lid-lens adapters allow the lenses to sit on the patient’s external eyelid to provide lens stability, eyelid
control and exact positioning for immediate image viewing.

Fundus Methods
Yellow filters that attach directly onto the lens are available to render patients more comfortable and
eliminate phototoxic wavelengths (blue and violet).
A steady mount is available to hold and stabilize the +60D, +78D, +90D lenses. Although it works well in
concert with the natural hand movement, the hand-held method is generally preferred.
The magnification (mag.) and field of view (FOV) produced varies with the power of the lenses.
The rule is:
 Power  Magnification  FOV
Note that the 78D lens has a larger diameter than the 90, so that although magnification is increased, no field of view
is lost. The characteristic of the high (+) lenses are shown in the following table:
Eye-lens distance
Lens Diameter (mm) Field of View (°) Magnification (X)
(mm)
+ 60 D 31.0 13.0 68 1.15
Super 66 27.0 11.0 80 1.00
+ 78 D 31.0 8.0 81 0.93
+ 90 D 21.5 7.0 74 0.77
SuperField NC 27.0 7.0 95 0.76
SuperPupil 16.0 4.0 103 0.45
Table 3.2: Comparison of characteristics of lenses
Advantages Disadvantages
Excellent optical quality of image Inverted and reversed image
Detailed magnified view Difficult to master
Good field of view Dilation (+/-) needed
Access to the peripheral retina
Stereoscopic view
Good contrast
Independent of patient refraction
View through dense media is possible
Lens options and accessories
Non-contact or contact
Rapid
Table 3.3: Advantages and disadvantages of high (+) lenses

Fundus Methods
Procedure
 The patient (preferably dilated) is comfortably aligned behind the biomicroscope with his/her chin on the chinrest
and forehead against the forehead rest
 The patient is directed to gaze straight ahead at the examiners ear or at the fixation light
 To facilitate first examinations, low magnification and light intensity settings are used
 A wide parallelepiped beam (2-3 mm width; 7-8mm height) is used
 The biomicroscope illumination is set with the angle coaxial (0°) with the observation system
 The beam is centered and focused on the cornea or slightly in front of it (~5mm)
 The lens is held between the examiner’s thumb and index finger
 The left hand is used to hold the lens while examining the right eye and vice versa
 Some lenses are symmetrical and can be used facing either side, while others are designed to be more aspheric
on one side to minimize reflections therefore should be used as indicated by the manufacturer (e.g., silver ring
indicating side to face patient).
 The examiner observes from outside the oculars of the biomicroscope and introduces the lens close to eye just
clearing the lashes (Fig. 3.2)
 The lens is centered on the beam so that the light enters the pupil
 The examiner’s hand is stabilized by placing his free fingers on the patient’s face or on the head-rest
 The examiner’s elbow is placed down on the biomicroscope table (a cushion, lens or tissue box is used if the
examiner’s arm is too short)
 The lids are controlled with the middle finger on the upper lid and the ring finger on the lower lid if needed.
 The examiner then views through the oculars and pulls the biomicroscope straight back until the blurry fundus
red reflex becomes apparent
 The examiner continues pulling the biomicroscope back until the retina comes into focus
 The beam height, width and intensity is adjusted to maximize viewing area and minimize patient discomfort
 The lens is tilted slightly to reduce reflections, if necessary
 The entire posterior pole is scanned in a systematic manner (Fig. 3.3) starting with the optic nerve head (ONH)
and finishing with the macula; this allows the macula to adapt to the bright light before being examined.
Figure 3.3: Systematic view of the posterior pole

Fundus Methods
TIPS FOR SUCCESS
Remember: the image seen is inversed (right is on left and vice versa) and inverted (upside down) (Fig. 3.4).
Figure 3.4: Examiner views inverted and inversed image of the fundus
 To examine the image of the fundus that has formed in front of the lens, the biomicroscope is moved using the
joystick – the lens is not moved
 To view the vitreous, the biomicroscope is moved back keeping the lens in position
 To view the peripheral retina, the patient is directed to change his gaze in the correct direction (e.g., up for a
superior view etc.), the lens must then be repositioned in front of the pupil
 With experience, the biomicroscope illumination system can be displaced slightly (<10°) from its coaxial position
from the observation system to reduce reflections
 Keep in mind that the lens-eye and lens-biomicroscope distances vary with different lens powers.
Direct Methods
In direct fundus biomicroscopy, high minus powered auxiliary lenses are used to neutralize the power of the eye so
that the biomicroscope can focus to the fundus. Direct methods offer the advantage of creating an erect, virtual
image but the field of view is limited to 5-15° because the pupil acts as an optical field stop. Two main types of direct
methods exist, the non-contact Hruby lens and a mirrored or non-mirrored contact lens such as the Goldmann-3-
mirror lens.
HRUBY LENS
The Hruby lens is a high -58D lens held in air. The lens is either mounted on the biomicroscope to swing down in
front of the observation system or it sits on a rod that fits into a sliding track in front of it. (Fig.3.6). The lens is
available as an accessory to many biomicroscopes, but it is an older technique rarely used anymore.

Fundus Methods
Figure 3.6: Direct fundus biomicroscopy through Hruby lens
Drawn from Fingeret M, Casser L, Woodcome HT. Atlas of Primary Eyecare Procedures. Norwalk, CT: Appleton and
Lange; 1990.
Non-contact Limited FOV of 5-8°
Image is erect Maximal area of exam ~30° (posterior pole)
Easy to learn Poor optical design – lots of reflections and
distortion
Often included with the biomicroscope Dilation required
Quick method Difficult on patients with unstable fixation
Table 3.4: Advantages and disadvantages of the Hruby lens
Procedure
 The patient is dilated (necessary) and comfortably seated with the chin on the chinrest and head against the
headrest of the biomicroscope
 The slit beam is in “click” position (angle of 0° between the illumination system and the observation system)
centered and focused on the cornea
 The magnification should be 10X and the slit beam width 2-3 mm. The height of the beam and intensity of the
illumination can be varied during the examination
 The lens is positioned with the concave side towards the patient and is placed in the path of the beam of light
 The biomicroscope is moved in toward the patient until the retina is in focus
 The fundus is scanned by having the patient change fixation using the fixation pointer.
GOLDMANN 3-MIRROR (G3M)
The G3M lens is a cone-shaped contact device containing a round concave central surface that is placed directly on
the corneo-sleral area of the eye (Fig. 3.7) The central face is actually a -64D lens (Fig 3.8, A) which serves to
neutralize the power of the cornea to allow a direct view of the posterior pole (30°). The contact also serves to
minimize reflections to allow a crisp clear view. In fact, this and other contact procedures are often utilized to assess
questionable areas with greater certainty.

Fundus Methods
The G3M also contains 3 mirrors inclined at various angles to offer views of the fundus from mid-periphery to far
periphery. The inclination angle denotes the angle between the mirror and the front surface of the lens; the greater
the angle of inclination, the more posterior the view. The trapezoidal mirror (Fig 3.8, B = 76°) allows a view of
the equatorial region, the rectangular mirror (Fig 3.8, C = 66°) from the equator to ora, the “thumb-nail” or U-shaped
mirror (Fig 3.8, D = 59°) allows the most anterior view from ora to the anterior chamber angle. The images seen in
the mirrors are erect but laterally reversed. Many similar lenses are available but the G3M is the most widely used.
Figure 3.7: The Goldmann 3-mirror lens
Figure 3.8: Mirrors used in fundus examination
Think: CAPE
C: Central
A: Anterior
P: Posterior
E: Equatorial

Fundus Methods
Image is erect Allows sector views (no panoramic view)
Excellent optical quality of image Image is laterally reversed through mirrors
Detailed magnified view is obtained Anesthetic and contact required
Reduced reflections Dilation required
Stabilizes eye movements Lens requires disinfection between patients
Reduces blinking interference More time consuming
Good view of the vitreoretinal interface Difficult to master technique
May produce corneal staining or abrasion
Contra-indications exist
 Post-operatively
 Traumatic hyphema
 Abrasions (+/-)
Table 3.5: Advantages and disadvantages of the G3M lens
Procedure (Fig. 3.9)
 The patient is educated, dilated and a topical anesthetic is applied

 The lens is properly disinfected (see Universal Precautions) and rinsed with sterile saline
 2-5 drops of an appropriate contact fluid (see diagnostic pharmaceutical agents) are placed in the concave
surface of the G3M lens
 The formation of bubbles should be avoided; if bubbles are formed, they should be removed with a tissue or the
installation of gel should be repeated
 The patient is seated comfortably behind the biomicroscope with the chin on the chinrest and head against the
headrest . Do not attempt to insert the lens before the patient’s chin is on the chinrest
 The biomicroscope is in “click” position (angle of 0° between the illumination system and the observation
system); a 2-3 mm wide parallelepiped beam is used
 The biomicroscope is fully retracted or moved out of the way towards the eye not being examined
 The lens is held with the practitioner’s dominant hand while the other hand pulls down the lower lid
 The patient is instructed to look up and the edge of the lens is placed on the inferior cul-de-sac
 The inferior lid is released, the G3M lens holds it down and the upper lid is then pulled up
 The lens is tilted gently upward onto the corneal surface and the upper lid is released.
Figure 3.9: Lens insertion of the Goldmann-3-mirror lens

Inspired by: Fingeret M, Casser L, Woodcome HT. Atlas of Primary Eyecare Procedures. Norwalk, CT: Appleton and Lange; 1990.

Fundus Methods
 The patient is instructed to slowly look straight ahead

 If viewing the posterior pole the biomicroscope can be used to focus the retina by moving it towards the patient
 Otherwise, the lens is rotated on the cornea to place the mirror needed 180° away from the area of interest
 For rotation, biomicroscope is released and both hands are used
 Alternatively, 1 hand may be used with the index finger placed on the surface of the lens to hold it in place and
the thumb and third finger used to rotate the lens (Fig. 3.10).
Figure 3.10: Lens rotation
Inspired by Fingeret M, Casser L, Woodcome HT. Atlas of Primary Eyecare Procedures. Norwalk, CT: Appleton and Lange; 1990.
 Enough pressure is kept on the lens at all times, to prevent the lens from uncoupling from the surface of the
cornea
 The patient’s head and fixation are controlled at all times by repeating instructions to the patient and using the
free hand to bring the patient back in position if needed
 The examiner may place his elbow down on the biomicroscope table (a cushion, lens or tissue box is used if the
examiner’s arm is too short) if needed for comfort
 Alternatively, the examiner holds his hand up hanging his fourth and fifth fingers from the headrest for support
(this may be less stable)
 The biomicroscope is moved towards the patient with the light beam projected on the desired mirror of the G3M
lens
 The examiner moves behind the biomicroscope and moves it toward the patient to obtain a retinal view
 The lens is rotated freely on the cornea and the various mirrors used to examine other areas
 Remember: the desired mirror should be 180° from the area to be examined
 To remove the lens, the patient is asked to look nasally and blink
 If the lens appears “stuck” onto the eye via interface suction, the examiner must not forcibly pull it off; instead,
gentle pressure must be applied through the inferior-temporal lid on the globe while pulling the lens in the
opposite direction to break the suction
 If preserved contact gel is used for the procedure, the eye must be irrigated with sterile solution or saline
 Note: in situations where an anesthetic is contra-indicated or unavailable for use, a soft contact lens can be used
to perform gonioscopy. Although not as comfortable as with the application of anesthetic, it reduces the
discomfort and allows the application of the G3M lens.

Fundus Methods
BINOCULAR INDIRECT OPHTHALMOSCOPY
DESCRIPTION
Figure 3.11: Binocular indirect ophthalmoscope
The binocular indirect ophthalmoscope (BIO) is a head borne device (headset or spectacles) that contains an
illumination system and viewing oculars (Fig. 3.11). A condensing lens is used to converge the light from the retina
to form a real, aerial, inverted and reversed image in front of the lens that is viewed through the oculars. The BIO
is the single most useful instrument for examining the entire ocular fundus with a panoramic and stereoscopic view
(Fig. 3.12) Now considered the standard of practice, it complements indirect fundus biomicroscopy in performing a
complete fundus examination.
In comparison to direct and monocular indirect ophthalmoscopy, the BIO offers significant advantages as the
comparative table below shows:
Ophthalmoscopy Direct Monocular Indirect Binocular Indirect

Stereoscopic view None None Excellent (P, stereo)
Field of view 5° (2 DD) 12° 40° (8 DD) with a 20D
Peripheral view Blurry / impossible Limited Excellent
Maximal view Equator (~60°) 70% of fundus Beyond ora serrata
Depth of focus Weak Fair Good
Magnification 15 x 5x (fixed) 3x (20D); 2x (30D)
Working distance Very close (often 15-20 cm Arm’s length
uncomfortable for the
patient)
Image Virtual / erect Real / erect Real / inversed-inverted
Dilation Not necessary Not necessary Recommended
Ease of procedure Easy +/- easy Difficult
Fundus Methods
Table 3.6: Comparison of features of various methods of examination

Illumination and Observation System
Light is projected from the headset and focused through a hand-held lens onto the fundus plane. The light is of
variable intensity, spot diameter and color. Some BIOs include a diffuser to soften the edges of the ‘spot’, expand
the field of view, and ease the need for a critical alignment.
A red-free filter is incorporated in most BIOs to enhance the observation of the nerve fiber layer and to facilitate the
differentiation of some findings. Pigmented lesions underneath the retinal pigment epithelium (e.g., a nevus) will be
indiscernible with the red-free filter. This filter also enhances the observation of hemorrhages and blood vessels. A
cobalt blue filter, incorporated for the purpose of performing fluorescein angiography, can be also be used to
enhance the detection of buried ONH drusen through induced fluorescence.
Figure 3.13: Image formation using a BIO
The observation system is composed of sets of mirrors and prisms that optically reduce the examiner’s pupillary
distance to fit it within the patient’s pupil along with the illumination beam (Fig. 3.13). This condition is termed pupil
conjugacy. One can easily deduct why pupil dilation is strongly recommended to enjoy the full advantages of BIO.
Figure 3.14: Pupil conjugacy
Some BIOs provide additional converging ability via prisms to allow BIO to be done on patients with pupils that have
not been dilated (Fig. 3.14). A respectable view can be obtained, but it is more difficult as it requires more critical
alignment. In addition, better stereopsis is obtained when the images of the examiner’s pupils in the patient’s pupils
are farther apart (smaller ocular PD).

Fundus Methods
Figure 3.15: Effect of ocular distance on the BIO view
To maintain stereopsis in the most peripheral views, some adjustments are necessary. Pupil conjugacy becomes
more difficult because the apparent pupil becomes elliptical (Fig. 3.16a). One must attempt to maintain the alignment
of the BIO parallel to the long axis of the apparent elliptical pupil in order to fit both of the examiner’s pupils in the
observed pupil. Sometimes it is necessary to decrease the ocular distance or use the enhanced optical convergence
setting available on some BIOs to maintain pupil conjugacy ((Fig. 3.16b). Alternatively, one can obtain a monocular
view by tilting the head 45° from the pupil axis so that only one visual axis enters the pupil (Fig. 3.16c).
Figure 3.16: Pupil conjugacy in peripheral views through ‘elliptical’ pupils
The observation system may contain focusing lenses of +1.00 to +2.50 to reduce accommodation and allow
examination of the aerial image comfortably from the 50 cm working distance. These lenses are usually only
required for examiners that are presbyopic and can be replaced by plano lenses for non-presbyopic examiners.
Condensing Lenses
The condensing lenses have 3 functions: they direct the light source into the eye, generate the aerial image of the
fundus and image the examiner’s pupils within the patient’s pupil. The lenses usually have double aspheric anti-
reflective surfaces which permit clear imaging over the entire lens. One side is typically made steeper to reduce
reflections and distortions from the illuminating beam. The flattest side, often indicated by a sliver ring, should face
the patient during the procedure. The lenses are available clear or yellow. The yellow filter minimizes the patient’s
discomfort and reduces phototoxic short wavelengths, but the yellow may slightly alters the color of fundus findings.
A detachable yellow filter is an available option.

Fundus Methods
The lenses are of various powers ranging from +15 D to +40D. Power adapters are available for the 20D lens
(50mm) to increase field of view. The +20 D lens is used in most clinical situations (Fig. 3.17).
The magnification and field of view vary with dioptric power of the lens. For a lens of the same diameter:
 lens dioptric power  magnification  field of view
The field of view varies with the lens power but ultimately, the extent of the field of view is limited by the diameter the
lens. With a 20D lens, approximately 3 full lens views are necessary to reach the ora (Fig. 3.18). High powered
lenses will facilitate viewing the ora through increased field of view.
Figure 3.18: Successive views to needed to reach the ora serrata
The magnification produced can be approximated using the formula: Magnification = Power of eye / Power of
Lens. Assuming the eye power to be +60D, a +20 D lens would have approximately a 3X magnification. Hence,
even strong refractive errors produce minimal change in the magnification. In contrast, high refractive errors cause
significant distortion in direct ophthalmoscopy.
The lens-eye focal distance is also variable with the lens power:  Power  Lens-eye distance (Table 3.7).
BIO is easier to do using higher powered lenses when examining patients with small pupils, children or non-
cooperative patients. This is due to the increased field of view, the reduced lens-eye focal distance and the
increased converging power provided by higher power lenses. Stronger lenses, however, provide a minified image
with lower stereoscopic detail.

Fundus Methods
Lens power (D) Lens diameter (mm) FOV (°) Lens-eye distance (mm)
15D 52 36 60.0
45 35 60.6
20D 50 46 43.0
35 32
25D 45 52 34.1
33 38
25.5D (Pan-retinal 2.2) 52 56 34.1
28D 41 55 29.0
30D 43 58 27.0
31 42
40D 40 64 17.7
Table 3.7: Comparison of characteristics of various BIO lenses
Resolution and Depth of Focus
BIO offers excellent detail resolution despite the low magnification. Most beginners think that because the image is
relatively minified with respect to direct ophthalmoscopy, there is a loss of resolution. However, the resolution is
dependent on the optical quality and illumination of the system, not only the magnification. Magnifying a blurred
image does not increase resolution. On the contrary, it provides a degraded image similar to what is seen with the
direct ophthalmoscope when examining patients with high myopia. With the BIO, therefore, the examiner can
distinguish incredibly fine detail even with the relative minification.
The BIO offers great depth of focus as well. Structures that are on different fundus planes will appear clear
simultaneously despite their different heights. In performing direct ophthalmoscopy, focusing is required to clarify
structures of different depth.
Stereoscopic view Inverted and inversed image
Wide range of view Low magnification
Wide panoramic field of view Dilation required
High resolution Difficult to master
High contrast May be difficult to perform for examiners with back problems
Excellent depth of focus
Independent of refractive error
Variety of lens options
Allows quick comparison between the eyes
Relatively easy view through disrupted media
Possibility of scleral depression
Relatively short exam time
Table 3.8: Advantages and disadvantages of BIO

Fundus Methods
PROCEDURE
Examiner Preparation
Note: Most problems with BIO arise from improper instrument set-up: excellent preparation is absolutely necessary
to perform BIO adequately.
 The examiner wears his habitual refractive correction

 The instrument is placed on the head placing most of weight on the crown strap
 The crown strap is tightened and the head band is snugly but comfortably fitted so that the BIO fits like a
baseball cap
 The light tower/ocular assembly is loosened using the appropriate knob and positioned at the same level and as
close to the eyes as possible
 Fixating a small target at a distance of about 50cm, the monocular PD alignment is performed, by sliding each
ocular, so that each eye sees the same field
 Using the vertical light alignment knob, the light source is placed in the upper 1/2 of the imaged field: this allows
the illuminating light to enter the upper ½ of the pupil and the image light to emerge from the lower ½ of the pupil
 Some BIOs have a combined system which adjusts the convergence setting by default with the pupil distance
setting. Where separate adjustments are possible, one should favor the setting for large pupils in order to
increase stereopsis. The small pupil setting should be reserved when pupil size becomes limiting to the view.
Patient Preparation
 The patient is informed about the procedure

 The bleaching phenomenon and transient nature of vision loss is explained as well
 The pupil is dilated (see diagnostic pharmaceutical agents) to allow optimum view (a non dilated view is
possible)
 The patient reclined horizontally in the ophthalmic chair (supine position) (Fig. 3.19a)
 If reclining is not possible, BIO is performed with the patient in a seated position (Fig. 3.19b)
 Reclining generally provides optimal stereoscopic views, facilitates scanning and permits scleral indentation.
Figure 3.19: BIO with patient in seated position

Fundus Methods
Examination Procedure
 The lens is cleaned

 The room lights are dimmed and extraneous light sources are minimized to avoid undue reflections
 The condensing lens is grasped between thumb and first finger with the white or silver line toward the patient
 The lens is held at an arm’s length (50cm), the more convex surface facing towards the examiner
 The examiner stands on the right side of the patient to examine the right eye and vice versa
 The examiner moves around the patient as needed
 Examination is begun with the lens close to the patient’s eye and centered on the pupil
 The free fingers of the hand holding the lens are anchored on the patient’s face.
 The beam is projected into the lens at a right angle to the lens surface and the red reflex is observed
 The lens is moved slowly upward by extending the second finger which acts as a pivot on the patient’s face
 The lens is moved upward keeping the pupil centered, until the fundus appears and fills the entire lens
 The free hand is used to retract the lids away from view
 The second finger of the hand with the lens may also be used to retract the lids
 The area under observation is examined
 If the image is lost, the lens is lowered towards the patient and the examiner starts the view over
 The patient is asked to change his direction of gaze; the lens may be removed from the light path to ensure the
patient complies with instructions
 The procedure is repeated
 The procedure is started at 12 o’clock and the examiner proceeds in a clockwise manner examining 8 directions
of gaze in a systematic way
 The examiner keeps his head positioned 180° away from the observed area
 In order to maximize stereopsis, the examiner should aim to keep his pupils parallel to the long axis of the
patient’s apparent elliptical pupil in peripheral views
 In each direction, the examiner “rocks” his body so that a view of the retina is obtained from the ora to the
posterior pole (i.e., scanned). The light beam must stay perpendicular to the lens surface during this scanning
process
 The posterior pole is assessed last when the patient is slightly more light adapted
 The light is kept on the same fundus area for a maximum of 40 sec. (ANSI recommendation).

Fundus Methods
Tips for Success
 Practice! Practice! Practice! BIO is one of the most difficult procedures to master
 Know the retinal landmarks
 Always start with the right eye
 The viewing distance (~50cm) must be kept constant - beginners have a tendency to move in closer
 Ambidexterity is ideal, but the same hand can be used if the examiner revolves around the patient as needed
 The examiner keeps his eyes, oculars, condensing lens and examined fundus on a “locked” common axis.
 The examiner moves his torso to perform scanning movements, not his head bending sideways
 The lens is kept perpendicular to his viewing axis, not parallel to the patient’s pupil
 Reflections are minimized by slightly tilting the lens very slightly from its perpendicular alignment
 “Crescent shadows” at the edge of the lens are eliminated in the lens by tipping the lens toward the side of the
shadow
 The lens’ focal distance (eye-lens distance) is respected to maximize the field of view
 Remember the inversed and inverted nature of the image and the motion of fundus findings
o In order to properly understand what is observed and correctly record it, the examiner should imagine himself
standing feet up on the ora viewing back into the eye (Fig. 3.22)
o The examiner must move his head towards a finding to move it more centrally in the lens
Figure 3.22 Viewing the retina with BIO

Fundus Methods
 Remember that the image formed of the retina is reversed and inverted; the area examined is not opposite to
your viewing position. i.e., the direction of the patient’s gaze is the area of the fundus under examination. If the
patient is looking inferior nasal then the examiner is looking at inferior nasal retina
 The view can be maximized with the examiner positioning his head 180° from patient’s direction of gaze
 If the patient’s facial anatomy (e.g. nose or eyebrow) is in the way when trying to examine a given area of the
retina, have the patient turn the head in the opposite direction while maintaining the gaze position
 The examiner should allow blinks. If these are excessive, instead of releasing the lid grip, the examiner may
open and close the patient’s eye
 Minor sideways lens movements may be needed to negotiate media opacities.
Distorted/blurry view  Condensing lens upside down

 Dirty lens
 Examiner distance not optimal to view the image of the retina, especially
important for examiners with presbyopia
 Uncorrected refractive error (examiner)
 Improper “common axis” alignment
 Oblique astigmatism in far peripheral view
 Inability to change accommodation for (+) ocular lenses
Reflections  Condensing lens upside down
 Dirty lens
 Lens perfectly perpendicular to line of sight
Diplopia  Incorrect PD setting
 Examiner distance too close
 Impaired fusional ability
 Tilted BIO (horizontal misalignment)
Poor stereopsis  Incorrect PD
 Poor dilation
Incomplete image in the lens  Lens-eye distance too close or too far
 Lens-eye distance too close or too far
 Illumination angled improperly
 Poor dilation
 Peripheral view with small apparent elliptical pupil
 Light spot too small or too focused
Uncooperative patient  Illumination too bright
 Involuntary eye movements
 Poor assigning of fixation target by the examiner
 One eye closed
 Restricting blinks
 Poor instructions by the examiner!
 Poor patient gaze control by the examiner!
Table 3.8: Trouble-Shooting

Fundus Methods
RECORDING/DRAWING LESIONS
Since the view obtained with BIO is inverted and reversed, documenting observed findings can be difficult at first.
You can reverse and invert the image in your mind before documenting it but it is a difficult method for many.
Alternatively, one can ease the drawing of lesions using the following method. Invert the fundus diagram with the
12:00 position towards the feet of the patient. The lesion is then drawn as seen in the opposite quadrant of where it
is perceived (Fig. 3.23).
ST
ST
Figure 3.23: Drawing fundus lesions
LENS CLEANING
Both fundus biomicroscopy lenses, BIO lenses, BIO oculars and contact devices should be treated with care to
maintain the optical quality and integrity of the anti-reflect coatings. Dry clothes or tissues should not be used to
wipe the lenses. They should be washed with warm water and a mild non-abrasive detergent such as hand soap,
photographic lens soap or even a contact lens cleaning solution. They should then be rinsed with warm water and
dried with a soft lint-free cloth. Some lens distributors provide their own lens cleaners.
Should disinfection be necessary, avoid the use of alcohol wipes, acetone or peroxide which can damage the anti-
reflective coatings. Soak the devices in a 1:10 part bleach/distilled water solution or a 3% hydrogen peroxide for 10
minutes (longer than 10 minutes exposure can damage some of the components). Some manufacturers also
recommend the use of 2% gluteraldehyde aqueous solution.

Fundus Methods
MONOCULAR INDIRECT OPHTHALMOSCOPY
DESCRIPTION (FIG. 3.24)
The monocular indirect ophthalmoscopy (MIO) is a method used for ocular fundus examination which employs
optical principles that are somewhat similar to those of the BIO. While it provides monocular viewing, MIO is useful in
that it provides a wider field of view than the direct ophthalmoscope and is easier to use than the BIO especially with
non-dilated pupils. Given its limited range of view and lack of stereoscopy, MIO is rarely used in comparison to BIO.
However, it may still be preferred in instances where pupil dilation is not possible.
Two methods of performing MIO exist. One uses the direct ophthalmoscope in combination with a condensing lens
(usually a +20D) to create the indirect optical setting. The other uses an actual instrument built with the optics to
produce the desired indirect ophthalmoscopy setting. The instrument provides better optics and imaging than the
direct ophthalmoscopy (DO)-lens scheme. While MIO is in general rarely used, the relatively recent Panoptic from
Welsch Allyn has gained some popularity.
Figure 3.24: Monocular indirect ophthalmoscope

Fundus Methods
The MIO principle is somewhat similar to the BIO. A condensing lens system is used to image a light source on the
fundus and to form a real aerial image which is then examined using an observing lens system, either the lenses in
the direct ophthalmoscope or the eyepiece objective in the MIO device. When the direct ophthalmoscope method is
used, an inverted and reversed image is created. With the Panoptic and other MIO devices, an additional set of relay
lens system inverses and reverses the image to present is as an erect image.
Panoramic field of view Limited field of view compared to BIO
Dilation of pupil not necessary Full retinal examination not possible
Erect image (with devices) No stereopsis
Relatively magnified image
Easy to learn
Quick method
Table 3.9: Advantages and Disadvantages of MIO
PROCEDURE
With Panoptic instrument
 The examiner removes his eyeglasses (optional)

 Use the focusing wheel on the instrument to focus an object 3 to 5 meters away
 Set the aperture dial to small
 Turn the instrument on using the rheostat on the handle
 The patient is seated, educated and asked to fixate a distant target
 Seated in front and at level to the patient, place the instrument approximately 10-15 cm. away from the patient’s
eye
 Position the instrument 10-15 degrees to the temple side of the examined eye, so as not to obstruct the other
eye’s fixation (Fig. 3.26).
Figure 3.26: Position of patient and examiner during MIO

Fundus Methods
 Look and center for the red fundus reflex through the device
 Move in towards the patient keeping the reflex in view until the eye cup sits on the patient’s orbital rim
 Adjust the focus to sharpen the fundus view
 Adjust the diameter of the light source to maximize the view
 Proceed with the fundus examination as one would in with a direct ophthalmoscope.
With DO and Condensing Lens
 The same set-up as above is followed

 A condensing lens (usually a+20D) is placed at its focal length (~5 cm) in front of the eye
 The direct ophthalmoscope is held at a working distance of approximately 20 to 30 cm
 The appropriate lens is dialed in the DO to view the red reflex and clear the fundus image.
FUNDUS LANDMARKS
ORIENTATION
In order to examine and document findings of the peripheral retina, a method of orientation & representation of the
fundus as a whole is necessary. The fundus is traditionally depicted on a circular flat surface that is divided into 3
sections that are based on several anatomical structures used to demarcate certain regions:
1. Posterior Pole: Area delimited by the ONH & the major superior and inferior vascular arcades (~6mm)
2. Mid – Periphery: Area between superior & inferior vascular arcades and the equator
3. Periphery: Area from the equator to & slightly beyond the ora serrata (~ 5mm)
Figure 3.27: Schematic division of the fundus
In illustrating the spherical eye onto a flat surface, one must accept that certain distortions are created. The disc &
macula are relatively minified while the equator, peripheral retina & ora are magnified. Therefore, on the diagram,
the ora appears larger than the equator but is not so in reality. The equator is the largest circumference of the eye.

Fundus Methods
For location purposes, the eye is divided further into 4 quadrants centered on the fovea. One can also refer to an
imaginary clock face centered on the fovea with the 12 o’clock position superiorly. The terms inner & outer are used
to denote location with respect to the center of the globe. Anything closer to the center of the globe is “inner”
compared to anything further from it. Finally, the Disc Diameter unit (1DD ~ 1.5mm) is used to indicate the size &
location of lesions with respect to the Optic Disc.
ANATOMICAL LANDMARKS
Vortex Vein Ampullae
The Vortex Vein Ampullae are collecting channels for the multiple thin curved venous tributaries that cover most of
the fundus. They are usually 4 (1 per quadrant) but can be fewer, or as many as 10-15. They are located around the
equator & mark the equatorial region but they are not always visible. They are red-orange, octopus-shaped & are
commonly found with significant surrounding pigmentation (RPE hyperplasia). The vortex ampullae drain into vortex
veins going through the sclera posteriorly.
Long Posterior Ciliary Arteries & Nerves (LPCA & LPCN)
The LPCA & Nerves appear as 2 straight lines typically white to yellowish with pigmented borders. They run in the
supra-choroidal space stretching from the Ora to the Equator at the 3 & 9 o’clock positions & divide the retina into
superior & inferior halves. The artery usually runs below the nerve temporally & above the nerve nasally. The nerves
are usually more visible than the arteries.
Short Posterior Ciliary Arteries & Nerves
The SPCA & Nerves are short, straight white to yellowish lines with pigmented borders found in the peripheral retina.
They are 10 to 20 in number but usually only 4 to 8 are visible. They extend from the mid-periphery to the periphery
usually congregating near the vertical meridian but they can be scattered anywhere. They are not as consistently
visible as the LPCA & LPCN.
Figure 3.28: Schematic division of the fundus
Inspired by: Bell FC., Stenstrom WJ. Atlas of the Peripheral Retina, W.B. Saunders Company, 1983.

Fundus Methods
Peripheral Vessels
The peripheral arteries & veins run parallel to the ora serrata & come to 1.5mm from the Ora serrata. As a result, a
1.5mm capillary free band exists posterior to the edge of the Ora serrata.
Ora Serrata
The Ora serrata represents the anterior limit of the neural seeing retina. It is a 360 junctional band that is more
narrow temporally (~1mm) than nasally (~2mm). It is scalloped (nasally > temporally) with 20 to 30 dentate
processes per eye. The brown rounded areas that extend posteriorly from the Ora are called Oral Bays while the
whitish anterior retinal extensions into the bays are called Oral Teeth.
Pars Plana
The Pars Plana is a 4-5 mm region that extends from the ora serrata to the ciliary processes (60-70/ eye). It is
composed of an inner non-pigmented epithelium & outer pigmented epithelium. The Pars Plana is chocolate color.
The ciliary processes are also brown in reality but appear cream color during ophthalmoscopy because of the
tangential illumination used to see them.
Vitreous
The vitreous is not truly a major anatomic landmark since it is usually invisible but is included here because of the
prominent role it plays in the appearance & development of peripheral findings. One must understand the close
vitreo-retinal relationships that exists throughout the fundus which may be altered during the development of
peripheral lesions or which may themselves cause the formation of peripheral retinal anomalies.
The vitreous is a type of gel, semi-solid to liquid in consistency, made up of 99% water, 1% hyaluronic acid, to allow
maximum light transmission. It occupies 67-75% of the ocular volume. It is clear & usually retains its clarity through
most of a person’s life. Vitreous strands & floaters which are debris of vitreous material are relatively common & may
be seen ophthalmoscopically.
The vitreous is attached at several locations in the eye. It is attached strongly at the posterior lens surface in young
persons, a fact that renders the extraction of cataracts difficult in the young. It is attached at the vitreous base with a
strong 2-4 mm connection that straddles the Ora serrata & holds the vitreous cortex, sensory retina & pars plana
together. It is attached at the ONH Margin with a strong ring-form attachment that is observable as the “Weiss ring”
following PVD. Finally it is weakly attached at the Macula & peripheral retinal vessels.
Vitreous Base (VB)
The vitreous base, while usually not visible, is also considered a landmark. The VB is a 2-4 mm band that straddles
the Ora & represents the limit between anterior & posterior vitreous cortex. The anterior limit is sometimes visible as
a whitish linear haze on & parallel to the pars plana. The posterior limit is usually invisible unless it is protuberant or
altered by severe vitreous traction in which case it is called a prominent VB. A prominent VB looks like a thin
elevated white line parallel to the Ora. The VB is the most adherent vitreal attachment. Its limits can sometimes be
denoted by the increased pigmentation that results from RPE hyperplasia at its limits.

GONIOSCOPY
AUTHOR
PEER REVIEWERS
Iqbal Ike Ahmed, MD, FRCS

Trillium Health Partners, Mississauga, Ontario, Canada
Credit Valley EyeCare, Mississauga, Ontario, Canada
Graham Belovay, MD
INTRODUCTION

• Theory
• Direct gonioscopy
• Indirect gonioscopy
• Lenses used in gonioscopy
• Pertinent angle anatomy
• Interpretation of gonioscopy findings
INTRODUCTION
Gonioscopy is a clinical technique that provides a view of the anterior chamber angle anatomy. The use of gonioscopy
is indicated in circumstances of narrow anterior chamber angles by Van Herrick estimation, suspicion of anterior
chamber angle abnormalities (resulting from trauma, maldevelopment, chronic anterior uveitis or neoplasia),
pigmentary dispersion, pseudoexfoliation, risk of iris or angle neovascularization, suspicion of glaucoma
(differentiation of open angle versus closed angle glaucoma), and established glaucoma patients (monitoring). The
use of gonioscopy is contraindicated post-operatively and in cases of traumatic hyphema, corneal abrasion, lacerated
or perforated globe.

Gonioscopy
THEORY
Light strikes the anterior corneal surface at an angle greater than the critical angle causing total internal reflection (Fig.
4.1).
Figure 4.1 Optics of light illuminating the angle of the anterior chamber
Despite this optical property, it is possible with the use of specialty lenses or prisms to view the anterior chamber
angle structures (Fig. 4.2). The two basic types of contact instruments used to perform gonioscopy are the direct lens
and the indirect lens.
Figure 4.2 Optics of light illuminating the angle of the anterior chamber with a gonioprism in place
TYPES OF GONIOSCOPY
DIRECT GONIOSCOPY
The direct gonioscopy system consists of a highly convex glass or plastic lens, an external light source and a hand-
held magnifier. The most common direct lens is the Koeppe lens (Fig. 4.3), which is a +50D convex lens available in
several different diameters. The lens provides 1.5X magnification, but one requires the use of a hand-held slit lamp or
other magnifying instrument. Typically a 16X hand-held magnifier is employed providing a total magnification of 24X.
The image is erect and virtual.

Gonioscopy
Figure 4.3 Koeppe lens
The patient is examined in a supine position and the lens is placed on the eye with saline or a clear viscous
preparation to provide a clear refractive medium. The clinician moves freely around the patient to obtain a direct
panoramic view of the anterior chamber angle structures. The technique is seldom used with the exception of
examination under anesthesia for infants or children.
INDIRECT GONIOSCOPY
With the advent of slit lamp biomicroscopy, the indirect method has become popular and much more commonly
performed than direct gonioscopy. Indirect lenses use a mirrored system or silvered prisms to allow for examination of
the anterior chamber angle structures. This view can be magnified using the slit lamp magnification system. However,
some indirect lenses have some magnification built in already (e.g. 1.5X). The angle under observation is opposite
(180°) the mirror being used. For instance, if the mirror/prism is placed superiorly, the inferior anterior chamber angle
is being examined. The image is inverted and virtual.
There are various types of indirect lenses. They differ in the amount of ocular contact imposed by the lens diameter
and by the number of mirrors/prisms within the system.
INDIRECT SCLERAL LENSES
Scleral lenses have a large diameter of ocular surface contact including the entire cornea, limbus and a portion of the
sclera. The most commonly used scleral lens is the Goldmann (Fig. 4.4). The Goldmann has one to three mirrors.
The one mirror Goldmann lens has a central lens to view the posterior pole and a mirror placed at 62° to view the
anterior chamber angle structures. The two mirrored Goldmann lens has a central lens to view the posterior pole and
two mirrors placed at 62° which are separated by 180° to view the anterior chamber angle. The three mirrored lens
has a central lens (C: circular) to view the posterior pole, one mirror placed at 59° (A: U-shaped) to view the anterior
chamber angle and 2 retinal mirrors placed at 66° (P: rectangular) and 76° (E: trapezoidal) to view the periphery and
the equator respectively. One is required to rotate the lens around in order to view the entire anatomy of the structure
being evaluated.
Figure 4.4 Goldmann 3 mirror lens (A: Anterior, P: Periphery, E: Equator, C: Central)
Gonioscopy
Figure 4.5 Goldmann lens placed on the eye
Picture courtesy of Pirindha Govender (University of Kwazulu Natal)
Other scleral lenses that are available include “Goldmann type” lenses by Ocular Instruments (Fig. 4.6), and the
Thorpe four-mirrored lens. The Thorpe four-mirrored lens is similar to the Goldmann design, but all four mirrors are
placed at a 62° angle to view the anterior chamber angle anatomy only and therefore require minimal rotation to view
the entire angle.
Figure 4.6 Other Goldmann lenses
Scleral lenses require the use of a viscous lubricant medium between the cornea and the lens to provide a smooth
refractive surface and a cushion between the lens and the cornea. Traditionally used gonioscopic solutions include
specially made viscous gels such as Gonioscopic gel, Goniosol, Gonak and Teargel. Presently, it is common to use a
less viscous solution such as the ones used for dry eye therapy (e.g. Celluvisc) because they do not disrupt the
corneal surface. If the more viscous lubricants are used, it is recommended to store the bottles upside-down to avoid
the introduction of air bubbles into the solution. A list of gonioscopic solutions follows.

Gonioscopy
Table 4.1 Comparison of Gonioscopic Solutions
Solution Manufacturer Material Preservative
Celluvisc Allergan 1% carboxymethylcellulose No preservative
0.01% benzalkonium
2.5 % hydroxypropyl chloride
Goniosol Iolab
methylcellulose
edetate dissodium
0.004% thimerosal
Gonioscopic Alcon hydroxyethyl cellulose
0.1% edetate dissodium
2.5% hydroxypropyl 0.01% benzalkonium

Gonak Akorn
methylcellulose chloride
Novartis (formerly
Teargel Carbopol 980 0.01% cetrimide
Ciba Vision)
0.3% hydroxypropyl
Genteal Gel Novartis methylcellulose sodium perborate
Carbopol 980
INDIRECT CORNEAL LENSES
Corneal lenses have a small diameter and the surface of contact does not extend past the limbus. The lenses have
multiple silvered mirrors which are used to view the anterior chamber angle. The advantage to this system is that
there is no need to rotate the lens while it is on the eye to view the other angles. The disadvantage of corneal lenses
is that they provide less stability than scleral lenses. However, unlike the indirect scleral lenses these can be used to
perform indentation gonioscopy. This is useful to differentiate between appositional and synechial angle closure as
well as evaluating for plateau iris. The different types available are the Zeiss 4-mirrored lens, Posner 4-mirrored lens,
and the Sussman 4-mirrored gonioprism.

Gonioscopy
Table 4.2. Comparison of various 4-mirrored lenses
Zeiss 4-mirrored lens Posner 4-mirrored lens Volk 4-mirrored

gonioprism
Contains a central lens to view Similar to the Zeiss design, Similar to the Zeiss
the posterior pole/fundus and four but its handle has a steeper angle in lens design, however it
mirrors placed at 64° to view the of attachment and is permanently does not have a handle.
anterior chamber angle structures. mounted.
The lens system is attached to

a removable handle which is used
to manipulate the lens.
Table 4.3. Comparison of various Indirect Lenses
Lens # of mirrors/prisms Contact surface Coupling Fluid
Goldmann 1 to 3 Scleral Yes

Ocular Instruments 1 to 3 Scleral Yes
Thorpe 4 Scleral Yes
Zeiss 4 Corneal No
Posner 4 Corneal No
Sussman 4 Corneal No

Gonioscopy
As previously stated, indirect gonioscopy lenses are more widely used than direct lenses. The chart below outlines
the advantages and disadvantages of both systems.
Table 4.4. Advantages and disadvantages of indirect and direct gonioscopic systems
Indirect • Upright patient position • Cannot simultaneously compare eyes
• Quickly and easily performed • Limited in pediatric cases
• Can alter beam width to optic section • Stereopsis poor in lateral views
• Performed in conjunction with
• Does not require an assistant
• Higher magnification available
• Greater detail viewed
Direct • Direct panoramic view • Supine position is cumbersome
• Simultaneous view of both eyes • Time consuming
• Useful in pediatric cases • Requires hand held magnifier
• Stereopsis good in lateral views • Requires external light source
• Usually requires an assistant
• Can’t alter beam width to optic section
PERTINENT ANATOMY
In order to visualize and understand the iridocorneal angle properly, it is necessary to review anterior chamber angle
anatomy. One can often easily perceive and assess the relevant structures from posterior to anterior. However if
Schwalbe’s line, the most anterior structure, is not properly localized it can lead to misinterpretation. It is therefore
safer to evaluate the structures from anterior to posterior in order to reduce error in interpretation. The structures from
anterior to posterior are Schwalbe’s line (SL), Trabecular Meshwork (TM), Scleral Spur (SS), Ciliary Body (CB), and
the Iris Root (IR).
a b
Figure 4.7 (a) Schematic of structures within the angle (b) Photo of structures within the angle
Photo courtesy of Ike Ahmed and Graham Belovay (University of Toronto)

Gonioscopy
SCHWALBE’S LINE (SL)
Schwalbe’s Line is the juncture between Descemet’s membrane of the cornea and the trabecular meshwork. Its color
varies from clear/white to light brown. Circumventing currents of the aqueous may cause pigments to deposit at the
junctures of Schwalbe’s line causing it to appears dark brown, in which case it is referred to as Sampaolesi’s line. To
properly localize Schwalbe’s line (which is most often non-visible) one must use an optic section that is aligned
perpendicular to the mirror and placed at an oblique angle (1-10°). The light will appear to be in the shape of a wedge.
Optically, two lines of light will be visible. The lines are formed from the anterior and posterior surface of the cornea.
The point at which the lines meet marks the end of Descemet’s membrane, the actual location of Schwalbe’s line (Fig.
4.8).
Figure 4.8. Using the corneal wedge technique to localize Schwalbe’s line
Picture courtesy of Ike Ahmed and Graham Belovay (University of Toronto)
TRABECULAR MESHWORK (TM)
The trabecular meshwork consists of a series of sheets of fenestrated epithelial tissue which account for the major
portion of the aqueous drainage system (80-90%). The coloring of the TM depends on personal pigmentation and can
vary from light gray to dark brown. The TM can divided into three parts: uveal meshwork, corneoscleral meshwork and
juxtacanalicular meshwork. The juxtacanalicular meshwork is the site of greatest resistance with 0.5-2.0 µm pores.
Debris such as that found in pigment dispersion syndrome is deposited in the corneoscleral meshwork. The aqueous
humour, produced by the ciliary body, travels over the anterior surface of the iris, circulates and passes through the
lamellae of the TM: uveal meshwork to corneoscleral meshwork to juxtacanalicular meshwork. Once through the
juxtacanalicular meshwork the aqueous enters Schlemm’s Canal (SC). The SC is not visible unless pressure is
applied on the eye with the goniolens. If pressure is applied, blood from the venous system regurgitates into SC and it
is seen as a fine red line beneath the TM. From SC, the aqueous drains into the episcleral venous plexus.
SCLERAL SPUR (SS)
The scleral spur consists of collagen and elastic tissue from the sclera. Appearing whitish-gray, it protrudes into the
anterior chamber and is visible just posterior to the TM. The scleral spur functions as the point of insertion for the
longitudinal muscles of the ciliary body.

Gonioscopy
CILIARY BODY
The ciliary body varies in color from light gray to dark brown depending on personal pigmentation. The portion that is
visible consists of longitudinal muscle and is referred to as the ciliary body band. The function of the ciliary body is to
produce aqueous humour.
IRIS ROOT (IR)
The iris root is the last role of the peripheral iris. Inserting onto the ciliary body, it varies in color depending on
personal pigmentation.
IRIS PROCESSES
In certain individuals, fine strands of iris tissue or uveal meshwork extend into the anterior chamber, span across the
CB and SS and insert into the TM. It is unclear why they occur. It is necessary to distinguish iris processes (a normal
entity which does not interfere with aqueous outflow) from iris/angle neovascularization or peripheral anterior
synechiae (which impairs aqueous outflow). Indentation or compression gonioscopy is performed to determine this
difference. Peripheral anterior synechiae continues to hold against the wall while iris processes appear lacier and
expose the wall behind them.
IRIS/ANGLE NEOVASCULARIZATION
Iris neovascularization is referred to as Rubeosis Iridis (RI). It occurs in cases of ocular or systemic ischemic/vascular
disease. Neovascularization begins at the pupillary margin or ruff and travels over the angle structures. A
fibrovascular membrane may develop which would contract and cause the angle to close. The vessels are red and
their appearance may be very subtle.
PERIPHERAL ANTERIOR SYNECHIA (PAS)
PAS are adhesions of the iris to the TM or to more anterior structures of the anterior chamber angle (Figure 4.9).
They can be found in cases of angle closure, inflammation, trauma, ICE syndrome and following argon laser
trabeculoplasty (ALT).
Figure 4.9: Image of the angle showing peripheral anterior synechia (PAS)
Picture courtesy of Ike Ahmed (University of Toronto)

Gonioscopy
PROCEDURES
INDIRECT SCLERAL LENS
• Position the gonioscope as you would for fundus biomicroscopy (refer yourself to chapter 3) but use the “A”
mirror (thumbnail or D shaped) for visualization of the angle.
Figure 4.10. Patient seated comfortably at slit lamp during gonioscopy procedure
Picture courtesy of Pirindha Govender (University of KwaZulu Natal)
Figure 4.11. Scleral indirect gonio lens insertion technique

Gonioscopy
Figure 4.12. Rotation of the gonio lens using one hand technique
Figure 4.13 Examiner resting his hand on the forehead rest
Picture courtesy of Pirindha Govender (University of KwaZulu Natal)
INDIRECT CORNEAL LENS
• Patient is educated and the cornea is anesthetized

• The lens is properly disinfected and rinsed
• A drop of saline (or an additional drop of anesthetic) is placed on the concave surface of the lens
• The patient is seated comfortably behind the slit lamp
• The SL is in “click” position (angle of 0° ); a wi de 2-3 mm parallelepiped is used
• The SL is fully retracted or moved out of the way towards the eye not being examined
• The patient is instructed to look straight ahead and the lens is placed directly on the eye
• Mirrors should be at 3, 6, 9 and 12 o’clock positions
• The examiner’s hand is stabilized on the side of the head rest or on the patient’s cheek
• Gentle pressure is placed against the corneal surface
Gonioscopy
• The examiner positions himself behind the SL and moves it forward to obtain a focused view
• To view another angle, the slit beam is simply moved to another mirror
• The lens is removed by releasing pressure on the corneal surface
TIPS
If too much pressure is applied, folds in Descemet’s membrane will appear and this will distort the view of the angle
structures.
Disinfection of all lenses should be performed by washing with soap and water after use and soaking for 10 minutes in
a 1:100 bleach:water solution and then rinsing with saline prior to use. Routine disinfection with alcohol will damage
lens surfaces and it does not provide adequate disinfection and therefore it is not recommended.
In the circumstance where all the structures are not visible certain techniques are used better examine the angle. For
instance, when the iris has a more pronounced convexity, it may be difficult to evaluate which structures are visible.
To more easily view the angle structures, the patient is instructed to look slightly towards the mirror. Some sources
recommend a technique of tilting the lens away from the mirror, however this may produce distortions.
Another special technique is performed to differentiate an angle closure from synechial closure. It is termed
indentation, pressure or compression gonioscopy and can only be performed with indirect corneal lenses. While
the lens is placed on the eye and the angle is in view, press lightly on the cornea. This pressure forces the aqueous
peripherally into the angle recess and this pushes the peripheral iris backward in cases of angle closure. Once the iris
is pushed backwards, the other angle structures will come into view. If a patient has peripheral anterior synechia and
indentation/pressure gonioscopy is performed, the peripheral iris will not bow backwards to reveal the angle structures
and the areas of adherence become visible.
Figure 4.14 Schematic of indentation/pressure/compression gonioscopy

Gonioscopy
ANGLE CLASSIFICATION
Once gonioscopy is performed, it is necessary to grade and document the appearance of the angle structures. This is
done with the use of angle classification schemes. The three available angle classification schemes are the Scheie,
Schaefer and Spaeth.
SCHEIE’S CLASSIFICATION
The Scheie angle classification scheme (Table 4.5) is based on the most posterior angle structure visible and from
that anatomical landmark, it is given a grade from I to IV (Schacknow and Samples, 2010).
Table 4.5. Grading the angle of the anterior chamber using Scheie’s classification
Grade Anatomical Landmark
0 All angle structures visible (wide open)
I Scleral Spur (open)

II Trabecular Meshwork
III Schwalbe’s line
No angle structures visible

IV (narrow/closed)
SCHAEFER’S CLASSIFICATION
The Schaefer angle classification scheme requires the observer to estimate the geometric angle between the iris
insertion with the plane of the TM (Fig. 4.14). Once the angle is estimated in degrees, a grade is given from I to IV
and the risk of angle closure is predicted (Table 4.6).
Figure 4.14 Estimating the geometric angle between the iris insertion with the plane of the TM
Table 4.6. Grading the angle of anterior chamber using Schaefer’s classification

Gonioscopy
Grade Angle in Degrees Risk of Closure
IV wide open ≥ 45° unlikely
III open 20°<45° unlikely
II moderate narrow 20° possible
I very narrow 10° probable
slit extremely narrow < 10° present
0 closed closed
Note: The Scheie and Schaffer classifications were originally described as above with Grade 0 being open and grade
4 closed. Being the opposite of the Van Herrick classification, this created some confusion and practitioners started
reversing the grading to match the VH. However, the inconsistent grading scheme, which is now found in many
textbooks, created additional confusion. To clarify this and facilitate interpretation, clinicians began to describe the
structures seen in each quadrant instead of assigning a number to the angle. The most recent system of angle
classification, the Spaethe method described below, is becoming the new standard because it does away with any
confusion by providing a clear angle description without using grading numbers.
SPAETH’S CLASSIFICATION
The Spaeth angle classification scheme (Table 4.7) incorporates the angular width of the Schaefer scheme with
documentation of the location of iris root insertion into the angle and a description of the iris contour configuration
(Kunimoto et al, 2004). The Spaeth angle classification is the most complex, yet it is the most descriptive and
comprehensive scheme. Therefore, we recommend it as a primary means to classify and grade the anterior chamber
angle when performing gonioscopy.
Table 4.7. Grading the angle of the anterior chamber using Spaeth’s classification
Site of Insertion
A Anterior to SL
B Behind SL - no TM visible
C sCleral spur
D Deep angle with CB visible
E Extremely deep (>1mm ciliary body)

Gonioscopy
Iris contour/approach
q queer: marked concave iris
r regular configuration - slight anterior bowing
s steeply convex iris
Insertion angle
in degrees
EXAMPLES
E 40 q = extremely deep iris insertion, 40° insertion angle, queer approach.
B 20 s = iris inserts behind the SL, 20° insertion angle, steeply convex approach.
C 30 r = iris inserts at the scleral spur, 30° insertion angle, regular or flat approach.

Gonioscopy
NOTATION
With any grading system, a cross is used to document the angle in each quadrant (S,I,T,N). Abnormalities are noted
and the amount of pigment visible within the angle (mainly in the TM) is also graded 0 to 4+.

Gonioscopy
BIBLIOGRAPHY
Fingeret M, Casser L and Woodcome HT. Atlas of Primary Eyecare Procedures. Norwalk, CT: Appleton and Lange;
1990.
Kunimoto DY, Kanitkar KD and MAkar MS. The Wills Eye Manual: Office and Emergency Room Diagnosis and
Treatment of Eye Disease. Lippincott Williams and Wilkins: Philadelphia. 2004.
Schacknow PN and Samples JR. The glaucoma book: A practical evidence-based approach to patient care.
Springer, New York. 2010.
Damji KF, Freedman S, Moroi SE, and Rhee D. Shields Textbook of Glaucoma, 6th Ed. Philadelphia, PA: Lippincott,
Williams and Wilkins, 2010.

INTRODUCTION TO THE VISUAL FIELD
AUTHOR
PEER REVIEWERS
INTRODUCTION
• Definition of the visual field

• Characteristics of the normal visual field

THE VISUAL FIELD – AN INTRODUCTION
DEFINITION
Every point in space is represented by a corresponding point on the retina. The sum of these points forms what is
termed the visual field. The visual field (VF) is that portion of space in which objects are visible at the same moment
during steady eye fixation (Fig. 5.1).
Steady Fixation
Figure 5.1: Extent of the visual field

Visual Fields
CHARACTERISTICS
The normal monocular VF will form nearly ½ of a sphere (“egg-shaped”) & will be situated in front of & surrounding
the fixating eye of the observer. The limits of the monocular VF are approximately 60° nasally & superiorly, 75°
inferiorly & 100° temporally (Fig. 5.2).
Physical traits such as the nose and brows form restrictions for the nasal and superior aspects of the field.
Figure 5.2: Limits of the monocular visual field
The VF shape is best described schematically using Traquair’s “island hill of vision surrounded by a see of
blindness” (Fig. 5.3). The island represents the VF as a 3-D structure with the tip representing the area of the VF
with the greatest retinal sensitivity (Fig. 5.4). The height of the “island” decreases as one moves away from the
center and sinks into the “ocean” in the far periphery. Hence the highest point of the island represent the foveal area
and the progressively flattening land represents the reducing retinal sensitivity towards the periphery.
Figure 5.3: Profile of the hill of vision
October 2013, UPDATED Clinical Optometric Procedures 2, Chapter 5-3

Visual Fields
Figure 5.4: Three-dimensional representation of the hill of vision
The height at various points of the hill represents different levels of sensitivity. The top of the hill represents the area
where the smallest and dimmest stimuli can be seen. The shape of the hill of vision is related to the photoreceptor
distribution and summation characteristics. As eccentricity increases, the concentration of cones decreases
while that of the rods increases. The ratio of photoreceptors to ganglion cells also increases towards the periphery
going from a 1:1 ratio in the fovea to ~300:1 in the periphery. Hence VA & peak sensitivity drop rapidly the further we
are from fixation. To be perceived in our peripheral vision, larger and brighter stimuli are required.
If a constant stimulus is moved from the center towards the periphery, it will become invisible at a certain distance
from the top of the island. The point on the island at which the stimulus becomes invisible represents the outer
boundary of visibility for that stimulus. Hence the target is the dimmest target perceived at that discrete retinal point
or the threshold. Suprathreshold stimuli (bigger or brighter) will be more visible than the threshold and will be seen
at that same retinal point; infrathreshold stimuli will be less visible and will not be seen.
Distance from fovea VA

0° 6/6
3° 6/12
5° 6/21
10° 6/30
20° 6/60
Table 5.1: Relationship between distance from fixation and visual acuity

Visual Fields
The shape, height and slope of the island of vision are established by drawing isopters. If the limit of visibility for a
constant stimulus is found at several points around the visual field (i.e. moving 360° circumferentially along different
X-Y axis), perimeters of equal threshold can be mapped. These boundaries, called isopters, represent borders of
equal sensitivity. The threshold stimulus used to draw the isopter will be visible everywhere within the isopter
and invisible outside.
Isopters can be mapped for different stimuli & represented on a 2-dimensional plane using contour lines just like a
geographical map. If the isopters are drawn on a 3-dimensional plane, with the height representing sensitivity, the
hill of vision arises. Aside from small interindividual variations, the isopters or contour lines are relatively constant in
size & shape in the eyes of healthy individuals of the same age.
The line connecting the men

is the isopter for the “man”
stimulus. The man will be a
supra-threshold stimulus
anywhere inside the isopter
and an infrathreshold stimulus
anywhere.
The man is visible up to here,

therefore he is visible at this
point.
Suprathreshold stimulus
(anyone brighter or bigger
than the man) will be visible at
this point.
Figure 5.5: Mapping if isotopers
Figure 5.6: Isotoper Plot vs. Profile section vs. 3-D profile plot

Visual Fields
A blind spot that corresponds to the ONH exists on the island of vision. The blind spot appears like a deep oval
"hole" (area of 5.5° horizontal X 7.5°vertical) of total blindness that lies 15° temporally from fixation. 1/5th of the
blind spot lies above the horizontal meridian (Fig. 5.6).
Figure 5.6: Isotoper Plot vs. Profile section
Figure 5.7: Representation of the monocular vs binocular VF

TESTING THE VISUAL FIELD
AUTHOR
PEER REVIEWERS
INTRODUCTION
 Testing the visual fields

o Purpose/indications
o General terminology
 Theory of visual field testing
o Units of measure
o Threshold
o Kinetic vs. Static
o Screening vs. Threshold
o Variables in VF testing
o Stimulus factors
o Response factors
o Clinical variable

Visual Fields
TESTING THE VISUAL FIELDS
Figure 5.8: Testing the visual field
Inspired by Anderson, D., Testing The Field of Vision, The C.V. Mosby Company, St-Louis, Mi, 1982.
PURPOSE/INDICATIONS
Certain characteristic VF variations, termed VF defects or VF losses, can occur as a result of abnormalities or
diseases affecting the visual pathway. Interpretation of these variations will allow the optometrist to detect, localize,
diagnose, and manage various conditions. The numerous conditions that may indicate the need for visual field
testing in an optometric setting are outlined in table 5.2.
VF testing is an integral part to the assessment of the visual, ocular and physical health of patients. A form of VF
screening test should be performed on every patient presenting for an eye examination. With any of the signs &
symptoms presented below, more elaborate VF testing procedures are needed. VF assessment is an absolutely
indispensable requirement to the practice of primary care optometry.

Visual Fields
General medical problems Ocular findings
 Vascular diseases (e.g. diabetes)  Unexplained loss of vision

 Demyelinating diseases (e.g. multiple sclerosis)  Proptosis
 Infectious diseases (e.g. syphilis, TB, etc.)  Abnormal confrontation fields
 Pupil abnormalities
Neurological problems  Motility abnormalities
 Pigment dispersion syndrome
 Unexplained headache  Exfoliation syndrome
 Unexplained orbital pain  Ocular hypertension (OHT)
 Paresthesias, numbness  Anomalous discs (FLD)
 Transient weakness of limbs  C/D asymmetry (OD vs. OS)
 Head injury  C/D asymmetry (vertical vs. horizontal)
 Notching
Ophthalmic problems  Disc hemorrhage
 Baring of the circumlinear vessel
 Diplopia  NFL defects
 Poor vision on one side of the body  Swollen ONH
 Bumping into objects on one side  Disc pallor
 Difficulty reading (inability to find or keep on line)  Retinal/choroidal disease
 Visual hallucinations
 Potentially toxic medications (e.g. chloroquine, Screening / Baseline information
ethambutol)
Table 5.2: Indications for visual field testing

Visual Fields
GENERAL TERMINOLOGY
A scotoma is an area of blindness (relative or absolute) surrounded by normal VF. An absolute scotoma is a
scotoma in which vision is entirely absent in the affected area; a relative scotoma is a VF loss in which the vision is
partially reduced or depressed with respect to the surrounding vision (Fig. 5.9). There is blindness to some stimuli
but not to others.
The term depth is used to refer to the severity of a relative scotoma. A deep scotoma indicates that the sensitivity
within it is low and that only stronger stimuli can be seen ; a shallow scotoma indicates that the sensitivity within the
scotoma is slightly reduced.
Figure 5.9: Relative scotomas and depth of relative scotomas
Figure 5.10: Characterizing scotomas
Figure 5.11: Characterizing scotomas

Visual Fields
A negative scotoma is a VF loss of which the person is unaware (e.g. the physiological blind spot); a positive
scotoma is one where the patient is aware of the visual loss.
Central VF refers to the central 30 visual area; Peripheral VF usually refers to eccentricities of greater than 30.
A central scotoma involves the fixation area (fovea) (Fig. 5.12a). A cecocentral scotoma is a VF defect that
extends from the blind spot (cecum) to the central area (fixation) (Fig. 5.12b). A paracentral scotoma involves the
area within 10 of fixation but does not include fixation (Fig. 5.12c). A pericentral scotoma surrounds fixation
without involving it (Fig. 5.12d).
Figure 5.12: Various types of scotomas
An arcuate scotoma is an arc-shaped defect that arches into the nasal field and follows the course of the retinal
nerve fiber bundles (Fig. 5.13a). Also known as Bjerrum’s, Seidel’s, “scimitar” or comet scotoma, the nerve
fiber bundle scotoma leaves the blind spot as a thin relative VF loss and becomes wider and deeper as it arches
around the fixation point usually between 10-20 and heads towards the nasal horizontal raphe. Arcuate scotomas
most often occur in glaucoma.
A nasal step is a step-like defect in the nasal field (typically associated to glaucoma), caused by asymmetrical
involvement of the retinal nerve fibers on either side of the horizontal raphe (Fig. 5.13b).

Visual Fields
An enlarged blind spot as the name suggests indicates an apparently larger blindspot (Fig. 5.14a).
An altitudinal defect involve the 2 quadrants of the upper or lower halves of the VF (Fig. 5.14b). The defect can be
complete or incomplete (Fig. 5.14c).
Split fixation indicate a VF loss of either the upper or lower half of the VF across the horizontal through fixation.
Hemianopsia (or hemianopia) is a loss of vision in 1/2 of the VF of one eye (unilateral hemianopsia) or of both
eyes (bilateral hemianopsia) with respect of the vertical midline.
Quadrantanopsia (or quadranopia) is a loss of vision in 1/4 of the VF of one eye (unilateral quadranopia) or of
both eyes (bilateral quadranopia) with respect of the vert. & horiz. Midlines (Fig. 5.15a).
Heteronymous refers to a hemianopic or quadrantanopic defect that occurs in opposite side of the VF. Hence a
heteronymous hemianopsia involves either both nasal (binasal hemianopsia) (Fig. 5.15e)or both temporal halves
(bitemporal hemianopsia) of the VF of the 2 eyes.
Homonymous refers to a hemianopic or quadrantanopic defect that occurs in the same side of the VF. Hence a
homonymous quadranopia involves the nasal side of the VF of one eye and the temporal side of the VF of the other
eye.
Complete and incomplete terms are used to define the extent of the hemianopic or quadranopic defect. Hence a
complete hemianopia implies a defect of the entire right or left hemifield; an incomplete hemianopia implies that a
portion of the right or left hemifield is affected.
Congruous and incongruous are terms used to denote the similarity of the defects in both eyes. A congruous
hemianopia or quadranopia is identical in size, shape and position in both eyes (Fig. 5.15c); it follows that
incongruous hemianopia or quadranopia are defects that are different in the 2 eyes (Fig. 5.15b).
A crossed defect refers particularly to a quadranopia that involves the upper field in one eye and the lower in the
other.
Macular sparing indicates that the central 5 to 15 is spared in both eyes in the presence of a homonymous
hemianopia (Fig. 5.15d).
A junctional scotoma indicates the loss of VA or VF in one eye with a superior temporal defect in the opposite eye
(Fig. 5.15e).

Visual Fields

Visual Fields
THEORY OF VISUAL FIELD TESTING
UNITS OF MEASURE
VF testing is a measure the ability of the visual system to detect a difference in contrast between the background
and the target luminance. It is a measurement of the sensitivity of the visual system to brightness differences. VF are
therefore described in units of light brightness.
The Apostilb (asb) is the unit of luminance used to denote the amount of light reflected from a surface (1 asb =
1lumen/m2). The brightness of the target and background are measured in apostilbs. The higher the value, the
brighter the surface. To give an idea, a healthy human can under optimal conditions perceive a 1asb stimulus at the
macula.
The Log units (LU) is often used to denote the apostilb brightness of stimuli to reduce the large range of luminance
of testing instruments and the sensitivity of the visual system to a more usable form. For example, the range of the
Humphrey VF has a 10 000 - 0.08 asb. This simply reduces to a range of 5.1 LU (log 10000 - log 0.8 = 5.1).
The Decibels (dB) is used to denote sensitivity. The decibel scale is a logarithmic scale that is reciprocally related to
brightness. A 10 dB increase (1LU) indicates that the stimulus is 10X dimmer (10 dB = 1 LU  10 X). Thus the
higher the dB numeric value, the dimmer the target, the higher the sensitivity.
The dB scale is a relative scale and the dB numbers on different VF instruments do not have comparable brightness
values (table. 5.3). On a given instrument, the maximal brightness of the target is assigned a value of 0 dB. With
each LU decrease in illumination from the brightest value, an increasingly higher decibel number is obtained. Hence
the decibel scale value will represent a different apostilb value on the two different testing units if the maximal
brightness is different. For example, the Humphrey VF has a maximum target brightness of 10,000 asb, while the
Goldmann VF has a maximum of only 1,000 asb. Hence 20 dB on the Humphrey unit is equal in brightness to 10 dB
on the Goldmann unit.
E.g. Humphrey VF Goldmann VF

Brightest target 10,000 asb = 0 dB 1000 asb = 0 dB
10X (1 UL) reduced 1000 asb = 10 dB 100 asb = 10 dB
10000X (1 UL) reduced 1 asb = 40 dB 0.1 asb = 40 dB
100000X (1 UL) reduced 0.1 asb = 50 dB
…
Table 5.3: Relationship between dB scale and asb on different instruments of visual field testing
Note that a sensitivity of 0 dB indicates that the maximal stimulus for a given instrument is not perceived. The
sensitivity is very low, but it is not necessarily an absolute zero sensitivity (i.e. blind area). A stronger stimulus than
what the instrument can maximally produce may be perceptible at the given tested area.

Visual Fields
THRESHOLD
VF testing is a measure of the ability of the visual system to perceive targets against their background. The visibility
of a stimulus at a given location in the VF depends on a number of factors such as stimulus intensity, size, colour,
duration, etc. If a given stimulus is not visible, one of the factors (usually size or intensity) can be adjusted until it
becomes visible.
At the borderline between visibility and invisibility, the patient’s response will be uncertain or inconsistent, so a
borderline stimulus is sometimes seen and sometimes not. This borderline stimulus can be adjusted to change the
percentage of time that it is seen by the patient.
The frequency-of-seeing-curve (Fig. 5.16) is a plot of the stimulus visibility versus the percentage of times that it is
seen. The threshold is defined as the target that is perceived 50% of the times that it is presented at a given
discrete point.
Figure 5.16: Frequency-of-seeing curve
Hence the threshold is defined as the dimmest or smallest stimulus that a person can perceive 50 % of the times
that it is presented. Threshold is therefore inversely related to sensitivity: the lower the threshold, the higher
the sensitivity. The fovea at the top of the hill of vision would have the lowest threshold (highest sensitivity) and see
the dimmest & smallest stimuli.
KINETIC VS. STATIC
In a clinical setting, it is impractical (impossible!) to establish a frequency of seeing curve for each stimulus at every
point in space. Instead, one can reasonably approximate the threshold by using a static or a kinetic approach.
The static (not moving!) approach uses a “bracketing” strategy to determine the threshold of a fixed point. The
intensity or size of the stimulus is decreased or increased in a step-wise staircase fashion until it reaches a point
adequately close to threshold. Most commonly, a 4-2 dB algorithm is used. Suprathreshold stimuli are decreased in
4dB steps until they are no longer seen. The stimulus intensity is then increased in 2 dB steps until the stimulus is
seen again. The threshold estimate is recorded as the weakest stimulus seen or the average of the weakest seen
and the weakest not seen. When this is repeated at a number of locations in the visual field, the hill of vision can be
reasonably mapped out (Fig. 5.17).

Visual Fields
Figure 5.17: Determination of threshold using the static approach
The kinetic method involves the determination of isopters by moving a constant stimulus from non-seeing areas
to seeing areas (Fig. 5.18). The stimulus used to determine the isopter can roughly be taken as the threshold
stimulus along the edge of the isopter.
Figure 5.18: Determination of threshold using the kinetic approach
The static method is sensitive & more precise than the kinetic approach. However, static testing is very laborious in
manual VF testing and for this reason kinetic is the preferred approach. In automated perimetry, however, the kinetic
method is facilitated and preferred since it provides quantifiable and analyzable data.
SCREENING VS. THRESHOLD
VF can be globally assessed using either a thresholding or screening approach. Thresholding implies that the
threshold is determined as precisely as possible as described above for a number of points in space. Each threshold
value can then be mapped on a 2 or 3-dimensional graph to numerically represent the hill of vision. Obviously this
method is more precise but more time consuming especially in manual VF testing.
Screening simply involves the use of a single stimulus to test the VF. Usually a suprathreshold target that is several
dB higher than the expected hill of vision is used. The target can be presented either statically at a number of
locations or kinetically to determine if it becomes invisible at some points. Obviously this method is much more
efficient than static. However, it is less precise and small relative defect can easily be missed (Fig. 5.19), especially if
the interval between the suprathreshold stimulus and the hill of vision is large.

Visual Fields
Figure 5.19: Determination of threshold using the kinetic approach
VARIABLES IN VF TESTING
VF results will depend considerably on a number of factors that may be related to stimulus, response or clinical
variables. The clinician must understand the effect that each element may have on VF, consider them during the
procedure and bear them in mind during VF interpretation. Table 5.4 summarizes the variables involved in VF testing
that are discussed more extensively below.
Stimulus Factors Response Factors Clinical Factors

Luminance Patient psyche Target blur
Stimulus size Instructions/examiner’s personality Spectacle correction
Duration Response criterion Pupil size
Kinetic/Static target Reaction time Media clarity
Speed of kinetic target Fixation Physical Limitation
Colour Learning curve Age
Fluctuation
Psychogenic factors
Figure 5.4: Variables involved in VF testing

Visual Fields
STIMULUS FACTORS
Luminance
The target brightness will affect its visibility. Obviously the brighter the target the more visible it is.
The background luminance, which is the brightness of the surface onto which the stimulus is projected, affects the
sensitivity by setting the level of retinal adaptation. In the photopic range (>3 asb), the cones are active and the
sensitivity is maximal (island of vision is high). In scotopic (0-0.003 asb) and mesopic (0.003-3 asb) levels, the cone
activity is reduced and the central sensitivity will be depressed (hill of vision will appear flattened). The low photopic
range is preferred in most perimeters (~31.5 asb).
The contrast, which truly denotes the light difference of a stimulus from the background, will naturally affect the VF
measurement. According to Weber’s law, the “just noticeable difference” in stimulus intensity (stimulus minus
background) divided by the background intensity is constant over a wide range of photopic conditions.
Constant = stimulus – background

background
Therefore, the stimulus will remain equally visible even if the absolute intensities of the target and background are
changed, as long as the constant in the above formula is maintained. In VF testing, the background is kept constant
and the contrast is altered by increasing the stimulus intensity.
Stimulus Size
For a given stimulus intensity, a large stimulus is more easily seen than a small one due to spatial summation.
Size, however, can be compensated for by increasing the light intensity of a stimulus. The relationship is expressed
by the following mathematical expression:
luminous intensity X (area of stimulus) k = threshold for a given location
One can therefore increase the intensity of a small stimulus to make it as visible as a bigger but dimmer stimulus.
“k” is a constant that varies with retinal position, adaptation level, individual characteristics, etc. so the relationship
can only be approximated. Although variable if necessary, the standard stimulus size used in most modern VF
testers is the Goldmann size III target (0.43 = 4mm2).
DURATION
Because of temporal summation, a static stimulus presented for 20 msec. is more visible than one presented for
10 msec. After a critical duration, however, temporal summation is complete and a stimulus presented for a longer
period of time will not become more visible. The critical duration depends on a number of target factors such as size
and luminance. In general, however, the temporal summation phenomenon begins to decline after 60msec and is
completed by 100 msec. Therefore a stimulus presented for 500 msec. will not be more visible than if presented 150
msec.
Below the critical duration, Block’s Law states:
contrast X time of presentation = constant threshold

Visual Fields
This implies that you can maintain the same threshold for a dimmer stimulus if you increase the time of presentation.
In order to avoid, this variable in VF testing, the time of presentation is best if kept above the critical duration.
The latency for saccadic movements, however, is 180-250msec. If the time of presentation exceeds the latency
period, tested subjects may attempt to fixate the presented targets. Hence the ideal time of presentation falls
between the critical duration and the latency of saccadic eye movements. Automated VF testers will have
presentation times between 100-200msec. Manual VF systems, unfortunately, have a presentation time between
0.5-1.0sec which is greater than the saccadic eye movement latency.
Kinetic vs. Static Target
Static VF are established with the use of non-moving stimuli presented a varying intensities to bracket the threshold
value. Kinetic VF are established by moving the stimuli from non-seeing areas into seeing areas until they hit the hill
of vision and are perceived. A moving target is always more visible than a static stimulus. For a similar stimulus,
therefore, the sensitivity to the static stimulus will appear lower than to the kinetic one (Fig. 5.20).
Figure 5.20: Threshold difference between static and kinetic targets
Speed of kinetic target
In kinetic VF testing, the target’s speed may introduce variability and error in the obtained isopters. A target that is
moved faster will have moved in a much further distance than one moving slower during the reaction time period.
For instance, with a 1sec. response delay, a target moving at 15/sec will be noted 13 further than a target moving
at 2/sec. The speed effect is more critical in the central 30 area. A high speed target of 15/sec and a reaction time
of 1 sec may reduce a peripheral isopter from 75 to 60, but it will reduce a central isopter from 20 to 5!
In performing kinetic VF in clinical practice, the ideal rate of a moving target is 2-4/sec.
Colour
VF can be performed using coloured targets and backgrounds. Naturally VF will vary due to a number of factors
such as selective photoreceptor testing and adaptation levels. Colour VF are not clinically widespread because of
the inconsistent and variable results obtained with the use of non-standardized parameters (colours, filters, light
sources, etc.). They are also controversial with regards to the exact nature of the psychophysical end points, the
question being whether the point of achromatic perception (target awareness) or the true chromatic recognition
(colour awareness) is established.

Visual Fields
With the advent of standardized automated VF testers, however, colour perimetry is gaining popularity and can be
used clinically. Red stimulus VF testing is typically used to measure threshold in central 10 to check for drug
toxicity (e.g. chloroquine, ethambutol). Current research may render blue-yellow VF testing useful in the early
detection of glaucoma as well.
RESPONSE FACTORS
Patient’s psyche
The state of mind is crucial to the performance of any difficult task. This is particularly true for VF testing which is in
general a very difficult procedure to complete for any individual. Factors such as mental status, anxiety/stress,
level of attentiveness, cooperation as well as intelligence may all play an important role in the results of the VF
test. Whenever possible, these variables should be qualitatively assessed, noted and kept in mind during VF
analysis.
Instructions/examiner’s personality
The instructions given to the patient and the examiner’s personality are extremely influential in the patient’s
state of mind and performance. As in any physical, psychological or psychophysical task, the quality of instructions
will play a significant role in motivating the subject to perform well, be attentive and answer the test as accurately as
possible. Additionally, proper instruction and guidance serve to establish the patient’s expectations towards the
performance by clarifying what exactly is required in performing the test and what the possible outcomes may be.
Response criterion
The response criterion, which directly influences the appearance of VF, is uncertain to many patients. A patient
with a strict criterion will be unwilling to answer unless the target is seen for sure. In comparison, another individual
with a more relaxed criterion may respond to a vague stimulus that is only possibly seen. Once again, the
examiner’s instruction can help minimize, but not eliminate completely, discrepancies between response criterion.
Reaction time
Reaction time is more relevant to kinetic VF testing than to static methods. An increased response time will allow the
stimulus to travel a further distance before the patient signals its presence. Hence, an isopter for a given stimulus
may appear smaller.
Reaction time will depend on the retinal location and the patient’s physical and mental status. In general, the
reaction time is longer for stimuli that are presented more peripherally. However, reaction time is more critical in the
central 30 area where small time delays make a more significant difference on the VF results. A 1 sec delay on a
target that is moving at 15/sec will reduce a peripheral isopter from 75 to 60, but it will reduce a central isopter
from 20 to 5!
Although not clinically controllable, one must factor the reaction time in VF results especially in older individual
where response time is increased.
Fixation
Steady fixation is crucial to the production of accurate VF. Unstable fixation leads to increased variability and
inaccurate results while shifted fixation results in displaced isopters. Even in healthy subjects, drifts and micro eye
movements tend to increase during VF testing due to fatigue, stress and the tendency to fixate peripheral stimuli.
Fixation needs to be constantly monitored while performing VF testing.

Visual Fields
Learning curve
As with many psychophysical tests, a learning curve is observable in VF testing. VF can change and improve
dramatically during the first few times that the test is repeated. The learning effect is greatest between the first and
second time but learning may be observable at the third or fourth times as well especially with advanced automated
VF tests. Therefore, first VF fields, and perhaps second as well, should always be interpreted with caution.
Fluctuation
Short term fluctuation is the variability of the patients responses during a short lasting exam (minutes). The short
term fluctuation can make results vary by as much as +/- 3dB over a few moments in normal individuals. Short term
fluctuation increases mildly with age but it may increase dramatically in disease processes.
Long term fluctuation is the normal variability of the patients responses over several exams (days or years). Like
many physiological functions, sensitivities are not fixed over time and individuals can manifest different VF results
from one test time to another.
Psychogenic factors
Psychogenic factors such as hysteria and malingering may also result in unusual VF results. In fact, some VF results
may be pathognomonic of psychogenic conditions. The clinician should always bear in mind this possibility in the
analysis of VF results.
CLINICAL VARIABLES
Target blur
When a spot is blurred or defocused, it becomes dimmer due to its apparent decreased density and edge contrast. A
blur can therefore yield an apparently reduced sensitivity and hill of vision. For each diopter of defocus the sensitivity
decreases by approximately 1.5dB. Uncorrected refractive error will therefore adversely affect VF results. The effect
is greater in the central field and is minimal with larger targets. Central VF must therefore always be performed
with the patient fully corrected.
A non-uniform retinal topography that may exist in certain conditions (e.g. staphyloma, macular edema) can induce
areas of relative defocus and result in refractive scotomas.
Media clarity
Light scattering effects by disturbed ocular media can decrease target contrast with the background. Media
opacities can also reduce the amount of light reaching the retina. As a result, retinal sensitivity will appear reduced
and depressions (focal or generalized) may be noted on VF testing.
Spectacle correction
High spectacle corrections can result in variable VF results due to the prismatic effects produced by spectacle
lenses. High plus prescriptions used for aphakes or high hyperopes can produce a compressed VF where the blind
spot is closer to fixation and smaller (Fig. 5.21). Alternatively high myopic corrections will show expanded VF
where the blind spot is further out and bigger. Contact lenses are recommended to perform VF when high refractive
errors (> +/- 10.00D) are present.

Visual Fields
Figure 5.21: Prismatic effect of high prescription lenses on the visual field
Pupil size
The amount of light entering the eye is proportional to the area of the pupil. Miosis produces an increased threshold
by decreasing the amount of illumination reaching the retina and by changing the level of retinal dark adaptation.
Remember that in mesopic conditions the retinal sensitivity is reduced.
Miosis can also induce diffraction effects especially if the pupil diameter is less than 2.4 mm. Diffraction produces a
target blur at the retinal level that increases threshold.
A small pupil will therefore produce a generalized depression of the VF. Pupils that are less than 3mm should be
dilated before performing VF testing.
Alternatively, large pupils can induce VF changes by producing aberrations that adversely affect the light entering
the eye.
The pupil diameter, therefore, should always be documented when performing VF testing in order to keep track of
“abnormal” results that may result from pupil size.
Physical limitations
A number of physical factors can affect the VF result. Overhanging eyebrows, ptosis of upper lid and large noses are
the most common ones. Droopy lids may need to be taped up should they limit the VF significantly. Trial lens frames
and glasses can also limit the extent of visual fields. Trial lenses and glasses need to be placed as close as possible
to the eye during central VF testing and need to be removed for peripheral evaluations. In cases of large (+/-10.00D)
refractive errors, contact lenses can be used to test the peripheral VF.
Age
Aging has dramatic effects on the VF. The overall hill of vision decreases with age at a rate of ~ 0.5 dB per decade,
as if the hill of vision is sinking in the sea of blindness. The reduction is due to nerve fiber loss normally associated
with aging. Other associated aging changes such as the mental health (delayed reaction time, reduced attention
span, increased variability, fatigue, etc.), the general status (physical fatigue, diseases, instability, etc.) and ocular
conditions (miosis, ptosis, media opacities) all contribute to adversely affect VF measurements.

CAMPIMETRY
AUTHOR
PEER REVIEWERS
INTRODUCTION
 Confrontation fields (CF)

 Amsler grids
 Tangent screen
 Other campimetric devices

Visual Fields
CAMPIMETRY
Campimetry involves testing the VF by presenting stimuli on a flat surface. The actual VF is somewhat deformed
from the transposition of the sensitivities of a spherical retinal surface onto a flat surface. With more eccentric
presentation (further from fixation) the test distance of a given stimulus increases while its angular size decreases.
For central VF testing, this effect is clinically acceptable. For more peripheral testing, however, circular surfaces are
necessary.
A number of methods are available to perform campimetry. Some methods are quite useful clinically especially in
circumstances where expensive modern equipment is not available. However, with the advent of the more precise
bowl perimetry, campimetry generally assumes a more secondary role in VF testing.
Methods of Campimetry
Confrontation Fields
Amsler Grids
Tangent Screen
Others
Autoplot
Harrington-Flock screener
Friedman
Automated Devices
Henson
Tubinger
CONFRONTATION FIELDS (CF)
CF testing is the simplest form of campimetry, the flat surface being an imaginary area midway between the
examiner and the patient. CF fields, with which you should already be familiar, are used routinely on every patient as
a screening VF test. CF testing is a relatively crude purely qualitative method that is suitable only to identify gross VF
defects. CF can also be useful to confirm other VF results that do not seem to correlate with clinical observations or
to test patients that are unable to perform sophisticated VF testing.
The CF test is simple, inexpensive and sufficiently reliable when performed thoroughly and adequately. A full CF
includes facial Amsler, central & peripheral finger counting, simultaneous finger counting, hand comparison as well
as colour comparison across meridians if necessary.
AMSLER GRIDS
The Amsler grids kit is a set of 7 charts (10 X 10 cm) used to detect small abnormalities (~1) in the central VF that
could remain undetected by the usual methods of VF testing. At the appropriate testing distance, the charts are
specifically designed to assess a central 20 field. Anatomically, this correlates with the area just inside the temporal
vascular arcades but excluding the optic nerve.

Visual Fields
Each chart has a different pattern and is recommended for different purposes. In general, however, the charts serve
to detect small central scotoma or metamorphopsia. Metamorphopsia is an anomaly of visual perception in which
objects appear distorted, larger (macropsia) or smaller (micropsia). This is generally due to pathological changes in
the fundus that result in a displacement of photoreceptors. Metamorphopsia may, however, also have a central
origin (e.g. migraine).
Figure 5.22: Amsler grid in relation to the visual field and represented over the retina
Instrumentation
Note: The following section is a review of the Amsler Grid section of the Clinical Optometric Procedures 1 chapter
Visual Fields.
Chart #1
The first Amsler chart is the standard grid which is the most familiar and widely used. It
is a 20X20 white square grid on a black background with a white central fixation dot.
Each square (5mm) corresponds to 1 of VF at the standard testing distance of 30cm.
The chart is used to reveal distortion, relative and absolute scotomas.
Chart #2
The second chart is similar to the first except that 2 diagonal lines intersect at the center
of the grid. These are used for patient with a central scotoma that cannot fixate the
central dot. The lines will orient the patient’s fixation by allowing fixation approximately
where the lines would cross.
Chart #3
The third chart is similar to the first but the squares are red instead of white. The chart is
particularly useful for patients with suspected central or cecocentral scotomas that are
commonly due to toxic (e.g. alcohol, chloroquine, etc.) or nutritional amblyopia. It may
also used as a deceptive test to detect malingering (faking, false vision loss) when used
with red-green lenses. In normal condition, the red grid will disappear when viewed
through a green lens but will remain when viewed through a red lens. Malingerers will
claim that the lines are invisible in both the red and green filters.

Visual Fields
Chart #4
The fourth chart is composed of small white dots (no lines) on a black background. The
chart is indicated for patients with one or more paracentral scotoma making it easier to
delineate the affected areas.
Chart #5
The fifth chart consists of 20 white horizontal lines evenly spaced by 5mm on a black
background. The chart may be rotated for evaluation in any meridian to facilitate the
identification of “oriented” metamorphopsia which primarily affects lines going in one
direction.
Chart #6
The sixth chart is similar to the 5th except that it is made of black lines on a white
background. It also contains 2 additional lines in the 1 region above and below the
fixation dot. This chart is meant to facilitate the observation of metamorphopsia along
the reading level.
Chart #7
The last chart is similar to chart # 1 but the inner 6 X 8 which corresponds
anatomically to the macular area includes smaller 0.5 white squares instead of 1. The
smaller grid is intended to facilitate the detection of subtle visual disturbances in the
macular area.
Clinical Procedure
The Amsler grids are performed under uniform bright illumination (F+) at a testing distance of 30 cm. The patient
must be undilated with the best near Rx in place. The test is performed preferably before any contact or fundus
observation procedure to insure that the result is unaffected by previous tests. Amsler grids are always tested
monocularly with the better eye tested first to facilitate the patient’s understanding and observations. Fixation must
constantly be monitored. The test is performed asking the following 5 questions of the patient:
1. Can you see the central white dot?
This question rules out relative or absolute central scotomas. If no central dot is visible then an absolute scotoma is
present and chart #2 should be used. If the central dot appears faint or blurry, a relative scotoma may be present.

Visual Fields
2. Continue looking at the central white dot. Can you see all 4 sides & corners of the large square?
This rules out arcuate, altitudinal, quadrantic, hemianopic or field constriction defects. If the answer is “no”, the
patient is asked to document the defect. Chart #3 may be used to facilitate the observation of a suspected
cecocentral scotoma.
3. Continue looking at the central white dot. Are any of the small squares blurry or missing on any part of
the grid?
This step rules out relative or absolute paracentral, cecocentral, or altitudinal scotomas. If the answer is “yes” first
rule out bad refractive correction or media opacities. If squares are definitely missing or blurry then an absolute or
relative scotoma may exist and the patient is asked to document the defect. To make defect clearer chart #4 may be
presented.
4. Continue looking at the central white dot. Do any of the horizontal or vertical lines that make up the
square appear wavy or bent?
Metamorphopsia is addressed here. If the answer is “yes”, first rule out artifacts resulting from multifocal lenses.
Then ask the patient to document the defect. Waviness can range from minimum to severe with some of the lines
being discontinuous or broken.
Macropsia, which results from increased photoreceptors density, will make a square appear rounded like a barrel.
Micropsia, the opposite, will make the square appear like a pincushion.
5. Continue looking at the central white dot. Is any part of the grid shimmering, flickering, or coloured?
This helps rule out scintillating scotomas which are commonly associated to migraines but which can also result from
retinal causes (e.g. serous detachment) or visual pathway lesions (e.g. AV malformation).
Modified Procedures
Threshold Amsler grids: A modified testing procedure can help increase the sensitivity of Amsler grids to detect
very shallow (subtle) VF defects. Two cross-polarized filters are placed in front of the eyes and rotated with respect
to each other to reduce the contrast of the grid against the black background until it is barely discernible. This sets
up a threshold situation that facilitates the recognition of VF alterations. Relative scotomas are easier to detect and
absolute scotomas easier to observe. The procedure is the same as described above.
Modified Amsler grids: Several modified Amsler charts are available on the market. Despite some additional
features that may present some advantages, their principle remains similar to the conventional Amsler grids.
The Yanuzzi card (Fig. 5.23) is a minified version of Amsler chart # 7 the size of a credit card (16 X 10). The
advantage of the Yanuzzi card lies in its ease of portability.

Visual Fields
Figure 5.23: Yanuzzi card
The Transilluminated grid is similar to the standard Amsler grid except that it is constructed by punching 1mm
holes (5mm apart) in a steel card to form the grid pattern. The transilluminated chart is advantageous in patients with
media opacities that cannot view the standard chart.
The Diamond chart (Fig. 5.24) is similar to Amsler chart #5 except that it has black lines on a white background.
The advantage of the Diamond chart lies in that it contains a 5mm central red fixation dot and a red diamond 10cm
to one side of the dot that allows for proper distance control. When held at the proper working distance (40cm for
Diamond grid), the diamond falls into the blind spot and disappears. The diamond also ensures monocular viewing:
should the test accidentally be performed binocularly, the diamond will not disappear.
Figure 5.24: Diamond card

Visual Fields
Additional information
Amsler grids are frequently dispensed for patients to perform self-monitoring at home. These are useful to monitor
progressive, recurrent, active or inactive diseases that affect the central area and threaten vision. Amsler grids
are particularly useful for age-related macular degeneration which affects a significant segment of the older
population.
The self-assessment Amsler grids are prescribed for the interval between eye examination. Depending on the
severity of the condition, the frequency of self-testing can range from once a day to once a week. The self-
monitoring Amsler grid should be placed in an area where patients will be reminded to perform the procedure (e.g.
on the refrigerator, toilet mirror etc.) The instructions described above are given both verbally and in writing and the
patient is advised to call the office and return for consultation immediately should any visual change be noticed.
Recording
If scotomas are noted, the patient is asked to describe, show and draw the location & delimitation on the chart (Fig.
5.25 a to e). Patient’s remarks about the appearance and depth of the scotoma are added. Comments about the
result’s reliability based on the patient’s characteristics and expressions are noted as well. The grid is identified,
dated and appended to the patient’s record.
Figure 5.25a-e: Documentation of various scotomas detected by the Amsler grid test

Visual Fields
TANGENT SCREEN
The tangent screen (TS) VF requires very simple and inexpensive instrumentation. It basically consists of a black
cloth hanging on the wall and a rod with variable targets on one of its extremity (Fig. 5.26). The TS is used to test the
central 30 area at a 1m distance. When performed properly & carefully, the TS is useful to detect & map some VF
defects but it is far from being precise & sensitive. With the current and more advanced methods, the TS is rarely
used.
Figure 5.26: Testing the visual field using the Tangent Screen
Inspired by Anderson, Testing the Field of Vision, C.V. Mosby Company, 1982.
The TS remains useful, with feeble, neurologically impaired or low vision patients that are incapable of taking more
sophisticated VF tests. The TS is the method of choice to help detect tubular fields that are pathognomonic of
malingering (hysterical patients). Unlike true VF loss, tubular VF are constricted and circular and will remain the
same size at any test distance.

Visual Fields
Instrumentation
The TS can be obtained commercially or simply fabricated. It consists of a single black cloth (2 X 2m) usually made
of felt material to absorb light. A white fixation target (button) is sown in the center. Concentric circles subtending 5
or 10, meridians at 15 or 30 intervals and the expected blind spot are also delineated using black thread.
Additional diagonal white lines may be added to orient fixation in patients with central scotoma. The test targets are
white spherical beads or flat discs (1, 2, 3, 5, 10mm) mounted on a ½ to 1 meter black non-reflecting rod. Black pins
are used to temporarily record the findings on the screen during the procedure before transferring them to a paper
chart.
Figure 5.27: Dimensions of the tangent screen plot

Visual Fields
Clinical Procedures
Examination Set-up
The TS can be done at any distance using a variety of stimulus sizes (0.25mm-75mm). The test is usually performed
at 1m to test the central 30 using stimuli of 1, 2, 3, 5, & 10mm. A 2m test distance is also used regularly to test the
central 15 or to magnify defects in order to study them more accurately. The TS is performed at both distances to
detect tubular fields. Good even illumination of the screen is very important: 1 spot light (150W bulb) above and
slightly behind the patient’s head is recommended. The examiner should be positioned side-ways so as to constantly
face the patient to monitor fixation and still be able to see the screen. Long enough rods should be used to allow the
examiner to stand clear from the screen. A black glove may be used so that the hand motion does not influence the
patient’s response.
Patient preparation
 Occlude non-tested eye with a patch

 OD or better eye is tested first
 Always use best Rx
 For astigmatic corrections < 1.00DC the equivalent sphere is sufficient
 Include the proper add for the test distance
 Seat patient comfortably with the tested eye at the same level as the fixation dot
 Instruct patient clearly to always maintain fixation on the white central dot of the screen
 Show & explain that targets will purposefully appear and disappear during test
 Instruct the patient to signal when the target appears (or disappears).
Testing Protocol
 Plot blind spot first

 This demonstrates the test & confirms the patient’s ability to take the test
 Use a 5mm target first to insure good fixation & understanding
 Adjust size if necessary according to patient’s VA, mental status & cooperation
 Start where the target disappears in the blind spot (~ 15 temporal & 1.5 below fixation)
 Move out (non-seeing to seeing) in the 8 cardinal directions to map the blindspot borders
 Retest the blind spot with smaller target (1mm)
 Place a pin at each point where the target becomes visible.
 Plot central isopter

 The standard target is usually 1mm; check its visibility in 4 quadrants
 If 1 mm spot is subthreshold, choose the smallest target visible at 30
 Slide the target inward (non-seeing to seeing) on the cardinal meridians.
 Maintain the constant recommended speed of 2-4/sec
 The 1mm isopter should almost reach the extreme limits of the screen.
 Place a pin at each point where the target becomes visible
 Avoid scanning exactly on the vertical & horizontal meridians
 Scan 5 to either side to help detect defects that respect the meridians

Visual Fields
 Perform the Bjerrum plot

 Static spot check the central area
 Areas of interest are the central 20 + the nasal 20-30
 Without moving the target, flip the spot from its black side to its white side
 Usually 76 central points are tested: 4 points within the 5 radius + 72 points where the 5-10-15 circles cross
the 24 meridians at each 15 (Fig. 5.28a)
 Additional points (~10-20) may be tested at the 20-30 nasal area to look for the nasal step
 Alternatively (less desirable but more efficient), test the central 20 radius in a kinetic zigzag presentation
(Fig. 5.28b)
 Mark any VF defects with black-headed head pin
 Like mapping the blind spot, assess defect from non-seeing to seeing (Fig. 5.28c)
 Use various targets to map the extent, slope & depth of any VF defect
 Consider increasing the distance to 2m to evaluate the scotoma with greater precision.
Figure 5.28: Tangent screen a)76 central points of the Bjerrum plot, b) testing the central 20  radius in a kinetic fashion, c)
documenting scotomas and testing from non-seeing to seeing
Tips
 During the procedure, constantly check the patient for fatigue & attention. Randomly present the spot inside the
blind spot or flip it on its black side in areas of visibility
 If physical restrictions are present, adjust the head to compensate for it. For example, if a bifocal line interferes
with the test, lower the head to allow viewing above the line.
Recording
Transfer your findings to the paper recording chart. Note test performed, stimulus size/test distance in mm and
target colour (e.g. 1/1000 W). Add any comments on fixation, patient cooperation & reliability of the test. Different
labels or colour pens may be used to identify the different isopters more easily (Fig. 5.29).

Visual Fields
E.g.: Note how isopters traced on the tangent screen appear smaller with the use of smaller less visible targets. The
right eye shows a general constriction.
Figure 5.29: Example of isopters documented on a tangent screen plot
E.g.: Note how scotomas detected with the tangent screen VF appear larger with the use of smaller less visible
targets.
Figure 5.30: Example of scotomas documented on a tangent screen plot

Visual Fields
OTHER CAMPIMETRIC DEVICES
Other types of campimeters are available. Like other forms of campimetry they are rarely used and may in fact not
be commercially available anymore. These methods are briefly mentioned for sake of completion.
The Autoplot (B&L) is conceptually similar to the tangent screen. The target, however, is a variable light spot that is
projected onto a flat screen 1 meter away. The examiner uses a sliding arm to control the projection. The arm
contains a pencil holder that moves over a chart where a VF schema is drawn. The procedure is followed exactly as
it would be using the tangent screen.
The Harrington-Flock screener (Fig. 5.31) consists of a “black light” (or UV lamp) that illuminates stimuli which are
painted with fluorescent ink on 8 large cards (total of 33 stimuli). Under white light the stimuli are invisible, but when
flashed with the UV lamp, they become momentarily visible. The test consists basically in spot checking statically the
central area (25) using different presentation cards. The patient is asked to identify the number of spots seen.
Wrong answers would signal the presence of a VF defect which would require further investigation. The Harrington-
Flock screener is exactly as the name suggests a screening test useful for gross VF evaluation. Since it uses stimuli
that are all suprathreshold, the test is not sensitive to small shallow defects. The test is rarely used today, but it
introduced the innovative method of simultaneous presentation to test multiple areas.
Figure 5.31: Harrington-flock screener
Inspired by Harrington DO, The Visual Field, C.V. Mosby Company 1990.
The Freedman VF analyzer (Fig. 5.32) also uses a multiple-stimulus presentation. The test consists basically of a
flash-tube covered with a face-plate. The plate holds a total of 98 holes and allows 2,3 or 4 holes to open at a time
for stimulus presentation. The Freedman offers a few advantages over the Harrington-Flock method. The stimuli are
smaller and more numerous allowing for a more sensitive and extensive screening. The test also allows a rough
foveal threshold estimate to allow the testing stimuli to be close to the actual threshold (0.2LU brighter). Finally, the
instrument contains a self-contained source of background illumination which renders testing conditions a little more
consistent. The Freedman VF is not used clinically anymore.

Visual Fields
Figure 5.32: The Freedman VF analyzer. Inspired by Anderson, Testing the Field of Vision, C.V. Mosby Company, 1982.
AUTOMATED CAMPIMETRY
A number of automated campimeters are available commercially. Some are screening devices that present multiple
static patterns to detect central VF anomalies. Although still used in situations where no other more sophisticated (&
expensive!) apparatus is available, these instruments present significant disadvantages. Generally not
recommended for clinical use anymore, they have for all practical purposes become obsolete.
Some recent devices however (e.g. Henson (Fig. 5.33), Tubinger), actually perform very usable screening and
threshold testing of central points. The data interpretation of these devices is very similar to automated perimetry
and will be covered under that section. Suffice it to say that some recent automated campimeter may prove useful in
certain clinical situations. Automated campimetry is commendable, but with the more sophisticated automated bowl
perimeters it remains a less than ideal choice in VF testing.

Visual Fields
Figure 5.33: Henson Automated Campimeter

PERIMETRY
AUTHOR
PEER REVIEWERS
INTRODUCTION
 The visual field – an introduction

 Introduction
 Instrumentation
 Examining set-up
 Recording: printout and data analysis
 Graphic representation
 Threshold tests
 Statpac analysis
o Single test analysis
o Summary of global indices graphic representation
o The glaucoma hemifield test
o Change analysis
o Overview
o Statpac II (update software of Statpac I)
Visual Fields
AUTOMATED PERIMETRY
INTRODUCTION
Automated perimetry is now the standard procedure for visual field testing. Automated perimetry moves visual field
testing from the previous manual and relatively imprecise procedures relying heavily on operator technique, to quick,
accurate and computerized exam that yield standardized and reproducible results. Automation offers a significant
number of advantages over manual perimetry (Table 5.6). Although some disadvantages are also created, the
benefits of automated perimetry far outweigh the drawbacks. The automated perimeter should be considered as
essential to primary eye care practice.
Ease of use Initial cost
Easy data collection Time consuming
Sensitivity Difficult testing procedure
Accuracy Complex interpretation
Reproducibility of standard testing set-up
Quantifiable results
Statistical analysis
Flexibility
Data storage (computer)
Table 5.6: Comparison of advantages and disadvantages of automated perimetry
A number of automated perimeters are available on the market. All offer their own special features that may appear
appealing to different practitioners and the automated visual field chosen is ultimately a matter of personal
preference. The components that are common but variable between the different automated visual field testers are
listed below (Table 5.7). Although the variability presents an important advantage in automated perimetry, it also
presents the disadvantage of not permitting the direct comparison of results obtained with different systems. For
example, a decibel on one machine does not equal a decibel on another (see table 5.3 on page 13).
Visual Fields
Targets Fixation Monitors

Size Telescopic device (manual)
Colour Video camera and TV monitor
Position/intervals Heijl-Krakau technique
Brightness range Eye movement tracking devices
Type (projected or Light Emitting Diodes)
Presentation time Computers
Built-in or peripheral
Backgrounds Software
Standard brightness Data storage
Range of brightness Data manipulation
Colour Statistical analysis
Database
Testing strategies
Static Printouts
Kinetic Graytones
Screening Numeric
Threshold Depth defect
Patterns Overviews
Limits Profiles
3-D maps
Head Position Monitors Statistical data
Head Tracking
Vertex monitor
Table 5.7: Components of various automated visual field testers
Probably the most commonly used automated perimeter, one which many consider the standard of care, is the
Humphrey Visual Field Analyzer (HVF) (Fig. 5.34). The interpretation of automated perimetry will be covered
extensively using the HVF principles, characteristics and terminology as a basis. Most other visual field testers use
features and methods that are very similar to those of the HVF. A solid understanding of the HVF should provide,
with a few adjustments, the necessary background to understand most automated perimeters available
commercially.
Visual Fields
INSTRUMENTATION
Figure 5.34: Humphrey visual field analyzer
EXAMINING SET-UP
HVF should be performed in a quiet dark room where the only the perimeter’s illumination is perceptible. The HVF
takes several minutes to auto-calibrate each time it is turned on. Once ready the patient information, test parameters
and test protocol must be adequately entered. Correctly setting up the instrument is crucial to run a proper
automated visual field. The set-up must be verified each time to insure that what is performed is exactly what is
desired.
1. Patient Information
The patient information is important both for information retrieval and for data analysis. Incorrect entry may result in
misinterpretation of the final visual field result. The information to enter is: patient name, date of birth, Rx used, VA
and pupil size. Particular care must be taken to enter the date of birth correctly since the statistical analysis involved
in automated perimetry is based on patient’s age. The pupil size is important to insure that future tests are performed
under similar pupillary conditions or to account for any variation in the results that may be due to differences in pupil
size from one exam to the other.
Visual Fields
2. Test Parameters
The test parameters on automated visual field afford a wide flexibility.
The stimulus size is usually fixed to the standard Goldmann size III (0.43), but it can be adjusted to match the
Goldmann visual field stimuli (I to V). Unlike the Goldmann visual field, in automated perimetry the size of the
stimulus is kept constant and intensity is varied to obtain stimuli of different visibility. The stimulus is usually white,
but coloured spot can also be presented and changed to red or blue to allow colour perimetry. The stimulus
presentation time is fixed at 200 msec. Unlike other parameters, the presentation time is fixed and cannot be altered.
The 200 msec. fulfills the criteria of being beyond the critical period but below the latency of voluntary eye
movements.
The background intensity and colour can also be varied but a white background of intensity 31.5 apostilb is usually
the standard setting for the HVF.
The fixation target is usually a central illuminated fixed spot. The HVF also includes two fixation diamonds of
different sizes located just below the central target. The diamonds can be used for patients with low VA or central
scotoma, fixation being set on the apparent center of the diamond. The diamond is also used to establish the foveal
threshold.
Fixation monitoring can be done in several ways. The manual method may still be used in some instruments with the
use of telescopes or closed circuit TV monitors, but it is rather cumbersome, requiring that the examiner subjectively
and constantly supervise fixation. Contrast sensor devices that are sensitive to eye (pupil) movements may also be
used. Using these methods, the computer can be programmed to disregard the tested point when an eye movement
is registered. This approach is precise, but very costly.
In automated perimetry, the Heijl-Krakau method is usually used. A test spot is occasionally projected in the blind
spot and the number of times that the patient responds to this test spot indicates the number of fixation losses. The
Heijl-Krakau method is practically the standard approach used in automated perimeters. HVF also uses a gaze
monitoring system to record the position of the eye during stimulus presentations. The results are graphed as shown
below.
Upward markings indicate that the eye deviated from fixation at the time of stimulus presentation; the higher the line,
the higher the deviation. Downward marks indicate that the gaze system could not locate the patient’s gaze (small
marks) or that the patient blinked (large marks). The clinical usefulness of this system is questionable.
Visual Fields
Head Position Monitoring may be performed with the Head Tracking and Vertex Monitor options. Head Tracking
helps maintain proper patient alignment during the testing by keeping the patient’s eye centered behind the trial lens.
During the test, the Head tracking device monitors the eye position relative to the fixation light and makes small
increment adjustments (0.3mm) to position the head rest back to its initial position. The Vertex Monitor controls the
patients distance from the trial lens. If the head moves 7mm or more away from the trial lens, the HVF beeps and
displays a message to that effect. The test continues but the examiner can halt the testing and reposition the patient.
Grid resolution refers to the spacing of the tested points on an automated perimeter. The resolution on the most
common HVF central tests (e.g. 24-2, 30-2) is 6 degrees and on common peripheral tests (30/60-1, 30/60-2) it is 12
degrees. However, merging functions which combines different test into a single printout can provide a higher
resolution impression. For example merging a 24-1 with a 24-2 creates grid density of 4.2 degrees. Custom patterns
can further reduce the grid resolution to as close as 1 degree. Other VF instruments may use different grid
resolutions or allow for it to be varied as needed.
The test speed can also be varied to allow a slower stimulus presentation for patients that may need it. The standard
setting is “fast” and rarely does it need to be changed. However, some visual field programs, like the HVF SITA,
adjust test speed according to patient normative data (faster for younger patients) and individual responses (faster
patient responses speed up the test and vice versa). The strategy reduces overall test time and fatigue with able
patients but also slows down the pace when patient performance or response time is reduced.
3. Test Protocol
A wide variety of protocols is permitted by automated perimetry (Table 5.8 and 5.9). Each method has its own
advantages and clinical applications that may be worth considering in some circumstances. The choice of protocol
will depend on the patient, the clinical condition under investigation and the examiner’s preference. The number of
truly useful clinical patterns and strategies can really be narrowed down to just a few. One must aim to constantly
use the same testing protocol (at least for a given patient) to allow comparisons upon retest.One must bear in mind,
however, be it for particular clinical situation or research purposes, that a gamut of potentially useful testing
possibilities is available with automated perimetry.
Pattern
Central, peripheral, full field and a number of custom and specialty tests can be performed with automated
perimetry. Ideally a comprehensive full field threshold test would be performed every time on every patient.
However, full field testing requires a substantial amount of time and effort that makes it a practically impossible test
to administer to anyone! Therefore visual field testing is usually limited to either the central or peripheral areas of the
visual field.
Visual Fields
Most visual field anomalies occur in the central 30 degrees of the visual field. Peripheral testing is therefore less
valuable clinically except when indicated in specific clinical cases (e.g. patients with a stroke). The central 30
degrees is the most clinically useful area to test and is still considered the standard test area. However many
clinicians opt for the central 24 degree pattern which provides almost the same clinical information but saves a
significant amount of testing time. Given the same testing strategy for example, the 24-2 tests 22 fewer points than
the 30-2 (75 test points) and should be at least 22/75 faster; practically it is about 40 percent faster. An automated
threshold visual field test is difficult to undertake for many patients including young healthy subjects. Increased
testing time will make the test strenuous and reduce reliability. Any amount of time saved will therefore be of benefit
to both patient and clinician. Furthermore, reducing the tested area from 30 to 24 may reduce anatomical artifacts
(e.g. lid interaction) that often affect the edges of the tested area.
Custom and specialty tests such as the Armaly, Nasal Step, Macula, Superior, Neurological and Easterman patterns
are also available. Except for the Easterman, these patterns concentrate on particular areas that may be more likely
involved in certain conditions. The Armaly and Nasal Step patterns are aimed to test areas commonly affected in
glaucoma. The Macula pattern is aimed at increasing the test resolution for macular defects. The Superior pattern
tests for superior hemifield defects. Neurological patterns concentrate on the horizontal and vertical meridians which
are most diagnostic for neurological diseases. The Easterman pattern, listed as a disability screening test,
incorporates a single intensity stimulus to test the field monocularly (100 points) or binocularly (120 points); the result
yield functional disability in a straight percentage score (%).
Notwithstanding the above, the central 24-2 pattern (or 30-2) provides the most widely used approach even for
specialty testing since it can quite reliably investigate the same areas and in most cases uncover the same
abnormalities. Note that the “-2” notation (24-2 vs. 24-1) simply denotes that the visual field is tested on each side of
the horizontal and vertical meridians rather than directly on the meridians. Testing on each side allows easier
identification of defects that respect the meridians, such as nasal steps or hemianopias.
The foveal threshold can also be tested during a visual field test to provide additional information about the central
sensitivity. Since it is not standard procedure, the foveal threshold option must be chosen each time a visual field is
performed. The threshold is established at the beginning of the test while the patient fixates the center of the fixation
diamond.
Visual Fields
Average
Visual
# of Last
Test Pattern Field Application Strategy Printout
Points Time
Tested
(min.)
Central 30 tests All screening tests All screening tests

Central 40 point 30 40 2-4 Gen. are possible in: can be printed in:
Central 64 point 30 64 3-5 Gen., G, N
Central 76 point 30 76 3-5 Gen., G, N Threshold related Threshold related
Central 80 point 30 80 3-5 Gen., G, N Three- zones Three- zones
Quantify defect Quantify defect
S Peripheral tests Single Intensity Single Intensity

Peripheral 68 point 30to 68 5-6 Gen., G, N, R
C 60
Full field 81 point 55 81 6-7 Gen., G, N, R
R
Full field 120 point 55 120 6-8 Gen., G, N, R
E Full field 135 point 87 T 135 Gen., G, N, R
E Full field 246 point 55 246 14-15 Gen., G, N, R
N
Specialty tests
I Armaly central 30 84 5-6 G
Armaly full field 50 98 7-8 G
N
Nasal step 50 14 2-3 G
G Easterman Monocular 75T/60 100 Functional
N Disability
Easterman Binocular 150 Bi- 120 Functional
T Disability
Superior 36 60 S 36 Superior Field
Defect
Superior 64 60 S 64 Superior Field
Defect
Custom tests
Any pattern: alone, in arc
or profile as individual
points, clusters or grid
positioned using x-y
coordinates to a possible
grid resolution of 1.
Figure 5.8: Screening protocols permitted in automated perimetry

Visual Fields
Visual Average
# of
Test Pattern Field Last Application Strategy Printout
Points
Tested Time
Central 30 tests

Central 24-1* 24 56 10-12 Gen., G Num, DD, GS, P
Central 24-2 24 54 10-12 Gen., G, N Num, DD, GS, P
Central 30-1* 30 71 12-15 Gen., G, N, R All threshold tests Num, DD, GS, P
Central 30-2 30 76 12-15 Gen., G, N, R are possible in: Num, DD, GS, P
Peripheral tests FastPac

Peripheral 30/60-1* 30to 60 63 12-15 G, R Full threshold (FT) Num, DD, GS
Peripheral 30/60-2* 30to 60 68 12-15 G, R Fast threshold Num, DD, GS
Peripheral 60-4 30to 60 FT from prior data Num, DD
Nasal Step 50 14 2-3 G Num, DD
Temporal crescent* 75 37 3-4 N, R, advanced G except custom
tests
only Full threshold
Specialty tests
Neurological 20 20 16 5-6 N SITA only with Num, DD
Neurological 50 50 22 8-9 N 30-2, 24-2, 10-2, Num, DD
60-4
Central 10-2 10 68 10-12 Macular, N, Num, DD, GS
advanced G
Macula 4 16 8-10 Macular, advanced Num, DD
G
Custom tests
Any pattern: alone, in
arc or profile as
individual points,
clusters or grid
positioned using x-y
coordinates to a
possible grid
resolution of 1.
Table 5.8: Threshold protocols permitted in automated perimetry
Gen = general G = glaucoma N = neuro R = retina Num = numeric DD = defect depth GS = gray scale P = profile
* Not available in all systems
Visual Fields
Screening Tests Pattern (adapted from the HVF analyser primer book)
Central Tests Peripheral Tests Specialty Tests
Central 40-points Peripheral 68-points (30-60) Armaly central Easterman Monocular
Central 76-points Full Field 81-points Armaly full-field Easterman Binocular
Central 80-points Full Field 120-points Nasal Step Superior 36
Central 166-points Full Field 246-points Superior 64

Custom

Visual Fields
Threshold Tests Pattern (adapted from the HVF analyser primer book)
Central Tests Peripheral Tests Specialty Tests
Central 24-1 Peripheral 30/60-1
Neurological 20 Neurological 50
Central 24-2 Peripheral 30/60-2Nasal Step
Central 30-1 Nasal Step Central 10 Macula
Central 30-2 Temporal Crescent

Custom

Visual Fields
4. Strategy
Screening vs. Threshold
Screening visual field generally involves the use of suprathreshold stimuli to qualitatively survey the visual field (Fig.
5.35). Traditional screening tests generally use a predetermined single intensity stimulus to investigate the whole
visual field. This method is the simplest and quickest, but obviously yields only absolute or very deep defects. With
the methods available today, it should probably be avoided clinically.
Figure 5.35: Screening visual field
Screening tests that are age-related or threshold-related are more reliable than single intensity suprathreshold
screening tests, since they usually use stimuli that are 6 dB brighter than the expected values for the patient (Fig.
5.36). Age-related strategies establish the testing stimuli from the expected (or mean) hill of vision for a given age
group.
Figure 5.36: Static screening test

Visual Fields
Age Theoretical central reference level (dB)

<40 36
40-45 35
46-50 34
51-55 33
56-60 32
61-75 32
Table 5.8: Theoretical central reference level in relation with age of the patient in threshold-related screening
Threshold-related strategies establish the testing level from the patient’s actual threshold at a given reference point.
The HVF uses a threshold-related screening approach. The expected visual field is estimated from 4 primary seeds
points located at x=9, y=9 in each quadrant. The threshold value of the 4 primary seed points is determined at the
beginning of the visual field test. The second most sensitive point value is then used to calculate the expected height
of the hill of vision used as a reference level for the subsequent screening test (Fig. 5.37).
The threshold-related method is a little more precise since it corrects for individual variations (e.g. cataracts, pupil
size…) which are “pooled” and averaged in an age-matched visual field. However, visual field defects that are small
and shallow (< 6dB) may still go unnoticed in either of these approaches.
Figure 5.37: Determining the expected height of the hill of vision in static screening test (threshold-related)
The HVF offers 3 different threshold-related screening strategies:
(i) The threshold-related screening is a standard screening test that records tested points as seen or not
seen. The screening is done at 6dB brighter than the expected threshold, and points missed twice at that
level are recorded as defects.
(ii) The three-zone screening test records tested points as seen, relative defects or absolute defects.
Screening is done at 6dB brighter than the expected threshold. Points missed twice are retested at 10 000
apostilb; if seen they are noted as relative defect, if missed again, they recorded as absolute defect.
(iii) The quantify defect screening test provides more precise information. Screening is done at 6 dB
brighter than the expected threshold. Points missed twice are threshold tested and the depth value of the
defect relative to the expected threshold is noted.

Visual Fields
The main advantage of screening visual field tests is speed, since in most cases very little time (2-5 minutes) is
required to perform the tests. They may prove useful in cases where patients are unable to take threshold tests.
They may also have clinical value in cases where the expected visual field defects are deep and gross qualification
is sufficient.
Whenever possible, however, clinical use of screening visual field should be avoided. The tests are unreliable and
somewhat dangerous since shallow and small visual field defects can be missed. They also present the additional
disadvantage in that criteria for abnormal screening tests are necessary for their adequate interpretation. These can
be rather cumbersome or difficult to observe and still not full proof. An example of an established criteria (Comer et
al.;1988) for failing a (HVF central 30, 76 point) screening visual field is:
 2 or more adjacent points missed and repeated misses on retest

 2 or more misses within the central 20 of fixation and repeated misses on retest
 a central reference level of 26 dB or less on threshold phase.
In addition, screening test results do not provide sufficient quantifiable data to be statistically analyzed or compared
to normal visual field results. Statistical analysis is an essential component to visual field analysis without which
results can be misleading and yield errors of interpretation. Finally, with the existing fast threshold testing methods,
the time saved using screening strategies is not clinically useful, thus essentially removing that edge from screening
tests.
Threshold involves a point by point sensitivity determination over the full visual field each point being tested
individually. Although more time consuming and difficult, threshold visual field tests afford much more precision and
data analysis capacity and provides the most definitive method of visual field assessment. In automated perimetry,
full-threshold visual field testing is probably the standard strategy to adopt.
The HVF offers several threshold testing strategies:
(i) The Standard Full-Threshold Strategy uses a 4-2 dB double staircase strategy based on the starting
value of 2 dB brighter than the subjects predicted threshold obtained from the four primary seed points.
Threshold is taken to be the last seen stimulus after 2 threshold crossings.
(ii) The Full Threshold from Prior Data begins testing at 2dB brighter than the thresholds established in a
previous visual field and follows the same bracketing strategy as the standard full-threshold strategy.
This theoretically saves time since a reference hill of vision very close to threshold is already available
and used throughout the test.
(iii) The Fast Threshold Strategy also begins from stored values but instead of re-establishing thresholds,
this strategy tests the whole field at 2dB brighter than the stored values from a previous threshold visual
field. Only the missed points are fully thresholded. The fast threshold strategy is practically a screening
test since it uses a threshold-related stimulus 2dB brighter than the hill of vision. However, the actual hill
of vision is used as a reference level instead of a “predicted” one. The method saves time since only
deteriorated points are retested, but points that may be improving are not documented this way.
(iv) The FASTPAC is a full-threshold strategy that uses a different bracketing algorithm to reduce testing
time (fig. 5.38). FASTPAC uses a 3dB step size instead of the 2dB step used in full threshold testing to
determine threshold. One half the points are tested from a starting value of 1 dB brighter than expected,
the other half from a starting point of 2dB dimmer. The threshold value is taken to be the last seen
stimulus after a single crossing where the stimulus goes from being seen to non-seen or vice-versa.
Threshold values that differ from the expected threshold by more than 4dB are re-tested, but the step of
3dB remains constant.

Visual Fields
Figure 5.38: Static screening test
With Fastpac, a reasonably reliable threshold visual field can be performed with approximately 40% less required
time, which is about 5min per eye. The time reduction is a significant advantage for the patient since it reduces
fatigue, increases acceptability and facilitates cooperation. In fact, Fastpac may even increase reliability by allowing
a threshold test in approximately the same amount of time as a screening test thus increasing patient compliance.
Unfortunately, it may do so at the expense of other reliability and statistical indicators.
Fastpac is therefore a viable alternative to screening and fast threshold tests since it offers more information within
similar time frames. It is frequently used as a first test in patients with suspected visual field loss since it produces
clinically useful information while teaching patients how to perform more reliably subsequent tests. However, clinical
decisions should probably not be based on Fastpac visual fields unless other clinical information supports the
obtained result.
(v) The SITA (Swedish Interactive Thresholding Algorithm) is the most recent threshold strategy
released for the HVF. SITA may reduce testing time by as much as 40% and maintain the same
reliability as a full-threshold strategy. Two strategies exist: the SITA Standard which is designed to
provide the same information of Standard Full-Threshold visual field and the SITA Fast which is
designed to cut the test time of the Fastpac strategy.
In comparison to previous algorithms, SITA is more “active” in that it continuously adjusts its strategy based on the
patient’s responses during a test. The test program tailors its approach according to the tested individual (both
normative and individual data) allowing the test to run more efficiently.
First SITA considers known factors such as age, normative data and detailed characteristics of abnormal and normal
tests to determine the stimuli to present. It thus starts with stimuli at each point that are already very near threshold,
avoiding the long, inefficient process of gradually brightening or dimming the stimulus while searching for threshold.
Second, SITA “intelligently” uses the information contained in the patient’s responses to a given stimuli to efficiently
determine the brightness of the next presented stimulus both at the tested point and at the next one. That means
that SITA continuously uses the answers provided by the patient to modify its algorithm (strategy) as the test
progresses. The SITA algorithm, therefore, is not fixed: it is “written” as the test runs using the answers given by the
patient to most efficiently determine the threshold of each point.
In the same vein, SITA tailors its testing pace to each individual. In a threshold test, less than half the stimuli will be
seen. Thus, the perimeter must decide how long to wait after a stimulus presentation before presenting another. The
test must allow a reasonable amount of time between presentations, but waiting too long will unnecessarily prolong
testing time, fatigue the patient and increase inaccuracy. SITA uses special techniques to measure the patient’s
response time. SITA then adjusts its pace to closely match the patient’s response time, thus minimizing time lost
between presentations.

Visual Fields
SITA also uses an “information index” which is continuously calculated from the patient’s responses during the test
to determine when to stop. The Standard Full Threshold strategy uses a fixed end-point and determines threshold
after 2 threshold crossings. The “information index” provides data regarding the consistency of a given result in
comparison to others. SITA is thus told to spend less time at locations where answers are in good agreement with
one another and to test further where results are unsure.
At the end of the exam, SITA looks at the complete pattern of patient responses assessing it globally for factors such
as response time and answer consistency. Unlike other strategies which use the last crossing of each point as the
determined threshold value, SITA considers all the responses obtained for each tested point, which provide
important reliability clues, to recalculate and refine the obtained measurements.
Kinetic vs. Static in Automated Perimetry.
The HVF allows both kinetic and static visual field testing. As discussed previously, static testing is more
advantageous than kinetic testing since it allows more precision and more data analysis versatility. In fact, the
relative ease of performing static perimetry on automated perimetry is one of its greatest advantages. Little
information is currently available as to the additive value of kinetic isopters as an adjunct to central static testing.
Kinetic perimetry is, however available and one should consider its use when clinically appropriate (e.g. patient
unable to perform static testing, to establish visual field limits for driving, etc.). Nevertheless, the method of choice
for HVF testing remains static perimetry.
White vs. Colour Perimetry
White is the standard stimulus used for perimetry. Colour perimetry is however possible with automated perimetry.
Although controversial and not clinically widespread, colour perimetry has some clinical uses. The Red Automated
Perimetry (RAP) and Short Wave Automated Perimetry (SWAP) tests are currently the most useful clinical options
with the HVF.
Red automated perimetry (RAP) makes use of a red stimulus to test for central toxic maculopathies due to certain
medications (e.g. chloroquine toxicity). A central 10 threshold test using red perimetry is believed to be more
sensitive at detecting early loss in central sensitivity.
Short Wavelength Automated Perimetry (SWAP) may be valuable in detecting very early glaucomatous visual
field loss and in predicting progressive glaucomatous damage. SWAP uses a size V blue stimulus (530nm) on
yellow background (440nm), colours very carefully chosen to isolate the blue cone system as much as possible.
Based on clinical studies, blue on yellow deficits may precede white on white visual field losses by several years.
The main issue with SWAP remains the difficulty most patients have in performing the test.
Patient set-up / procedure (Fig. 5.39)
 Using full aperture thin rim trial lenses, insert Rx and near add (30 cm distance)
 Place Rx lenses as close to the eye as possible without touching the lashes
 To reduce fatigue in prolonged testing, it is better to be generous on the addition
 For astigmatic Rx < 1.00 DC the equivalent sphere is sufficient
 Use Rx and Add for central 30 ; remove for peripheral test
 Consider contact lens for Rx > +/- 10.00 D
 The HVF can calculate the required add if needed but it is not error free; one must double check its calculation
 Clean head and chin rests using alcohol swabs
 Comfortably position the patient in the instrument
 Adequately adjust chair and instrument height
 Instruct patient clearly on fixation target, response button and responses expected

Visual Fields
 Patch non-tested eye; always test OD or better eye first

 Position patient’s head on chin and forehead rest
 Use the head alignment level to center the pupil precisely with the reference point on the screen’s eye video
monitor
 Measure the pupil size; dilate if < 3mm
 Compensate physical obstruction if necessary
 (e.g. tape lid, tilt head for big nose)
 Provide strong encouragement notes
 Perform a demonstration run if necessary
 Run the test continuously monitoring fixation and adjusting centration
 Save on disc
 Print results
 Add pertinent comments to printout.
Figure 5.39: Automated static screening test with HVF

Visual Fields
Tips
 Insist to patient on the importance of remaining as still as possible during the test
 Encourage the patient to take breaks, if mental or physical fatigue affects their concentration or positioning in the
perimeter; instruct the patient to hold the response button in if they need a break
 Pause the instrument yourself if in the midst of the test, the patient appears tired, restless or moves excessively.
Allow a break, reposition the patient and resume testing
 Constantly monitor the alignment of the eye during the test and make adjustments as needed to re-center the
pupil. Adjustments can be made without stopping the test
 Do not pursue a test that appears unreliable from its very beginning. Stop the test, re-instruct the patient and re-
start
 If the pupil is dilated or dilating during the visual field test, provide the full +3.25D add to compensate for the
induced cycloplegia even on young patients
 Avoid the most common errors made in performing the HVF (Table 5.9).
 Poor patient alignment

 Poor patient instruction
 Poor encouragement notes
 Bad Rx especially Add!
 Bad vertex distance of Rx
 Examining wrong eye!
 Leaving the patient unattended during exam
 Running an initially poorly reliable field
Table 5.9: Common error in performing HVF
RECORDING: PRINTOUT AND DATA ANALYSIS
Most automated perimeters use printers either within the instrument or on the side to hard copy the results. The HVF
printout involves a number of different printing and data manipulation options (Fig. 5.40). Understanding the printout
format and the specific data analysis involved in automated visual field is crucial to their interpretation. The printout
can be broken down in 4 parts:
1. Test Information
The first part of the printout includes the general patient information, test parameters and test protocol. Before
proceeding with the analysis of a visual field printout, the test information should always be reviewed to ensure that
the correct information was entered and obtained.

Visual Fields
Figure 5.40: HVF printout

Visual Fields
2. Reliability indices
The reliability indices indicate the extent at which a visual field result can be reliably interpreted. Questionable
results render visual field interpretation practically unfeasible (but not always impossible!). A certain amount of
“normal” error that does not significantly affect the results is generally permitted in automated perimetry. In certain
cases, however, obviously unreliable results can still yield valuable and useful clinical information.
Fixation losses (FL) indicate the patient’s ability to maintain fixation. The HVF uses the Heijl-Krakau method and
randomly spot checks in the blind spot to test fixation. The number of times that the patient responds to a stimulus
presented in the blind spot are counted as fixation losses. If FL are greater than 20%, the computer flags the visual
field as being unreliable and crosses appear next to the FL number.
False positive errors (FP) give an indication of the patient’s ability to respond truly to the visual stimulus. In a false
positive error, the patient clicks as if a stimulus had been perceived but either it was sub-threshold or not presented.
Some patients misunderstand the instructions, respond rythmically, are anxious, “trigger happy” or base their
response on the HVF noises rather than to the actual visual stimulus. The HVF will occasionally not present any
stimulus but still make the sound of projection to test for the patient’s false responses. If the number of FP is greater
than 33%, they are flagged by the computer.
False negative errors (FN) are an indication of the patient’s level of attention. In a false negative error, the patient
does not click even if a stimulus is perceptible (according to already established thresholds). The HVF occasionally
presents very bright stimuli in areas where normal sensitivity has already been established. Inattentive or fatigued
patients will not always respond to these stimuli and the HVF will flag the FN if they exceed 33%. An interesting point
to remember about FN is that a high FN rate may indicate diseases. Some sick areas of the retina may require
more time to recover from the bleaching effect of the first time that they are tested. Upon retest, the stimulus may not
actually be seen, but the HVF interprets it as a FN.
The test time may be regarded as an additional indicator of visual field reliability. Lengthy subjective tests such as
automated visual field render the procedure less reliable because of fatigue and loss of patient cooperation. In the
HVF, test times that exceed 15-20 minutes for 1 eye should be regarded a little more suspiciously with regard to
their reliability.
The short term fluctuation (SF) is an indication of the intra-test variability. Ten centrally located points are tested
twice to measure the difference in response between the first and second test. As in any psychophysical test, a
certain level of fluctuation in the obtained value is normal and expected. A higher than expected SF indicates
unreliable patient responses. The HVF will flag SF that exceed age-matched normal values. It is noteworthy that like
the FN, a high SF may also indicate pathology. If an area is diseased, it may respond well the first time that it is
tested but not respond as well upon retest due to the bleaching effect and the decreased re-adaptive ability of the
sick retina. The HVF interprets this as abnormal SF.

Visual Fields
GRAPHIC REPRESENTATION
The visual field results can be represented graphically in a number of ways depending on the type of visual field
performed.
Screening tests
In HVF screening tests, the visual field are graphically presented according to the test strategy used.
In threshold-related schemes, the points tested are shown as seen using an “o” or defective using a “” (Fig 5.41).
Figure 5.41: Threshold related scheme

Visual Fields
In the three-zone scheme the same symbols are used but a “” is used in addition to denote a relative defect (Fig.
5.42).
Figure 5.42: Three-zone scheme
In the quantify defect scheme, a value is given that represents the depth of the defect from the expected value
(Fig. 5.43).
Figure 5.43: Quantify defect scheme

Visual Fields
THRESHOLD TESTS
Threshold visual field can be represented using numeric, graytone or profile formats (Fig. 5.44).
The numeric plot grid is a simple graphical representation of the actual sensitivity (threshold) of the tested retinal
point in decibel. Values that depart from the expected value by more than 5dB are retested automatically to insure
that the departure is not simply a mistake in the patient’s response. The re-test value is presented in brackets below
the first. If a Fast-Threshold Strategy is used, the numeric plot will show the reference level in brackets below each
tested point. The Fast-Threshold tests each point at 2dB above the reference level which is in fact the result of an
earlier test.
The threshold graytone is a graphic representation that uses different shades of gray to represent different levels
of retinal sensitivities. The HVF reorganizes the numeric dB scale into 10 gray scale steps of 5 dB each. The darker
grays are used to indicate the lower dB values, hence the less sensitive areas. The graytone graph yields a gross
overview of the visual field. Be aware that it is not compared to age-matched expected values and it may be
dangerous towards visual field interpretations. Furthermore, in the grayscale, the interval between tested points
intervals is interpolated and truly misrepresents what the actual visual field may be in those areas.
Figure 5.44: Representation of the threshold tests

Visual Fields
Finally, the threshold profile format is a “section” outline of the hill of vision through any chosen meridian (fig. 5.45).
Figure 5.45: Threshold profile format
An example of the numeric plot in a Fast Threshold strategy (fig. 5.46). The circles indicate that the stimulus at 2dB
brighter than the reference level in bracket is seen.
Figure 5.46: Numeric plot in a fast threshold strategy

Visual Fields
Threshold visual field results can also be presented using simple data manipulation schemes such as Average and
Compare.
Average calculates the mean of up to 5 visual field results onto a single graph and presents in graytone, defect
depth or dB values (Fig. 5.47).
Figure 5.47: Average threshold visual field
Compare calculates the numerical difference between the last visual field and the new field for a quantitative
measure of change is sensitivity.
Figure 5.48: Compare threshold visual field
(Fields drawn from Humphrey Field Analyzer Capabilities & Applications, Allergan Humphrey, 1989).

Visual Fields
STATPAC ANALYSIS
The range of visual field responses in the normal population is very extensive and the amount of data obtained in
automated perimetry is quite vast. In addition, a precise psychophysical method such as automated perimetry can
be coated with testing artifacts (e.g. fluctuations, media scatter, etc.). Differentiation of normal from abnormal results
and interpretation of automated visual field therefore becomes a very complex process and nearly impossible
without the use of statistical analysis.
Statpac is a statistical package that is provided with the HVF to analyze visual field results. Statpac includes a
database of reliable visual field results that serves as the basis for comparison. The database was obtained
empirically from a large number of experienced normal individuals of different age groups. Statpac establishes the
point by point numerical difference between the measured visual field results and the age-matched normal results.
Unwanted information is also mathematically filtered out to make truly suspicious areas more obvious.
Numerical differences, however, are not sufficient since one can never say with 100% certainty that a given result is
normal or abnormal. In some instances, an apparently abnormal result (e.g. a foveal threshold of 20dB in a 20 year
old person) can be found in completely normal individuals, just like a normal person can be 2.5 meter tall. The
probability of that occurrence is very low but not impossible. Given the range of normal results, only the likelihood or
probability of finding the given result in the normal population can be established.
Statpac uses the database and statistical manipulation to determine a probability match for each numerical result
obtained in the visual field. Probability matches indicate the statistical likelihood that the obtained value at a
given point is found in the age-matched normal population. HVF probability matches are denoted by “p” values
of ½, 1, 2, 5 and 10%. For example, p<5% indicates that the threshold obtained is a possible normal occurrence in
less than 5% of the normal population of the same age as the patient. Obviously, the lower the p-value, the higher
the chance that a given result is abnormal. One must remember, however, that it is never possible to affirm with
100% certainty that a given result is abnormal, because everything is possible!
Figure 5.49: Statpac printout

Visual Fields
In assessing Statpac results, one must bear in mind that statistics are far from representing the perfect science and
Statpac is not free of errors. If all statistical parameters (no p-values are given) produced by Statpac are within
normal range, chances are the visual field is normal. The opposite is not true. Due to the high number of artifacts
related to automated perimetry, statistical parameters often appear abnormal in the presence of normal patients with
normal visual field.
Probability matches can be graphed using a gray scale format. Dark shades of gray indicate a lower probability
match, therefore darker spots are most likely abnormal. Do not confuse the probability match gray scale with
the graytone printout. In the graytone printout, dark areas indicate low sensitivity areas: the darker the area, the
less sensitive (“blinder”) the area. In the probability match graph, darker spots simply indicate lower probability of
occurrence - they do not indicate non-seeing areas!
Statpac can investigate and present the results in a number of clinically useful manners either numerical or graphical
(Table5.10). An additional and noteworthy advantage of Statpac is the compilation of visual field results that allows
quantifiable change analysis to be made over time.
 Single Test Analysis

Foveal Threshold
Total Deviation Plot
Pattern Deviation Plot
Global Indices
Glaucoma Hemifield Test
Statpac I
 Change Analysis
Box Plot
Summary of Global Indices
Linear Regression Analysis of MD
 Overview
Global view of up to 16 tests on 1 page
 Glaucoma change probability analysis
Statpac II
 Modified Linear Regression analysis of MD
Table 5.10: Uses of Statpac results
Note: Statpac II is an update of the original Statpac I version.

Visual Fields
SINGLE TEST ANALYSIS
The single test analysis involves statistical investigations of the data obtained within a single visual field test. The
analysis provides 5 useful numerical or graphical formats (Fig. 5.50):
-1-
Foveal
Threshold
-5-Glaucoma
Hemifield Test
-2-
Total -3-Pattern
Deviation Deviation
- 4-Global
Indices
Figure 5.50: Standard HVF threshold printout

Visual Fields
1. The Foveal Threshold obtained at the beginning of each visual field is compared to the values in the age-
matched normal individuals. The foveal threshold will have an assigned probability match if it falls outside the
normative range.
2. The Total Deviation Plot is a numeric defect depth and probability plot of the obtained visual field in
comparison to the age-matched normal population results. The graphical representation indicates global
deviations (defect depth) of the results from normal patients found in the database (expected norms). Deviations
(scotoma, depressions) are plotted in a numerical graph indicating the difference between the obtained value and
the expected value. The probability plot represents graphically the probability that the obtained threshold value for
a given point is found in the normal population. Refer to Fig. 5.51.
Figure 5.51: The total deviation shows a typical VF with general reduction in sensitivity with respect to expected results in age-
match normal individuals

Visual Fields
3. The Pattern Deviation Plot is a statistical representation that adjusts the “general height” of the hill of vision
obtained for an overall decrease or increase in sensitivity. Focal defects can be “buried” within generalized defect
and not show up on the Total Deviation Plot. If the hill of vision is reduced overall by a statistically significant
value (e.g. p< 0.5%), a deeper scotoma along the visual field will not reduce the p-value even more. The
apparent total deviation will remain the same and the focal defect will not be manifest. A clinical example of this is
a glaucomatous defect in a patient with significant cataracts! Refer to Fig. 5.52.
4. The Pattern Deviation Plot removes or filters out a common denominator (common factor) found within each
field point tested. By eliminating a homogeneous component of the field, deeper, more localized deviations will
surface on the graph. A numeric plot is then used to indicate the actual difference of the tested point from the
expected level. A probability plot denotes the statistical distribution of the noted difference within the normal
population. It follows that if no general reduction or increase in sensitivity is noted, the total deviation and Pattern
Deviation Plot will be identical. Clusters of 2 or more points together on the PD graph should be considered as
suspicious if they are repeatable on separate tests.
Figure 5.52: A typical VF in an elderly patient suffering VF loss due to both cataracts and glaucoma

Visual Fields
5. The Global Indices are overall numeric representation the obtained visual field results. Similar to Total and
Pattern Deviation Plots, they allow quantification and separation of diffuse damage from local scotoma. The
indices however provide additional information that allow differentiation of true defects from ‘noise’ and facilitate
the follow-up of visual field especially when the field defect deepens without visibly enlarging. The actual formula
used to calculate indicators in automated perimetry is complex and beyond the scope of this reading. The
concepts can however be demonstrated using a simplified numerical scheme that assumes that the hill of vision
is flat and contains 10 points (see examples below)
The Mean Deviation (MD) represents numerically the difference in average height of the hill of vision (mean
sensitivity value) from its expected value. One can think of the MD as being the global numeric representation of the
Total Deviation Plot. The sensitivity values obtained over the whole field are averaged and compared to age-
matched normal values. Like any average value, the MD is not affected so much by small focal numerical deviations
(focal scotoma!) unless they are extreme (deep scotoma!). The MD is an indicator of the size of visual field defects
and is most affected by diffuse damage such as general depressions and large or deep scotoma. Refer to Fig. 5.53.
situation # 1 : small non-significant fluctuations along field
expected field: 30 30 30 30 30 30 30 30 30 30 mean sensitivity = 30 dB
obtained field: 30 32 28 30 30 32 34 26 26 30 mean sensitivity = 30 dB
MD = 0 dB
situation # 2: overall general field depression
MD = - 3 dB
situation # 3: small but deep defect along field
MD = - 3 dB
Figure 5.53: Calculation of mean deviation
The Pattern Standard Deviation (PSD) is a representation of the uniformity (smoothness) of the hill of vision. The
PSD, as the name denotes, is a measure of the standard deviation of the obtained threshold values from the
expected values. It represents the variability or irregularities along the hill of vision. Contrary to the MD, large field
depressions will not affect the PSD dramatically. Numeric variations from focal scotoma and response fluctuations
which render the visual field uneven will affect it most. The PSD can therefore be thought of as a global numeric
representation of the Pattern Deviation Plot. This can also be shown numerically using the 10 point flat hill of vision
scheme (Fig. 5.54):

Visual Fields
situation # 1 (small non-significant fluctuations along field)
PSD = [ (point value - mean value)2 / # points]1/2 MD = 0 dB

= [(0+4+4+0+0+16+16+16+16+0)/10] 1/2 = 2.68 PSD = 2.68
situation # 2 (overall general field depression + small non-significant fluctuations along field)
PSD = [ (point value - mean value)2 / # points]1/2 MD = - 6 dB

PSD = 2.68
= [(1+1+1+9+1+1+1+1+9+1)/10] 1/2 = 2.68
situation # 3 (small but deep defect along field)
MD = - 3 dB
PSD = [ (point value - mean value)2 / # points]1/2 PSD = 5.6
=[(9+9+121+121+9+9+9+9+9+9)/10]1/2 = 5.6
Figure 5.54: Calculation of pattern standard deviation
Figure 5.55: Schematic representation of possible MD and PSD variations

Visual Fields
A VF with generalized or diffuse loss secondary to cataracts (Fig. 5.56). Notice how significantly the MD is affected
(p< 0.5%).
The PSD is also affected but less significantly than the MD (p<5%). The small defect noted in the pattern deviation
may be caused by the non-uniformity of the cataract. This results in deeper loss of sensitivity at certain points
across the field and hence affect the PSD.
Figure 5.56: A VF with generalized or diffuse loss secondary to cataracts

Visual Fields
Below is a VF with a very deep local defect (Fig. 5.57). The PSD is markedly affected by the defect causing a
pronounced “irregularity” in the field.
The MD is also affected because the defect is very deep, but it is only minimally affected (-2.72 dB p<10%).
Figure 5.57: A VF with a very deep local defect
The Short Term Fluctuation (SF) is a measure of the intratest variability. A specific point tested twice may not yield
the exact same dB value even if it is tested within a small interval. In the HVF, the SF is calculated by testing 10
specific points 2 times and averaging the differences obtained. A high SF usually indicates unreliable responses, but
it can also denote an early disease process, as discussed previously.
The Corrected Pattern Standard Deviation (CPSD) is the PSD corrected for the SF. SF fluctuations can make the
field appear very irregular. High intratest variability will adversely affect the numerical uniformity of the hill of vision
and hence mathematically increase the PSD. The CPSD can be considered in principle as the PSD minus the
deviation caused by the SF. If the SF is small, the CPSD and PSD will be very similar. If the SF is high, the CPSD
will usually be significantly smaller than the PSD. The CPSD is a more reliable indicator of the smoothness of the
field. Just like the PSD, it will be most affected by small scotoma.

Visual Fields
With the increasing use of the SITA strategy, newer automated perimeter have ceased to include SF and CPSD.
Figure 5.58: Simplified schematic presentation of possible MD, PSD, SF and CPSD
Figure 5.59: The small VF defect may be true. The SF only partially accounts for it and the CPSD is significantly affected (p<5%)

Visual Fields
SUMMARY OF GLOBAL INDICES GRAPHIC REPRESENTATION
Indicative of: Sensitive to:

MD Height of the hill of visionwith respect to age- Diffuse damage
matched normals Progression of advanced stages
Deep local scotoma
PSD Smoothness of hill of vision Small scotoma
Uniformity of visual field loss Fluctuation
SF Response variability Unreliable patient
Early disease
CPSD Smoothness of hill of vision Small scotoma
Uniformity of visual field loss
Table 5.11: Summary of global indices
Based on the above explanations, the most important global indices are probably the MD and CPSD. By looking at
these 2 values, it is possible to predict the nature of the visual field defect even without looking at the graphical
representation. However, CPSD and SF are not useful when using SITA software and these indices have been
removed from newer machines that use SITA.
Most probable visual field result:

MD Normal Visual field is probably normal
CPSD Normal
MD  Normal Most probably a pure generalized defect is present
CPSD Normal
MD Normal Most probably a small purely localized defect is present
CPSD  Normal
MD  Normal Most probably a large defect with a localized component
CPSD  Normal Or artifacts are present
Table 5.12: Summary of global indices

Visual Fields
Figure 5.60: A true focal VF defect Figure 5.61: The right eye of the VF on the left
The CPSD is significantly affected while the MD isn’t. Notice how the CPSD is slightly altered by the SF. The SF
in this case may be increased because of the presence of
disease.
THE GLAUCOMA HEMIFIELD TEST
The Glaucoma Hemifield test (GHT) is based on the anatomy of the nerve fiber layer (NFL). The GHT evaluates 5
zones in the superior field and compares these zones to their mirror image zones in the inferior field. Primarily
intended to facilitate the observation of asymmetric defects between superior and inferior hemifields, it also indicates
diffuse visual field loss and abnormally high sensitivities.
The point-by-point results are based on Statpac pattern deviation maps rather than on threshold numerical values
(note: there is some uncertainty as to whether the pattern deviation or pattern standard deviation is used). The
analysis shows the significance of deviations from normal age-matched values corrected for overall sensitivity. The
GHT enhances the detection of early defects that may be more visible in one hemifield in comparison to the other.
Five possible results can be obtained from the GHT.
 Within normal limits  no significant difference between sup. and inf. fields
 Borderline  significant difference (p< 3%)
 Outside normal limits  significant difference (p< 1%)
 General reduction of sensitivity  overall depression (p<0.5%) - no hemifield difference
 Abnormally high sensitivity  abnormally high sensitivity (p< 0.5%)

Visual Fields

Visual Fields
Figure 5.62: VF printout with the Glaucoma Hemifield Test
CHANGE ANALYSIS
Statpac allows the compilation of visual field results such that quantifiable change analysis can be made over time.
Statpac Change Analysis provides a statistical summary of up to 16 serial visual field tests. Using regression
statistics, the analysis indicates the significance of field changes over time. Change analysis can be represented in
several ways (Fig. 5.64).

Visual Fields
STATPAC I (first software version of Statpac)
1. The Box Plot is a modified histogram that illustrates in summary the distribution of values after comparison to
normals. The X-axis of the histogram indicates time while the Y-axis indicates the departure of the results from
normal, “+” indicating better, “-“ indicating worst. The normal distribution is shown to the left of the box plot, while
the patient’s distribution over time is plotted to the right. Downward shifts of the histogram indicate progression
in the visual field defects. The box plot uses 5 number to show test results.
Figure 5.63: The box plot
Four things must be observed when analyzing the box-plot:
 The overall shape of the box (elongated vs. compact)

 Location of the median
 Top and bottom location of the “T”
 Location of box-plot in comparison to normal age-match scale on left.
General depressions will keep the shape constant but depress the whole symbol downward. Deep scotoma affecting
few points will give box an approximately normal shape but lower the negative tail (worst point). Enlarging scotoma
(>15% of points) will elongate the lower limits of the box.
2. The Summary of Global Indices uses a graphic representation to plot the global indices (MD, PSD, SF, CPSD)
over time. The graph includes dotted lines indicating the p<5% and p<1% limits to facilitate interpretation.
3. The Linear Regression Analysis of MD is a linear plot of the MD over time. The test determines whether the
slope of the MD plot, which indicates the MD change in dB/year, is statistically significant or not. A “significant”
result indicates that the MD has changed in the direction of the slope. A p-value is also noted to indicate the
level of confidence: the lower the p, the more likely the MD change is true. Note that a minimum of 5 serial visual
field are needed for this test to be valid.

Visual Fields
Figure 5.64: Change Analysis Printout

Visual Fields
OVERVIEW
The Overview is a printout that simply groups a number of visual field (up to 16 tests) on the same page (Fig. 5.65).
The gray scale, total deviation and Pattern Deviation Plots are plotted with the corresponding global indices. The
overview allows easy visualization of the changes in the visual field.
Figure 5.65: Overview Printout

Visual Fields
STATPAC II (UPDATE SOFTWARE OF STATPAC I)
Glaucoma Change Probability Analysis (GSPA)
The GSPA is designed specifically for glaucoma patients. In glaucoma patients, there exists a greater than normal
inter-test variability (random variation, long term fluctuation) that is typical of stable glaucoma patients. The GPSA
attempts to separate visual field changes on glaucoma patients that are due to progression of damage from those
that are due to the increased random variation. Refer to Fig. 5.66.
The GSPA shows the statistical significance of the changes in sensitivity (dB) of each visual field from a baseline
visual field plot established from the average of two earlier field tests. The total deviation probability plot and MD of
each visual field is analyzed and compared point-by-point to the baseline plot. A comparison of the change is then
made to the expected inter-test variability to insure that the change is not due to the random variation. The expected
inter-test variability is obtained from a database of visual field repeated in stable glaucoma patients.
The results are shown graphically. The display shows the gray scale, Total Deviation Plot and the difference in
threshold from baseline values for a series of visual field. To the right of these, a plot represents the probability that
the change at each test point is a true deterioration using symbols (note symbols may vary across
machines/regions)
ᴼ  A single, solid dot indicates a point not changing by a significant amount.

Δ  A small open triangle identifies a degree of deterioration expected less than 5% of the time at that location
in stable glaucoma patients (p < 0.05).
∆  A half-filled triangle indicates significant deterioration at that point in two consecutive tests.
▲  A solid triangle indicates significant deterioration at that point in three consecutive tests
x  deterioration is present but significance is impossible to determine
An additional message stating that the “average mean deviation of all tests is too low” indicates that the MD is lower
than –15.
Progression of glaucomatous defects will therefore be indicated by clusters of solid triangles that enlarge over time.
Noteworthy is the fact that at least 6 serial visual field are needed for the GSPA to be valid.
Modified Linear Regression Analysis of MD
The modified linear regression analysis of MD is a variation of the linear regression analysis of MD available in
Statpac I. The analysis also plots the changes of MD over time to determine whether the slope is statistically
significant or not. However, the newer version modifies the analysis to compensate for the presence of marked
learning effects. In cases where the MD obtained in early visual field results is significantly (p<5%) out of line from
the trend observed in later fields, the Statpac II regression analysis discards the first test results. Similar to the
Statpac I test, the significance of the modified MD slope is then given.

Visual Fields
Figure 5.66: Overview Printout

ANATOMICAL CORRELATION OF VISUAL FIELD
DEFECTS
AUTHOR
PEER REVIEWERS
INTRODUCTION
• Pertinent visual pathway anatomy

• Localization of lesions causing VF defect
• Pre-chiasmal VF losses
• Optic chiasm VF losses
• Post-chiasmal VF losses

Visual Fields
ANATOMICAL CORRELATION OF VF DEFECTS
VF interpretation, like most clinical procedures, involves the association of findings to the pertinent anatomical
structures. The correlation of VF losses to the neural & visual pathways and their clinico-pathological implication
begins with recognizing & classifying particular characteristics of VF defects. Proper categorization of VF
abnormalities provides clues to the location of causative lesions. In turn, the location of lesions often points towards
the possible etiology and facilitate the diagnosis of conditions. One must therefore know and understand the visual
pathway very thoroughly and bear the complete anatomical picture in mind when VF defects are analyzed.
PERTINENT VISUAL PATHWAY ANATOMY
The visual pathway is a sensory tract that carries afferent impulses to the brain. The pathway is a 4 neuron pathway
that begins at the retina and terminates at the occipital cortex.
1. The 1st order neuron starts from the end organ photoreceptors (rods & cones) and finishes with a synapse at
the bipolar cells within the retina.
2. The 2nd order neuron is the bipolar cell within the retina which transmits the neural signal from the
photoreceptors to the ganglion cells.
3. The 3rd order neuron involves the long ganglion cells. Each nerve fiber will cross the surface of the retina,
enter the ONH, travel through the chiasm, optic tract and terminate with a synapse in the lateral geniculate body
(LGB).
The nerve fibers of the retina are arranged in a characteristically constant topographical pattern which is carried
on relatively unchanged throughout the 3rd neuronal pathway. It is crucial to understand this organization to properly
correlate VF losses to anatomical lesions involving the 3rd neuron.
The retinal nerve fiber pattern consists of the papillomacular bundle that composes 65% of all nerve fibers, the
superior and inferior arcuate bundle which arch around the papillomacular bundle from the horizontal raphe to the
ON and the superior & inferior radiating bundles that pass through the nasal portions of the retina into the optic
nerve (Fig. 5.67).

Visual Fields
Radiating bundles
Arcuate bundles
Papillomacular bundles
Figure 5.67: Topographical pattern of retinal nerve fibre layer
Modified from Harrington DO, Drake MV, The Visual Fields:Text & Atlas of Clinical Perimetry, C.V. Mosby, 1990.
The papillomacular bundle will pass directly into the ON on its temporal side adjacent to the central vessels (Fig.
5.68). In the intraorbital ON, these fibers are grouped in the same pattern as in the retina keeping their temporal
position. As they approach the chiasm, the papillomacular bundle move from the temporal side to a more central
position and lose the bundle arrangement to become spread out and scattered mixing freely with all fibers. In the
chiasm, the macular fibers are dispersed in almost all areas except for a the anterior & infero-posterior parts. In the
optic tract, the macular fibers rise to a more superior aspect.

Visual Fields
Figure 5.68: Organisation of the nerve fibers in optic tracts and chiasm
Drawn from Harrington DO, Drake MV, The Visual Fields: Text & Atlas of Clinical Perimetry, C.V. Mosby, 1990.
The superior and inferior temporal fibers of the peripheral retina (nasal VF) will maintain their respective position
in the upper and lower outer quadrant of the ONH. Since the papillomacular fiber bundle enter on the temporal side
of the optic disc, the fibers from the temporal retina are "squeezed" into the superior and inferior poles of the disc.
More posteriorly in the ON, however, the macular fibers take a more central location, and the fibers from the
temporal retina assume a more temporal location in the nerve. The temporal fibers remain on the same side and
become the uncrossed fiber bundles in the optic tract.
The superior & inferior nasal fibers (temporal VF) also maintain their position throughout the ON. In the chiasm,
these will decussate to become the crossed fiber bundles. Inferior fibers will decussate immediately while the
superior fibers will wait until the end of the chiasm. Some inferior fibers crossing in the anterior chiasm will loop
anteriorly into the contralateral nerve before heading posteriorly forming what is known as “Knee of Wilbrand”.
In the optic tract, all superior fibers (crossed & uncrossed) become medial, all inferior fibers become lateral. The
macular fibers rise into a more superior position.
The 3rd order neuron synapses in the LGB which is a small 6-layer oval structure. Crossed fibers terminate in layers
1,4,6 while uncrossed fibers terminate in layers 2,3,5. Corresponding points of both retinas represented in all layers
of the LGB and are thus somewhat distant from each other.

Visual Fields
1. The 4th order neuron starts from the LGB and forms the optic radiations that will end in the cerebral cortex
(geniculo-calcarine radiations) (Fig. 5.69). The optic radiations run in a broad band towards the cortex. The
dorsal fibers (superior fibers) that leave the LGB run backward in a fairly direct route through the parietal lobe.
The ventral fibers (inferior fibers) initially run forward and downward into the temporal lobe to form Meyer’s
loop before running backward to the cortex. The visual fibers lose the “compact” arrangement in the optic
radiation and become widespread making them susceptible to a wider range of lesions. However, throughout
the optic radiations, upper and lower fibers will retain their respective upper & lower positions.
Figure 5.69: Anatomy and disposition of optic radiations
Inspired by Harrington DO, Drake MV, The Visual Fields: Text & Atlas of Clinical Perimetry, C.V. Mosby, 1990.
Figure 5.70: Lateral and medial views of the occipital lobe

Visual Fields
Figure 5.71: Mapping of the visual cortex
Diagrams inspired by Harrington DO, Drake MV, The Visual Fields: Text & Atlas of Clinical Perimetry, C.V. Mosby, 1990.

Visual Fields
LOCALIZATION OF LESIONS CAUSING VF DEFECT
Given the anatomical organization of the visual pathway, certain characteristics of VF defects will provide clues to
the localization of causative lesions. A first set of VF defect descriptors will provide clues to gross location while a
second set will help finer localization:

Visual Fields
Figure 5.72: The appearance of visual field loss resulting from lesions at various points throughout the visual pathway
Diagrams inspired by Harrington DO, Drake MV, The Visual Fields: Text & Atlas of Clinical Perimetry, C.V. Mosby, 1990.

Visual Fields
PRE-CHIASMAL VF LOSSES
Pre-chiasmal VF defects are monocular. Although diseases affecting the VF often occur bilaterally, the damage &
resulting VF loss in each eye is independent and essentially monocular. Pre-chiasmal defects can take on many
shapes. Based on the appearance and the causes, they can grossly be placed in 2 categories:
No respect of the horizontal meridian
• Preretinal Type
o Preretinal factors are abnormalities that produce light blockage, light scatter or image defocus (e.g. cataracts,
medial opacities, miosis, etc.). These usually result in a generalized visual depression but they can also result
in focal irregular reduction in sensitivity. Pre-retinal factors are often revealed by anterior segment evaluation.
• Retinal & Choroidal Type
o Lesions of the retina and choroid will produce defects that do not follow the anatomical feature of the visual
system. The defects correspond directly to the affected areas often as they are perceived
ophthalmoscopically (e.g. retinal detachments, chorioretinal scars, ARMD, etc.).
Respect of the horizontal meridian
Optic Nerve Type

Visual field defects produced by ON lesions generally respect the characteristic arrangement of the NFL within the
retina and ON.
Several forms of defects can be observed:
• Paracentral scotoma occur in the early stages of conditions that affect the ganglion cells (e.g. early glaucoma)
in an irregular fashion
• Arcuate scotoma involve the curvilinear nerve fiber bundles that arc over and below fixation. Lesions of the
optic nerve fibers such as glaucoma (through fusion of paracentral scotoma), optic disc drusen and anterior
ischemic optic neuropathy often produce arcuate scotoma that end abruptly along the horizontal midline
• Nasal steps occur by uneven damage in the superior & inferior portions of the NFL
• Central scotoma occur in conditions that affect primarily the macular fibers. When unilateral, this defect is
characteristically found in patients with compressive lesions of the ON (e.g. papilledema, drusen, etc.) or
demyelinating optic neuropathies. When bilateral, differential diagnosis includes nutritional deficiencies, toxic
optic neuropathies, and hereditary disorders
• Cecocentral scotoma are classically found in patients with toxic optic neuropathies but can be seen with any
condition that produces a central scotoma
• Altitudinal defects are characteristically associated with Anterior Ischemic Optic Neuropathy (AION) which is a
vascular disease of the ON
• Temporal wedge-shaped sector defects is a rare pie-shape defect that arises from the blind spot and does
not respect the horizontal meridian. Associated with glaucoma, it results from damage to the nasal fibers.

Visual Fields
OPTIC CHIASM VF LOSSES
Chiasmal syndromes are usually, but not solely, caused by tumors especially pituitary tumors (~50%) &
craniopharyngiomas (~25%). Of all brain tumors, 25% are in the chiasmal area. Half of the chiasmal syndromes
present initially with vision loss complaints. Because chiasmal lesions interrupt the 3rd neuron pathway, chiasmal
syndromes will often be accompanied by ON “company” such as VA loss, RAPD, ONH atrophy, loss of colour vision,
etc. Because of the wide spread of macular fibers, VA is usually normal in chiasmal lesions unless the optic nerve
is also involved.
Chiasmal syndromes will cause variable & mixed VF losses. The appearance of the defect will depend on the
particular lesion affecting the chiasm and the direction with which it insults the chiasm. The resulting VF defect will
also depend on the anatomical location of the chiasm. The position of the chiasm with respect to the bony
tuberculum sellae which holds the pituitary body is variable among individuals: 80% of chiasms sit on the posterior
2/3 of the sellae, 12% directly above it, 4% are pre-fixed (short ON) and 4% are post-fixed (long ON).
The distinguishing characteristic of VF losses arising from chiasmal lesions is the bitemporal hemianopic nature
of the defect. With the understanding that most chiasmal insults arise from the pituitary body and hence from below,
chiasmal VF defects roughly fall within 2 categories: scotomatous and non-scotomatous. Remember that these are
only guidelines for the most commonly occurring causes of chiasmal syndrome. VF defects arising from the chiasm
can truly take on any shape.
Scotomatous bitemporal hemianopia (a.k.a. Junctional defects)
• Anterior chiasmal lesions

o Anterior chiasm lesions typically produce junctional scotoma which show a central scotoma quadrantic or
hemianopic) that respects the vertical midline in one eye and a peripheral superior temporal defect in the
other eye. This results from ipsilateral optic nerve damage & contralateral damage of the crossing fibers in
the Knee of Wilbrand
Non-scotomatous bitemporal defects that respect the hemianopic vertical midline
• Middle chiasm lesions: denser above

o Lesions affecting the central body of the chiasm present (mid) peripheral bitemporal VF defects. The defect is
usually denser above than below because crossed fibers of the chiasm are more sensitive to compression
than uncrossed fibers due to their anatomical location.
• Posterior chiasm lesions: denser below
o Posterior chiasm lesions destroy primarily posterior crossing fibers resulting in (mid) peripheral bitemporal VF
defects with one eye presenting a denser loss inferiorly.
Binasal hemianopia due to lateral chiasmal compression is possible but extremely rare. It can only be produced by
chiasmatic lesions that compress and displace the chiasm laterally against the internal carotid arteries thus
producing binasal field loss. Associated homonymous VF defects are also possible when chiasmal lesions extend
posteriorly onto the optic tracts.

Visual Fields
POST-CHIASMAL VF LOSSES
Post chiasmal VF defects are caused by lesions affecting the Optic Tract (3%), the Lateral Geniculate Body (1%),
the Optic Radiations (58%) and the Occipital Lobe (38%).
Because of the widespread distribution of the anatomical pathway retro-chiasmatically, VF defects can be produced
by a number of different insults. Lesions that produce VF defects in this region, however, tend to “keep company”
by producing other neurological signs and symptoms that help localize & identify the responsible lesions. Lesions in
the optic tracts or lateral geniculates interrupt nerve fibers from the retinal ganglion cells of both eyes. These lesions
can produce characteristic retrograde ONH and NFL atrophy as well as an RAPD of the eye with the most affected
fibers. Temporal lobe lesions often cause seizures and form visual hallucinations while Parietal lobe lesions may
have associated hemiparesis, visual perceptual difficulties, agnosias, apraxias and right-left confusion. Lesions of
the primary visual cortex may produce unformed visual hallucinations.
Post-chiasmal lesions are characterized by their essential homonymous hemianopic aspect where the same side
of the visual space is affected (temporal side of one eye, nasal side of the other). In general, post-chiasmal defects
can be classified according to the law of congruity:
The more posterior the lesion,

The more congruous the VF defect.
Incongruous type defects
The visual pathway “spreads out” retro-chiasmatically such that corresponding retinal elements lie further away from
each other. Proximal post-chiasmal lesions will thus affect corresponding fibers at different degree. Affections of the
optic tract, LGB & optic radiations will thus mostly produce VF losses that are incongruous.
Increasing Congruity
Nerves carrying corresponding retinal information move gradually closer to each other such that the visual pathway
becomes more compact as it progresses towards the occipital lobe. Lesions in the posterior optic radiations affect
corresponding fields more equally. VF defects therefore appear progressively more congruous with more posterior
insults.
Lesions in the temporal lobe (25%) tend to be incongruous homonymous hemianopias that are denser above.
The temporal lobe fibers spread out into Meyer's loop which holds the inferior areas of both retinas. When damaged,
"pie-in-the-sky" defects are produced.
Lesions in the parietal lobe (33%) tend to be slightly more congruous homonymous hemianopias that involve the
inferior VF to a greater extent. A tighter bundle of fibers representing superior retinal areas courses through the
parietal lobe. Damage to these fibers results in ''pie-on-the-floor" defect.

Visual Fields
Congruous
Due to the specific retinotopic arrangement of the striate cortex, fibers relaying input from corresponding retinal
elements of the two eyes lie extremely close together by the time they reach the occipital cortex. VF defects,
therefore, become exquisitely congruous with occipital lesions.
Lesions of the occipital cortex may spare fixation (i.e. not split it in hemifields). The anatomical reason for this
macular sparing remains controversial. Some explain it on the basis of the dual blood supply of the occipital tip by
the middle and posterior cerebral arteries while the rest of the occipital cortex is supplied only by the posterior
cerebral artery. Vascular insults affecting the posterior cerebral artery may thus spare the macula. Lesions that affect
strictly the occipital tip may produce congruous central homonymous hemianopias.

CORNEAL PROCEDURES
AUTHOR
PEER REVIEWER
PURPOSE
Various procedures are necessary when a patient presents with a corneal disruption secondary to foreign body (FB),
recurrent corneal erosion or viral infection. The following will cover FB removal, rust ring removal, corneal
debridement and pressure patching. The presentation is given in a SOAP format in order to apply a problem oriented
approach.
S: Patient presents with a history of a FB entering the eye and/or Signs(Si)/symptoms (Sx) of discomfort. The
level of discomfort varies from mild to severe and increases after 12 - 36 hours. The Si/Sx may include:
Symptoms Signs
Irritation Conjunctival injection
FB sensation FB
Tearing Rust ring
Photophobia Anterior uveitis
Blurred vision Lid edema/blepharospasm
Table 6.1Signs and symptoms of a foreign body on cornea
Within the case history the clinician must determine the following:
• What matter entered the eye?

• Was it organic or inorganic?
• When did the matter enter the eye?
• How much matter entered the eye?
• How did it happen? (hammering, working under a car, working with fiberglass, wind blown ,etc.)
• Where did the incident occur?
• Did the matter enter the eye at a high velocity or in a projectile nature?

Corneal Procedures
O: The following diagnostic tests are essential:
• Corneal anesthesia may be necessary to perform any or all of the objective evaluation to alleviate the patient’s
discomfort & allow examination (sometimes even before Case History!)
• Visual acuity
• Pupils
• Extra-ocular muscles mouvement (EOM)
• Intra-ocular pressure (IOP)
• Slit lamp examination (SLE)
• Seidel’s Test
• Comparative Tonometry - IOP will be drastically reduced with penetrating injury
• Dilated fundus examination (DFE) to rule out (R/O) intraocular FB from high velocity projectile entrance
• B-scan ultrasonography to R/O intraocular FB from high velocity/projectile entrance
• CT scan to R/O intraorbital FB from high velocity or projectile entrance.
On SLE the clinician must assess the following:
• The location & depth of the FB or abrasion

• Coat's White Ring: a white infiltrate that may surround the FB after 12 hours
• Rust rings: occurs after certain metallic FBs oxidize
• Epithelial cell growth over the FB: occurs after 6 hours
• Anterior chamber inflammation
• Under tarsal plate through single or double lid eversion
• Fornices for additional foreign material
• FB tracks & Seidel’s sign with fluorescein
Figure 6.1 Layers of the cornea with localized disruption
Inspired Catania Louis J., Primary Care of the Anterior Segment, Norwalk, CT: Appleton & Lange; 1994.

Corneal Procedures
A: Corneal FB (include descriptors):
OD, OS, OU
location
superficial versus deeply embedded
organic versus inorganic
penetrating/perforating
associated uveitis
Intraocular penetration
Figure 6.2 Possible location for foreign bodies
Inspired by Stein R. et al., Management of Ocular Emergencies, 2nd Edition
P: Superficial FB (epithelial-anterior stroma):
Remove
Antibiotic Ointment or drops
Cycloplegia (if indicated)
Hyperosmotic (if indicated)
Patch (if indicated)
Deep FB (deep Stroma-Descemet)
Should be considered a penetrating/perforating injury and referred immediately for a special consult including
orbital X-rays. Intraocular metallic FBs become highly visible on X-ray.

Corneal Procedures
FOREIGN BODY REMOVAL TECHNIQUES
INSTRUMENTATION
• Saline solution
• Golf club spuds
• Hypodermic needle
• Bailey nylon loop
• Jeweler’s forceps
• Cotton swab
Figure 6.3: A - Bailey loop, B – hypodermic needle, C – golf club spuds, D – jewellers forceps, E – battery powered drill, F –
Alger brush, G – assorted instrument trays
Drawn from Catania Louis J., Primary Care of the Anterior Segment, Norwalk, CT: Appleton & Lange; 1994.
FLUSHING
Flushing the eye is indicated for superficial FBs especially those that contain multiple particles or fluids or those
that can’t easily be seen (e.g. glass). Balanced ophthalmic irrigating solution in squirt bottles or regular saline can
be used for that purpose. It may be necessary to “squirt” the eye with some pressure to dislodge & remove all the
particles.

Corneal Procedures
Procedure
• Apply topical anaesthetic

• Have the patient hold towels or a basin against cheek to prevent soaking their clothes
• Send a forceful stream of saline tangentially at the FB until it is washed from cornea
• Treat the abrasion.
GOLF CLUB SPUD
The Golf Club Spud is indicated for superficial or deeply embedded FBs. The spud is used to loosen & lift the edges
of the FB and scoop it from the cornea. The blunt edges of the spud protect against penetration into the deeper
corneal layer during removal.
Procedure

• Seat patient comfortably & securely at the slit lamp
• Use a parallelepiped with moderate magnification
• Direct patient’s fixation to allow for easy access to FB
• If necessary hold upper eyelid to prevent blepharospasm
• Stabilize your arm by placing your elbow down on the SL table
• Stabilize your instrument by placing the back of your hand on the patient’s face
• Align the spud tangential to the cornea
• Slide golf club spud under FB and scoop or lift FB away
Figure 6.4 Using the golf club spud for removal of a FB

Corneal Procedures
STERILE SYRINGE NEEDLE
The sterile syringe needle is indicated for partially or completely embedded FBs. An advantage to the syringe is that
it comes sterile & can be discarded after procedure. Since the tip is smaller than the golf spud, it is ideal for smaller
size foreign bodies. A 5 cm hypodermic needle (18, 20, 22 or 25 gauge) is most commonly used with or without a
syringe.
Procedure

• Align the needle tangential to the cornea
• Use the beveled tip to loosen overlying cells and rust rings (if present)
• Lift the entire FB from the cornea
Figure 6.5 Using a sterile syringe needle to remove a FB
Note:
• Avoid “snagging” Bowman’s membrane which feels like tugging on canvas. If it occurs transient striae lines will
become visible & possibly cause scarring
• Cockburn curve technique - the needle can be modified to provide a safer method to remove the FB. When
removing needle from its plastic container, drag the back side along the wall of the jacket. This will bend the
needle in a curve and reduce the risk of tearing Bowman’s layer. Some bent needles are available commercially.

Corneal Procedures
BAILEY NYLON LOOP
The Bailey Nylon Loop is smooth & flexible & therefore safer. It is indicated in non-cooperative patients
(e.g. children) or patients that are nervous and constantly moving. It can only be used if the FB is partially
embedded.
Procedure

• Align the loop tangential to the cornea
• Aggressively “tease” the edges of the FB
• Place the loop under the FB
• Lift the loop up in a flicking motion to remove FB
Figure 6.6 Using the Bailey nylon loop to remove a FB
Catania Louis J., Primary Care of the Anterior Segment, Norwalk, CT: Appleton & Lange; 1994.

Corneal Procedures
JEWELLER’S FORCEPS
The Jewelers forceps are indicated for superficially embedded large FBs. The method is similar to using a needle
because you close the forceps initially to lift the edges of the FB.
Procedure

• Seat patient comfortably and securely at the slit lamp
• Align the forceps tangential to the cornea
• With forceps closed lift the edges of the FB, loosen and lift FB away from cornea
• Open forceps to grasp & lift the FB above the epithelium
Figure 6.7 Using the jeweller’s forceps to remove a FB
Catania Louis J., Primary Care of the Anterior Segment, Norwalk, CT: Appleton & Lange; 1994.

Corneal Procedures
COTTON SWAB
The cotton swab (sterile Q-tip) is indicated for superficial FB. The swab is recommended only when nothing else is
available because it removes far more epithelium than necessary & it can fragment the FB. The cotton swab is more
useful for removing conjunctival FBs that are not deeply embedded.
Procedure

• Wet the cotton swab with sterile saline or irrigating solution
• Lift the FB from the surface of cornea
Figure 6.8 Using a cotton swat to remove a FB
CORNEAL RUST RING REMOVAL TECHNIQUES
Corneal Rust Ring Removal is indicated for removal of stained cells & oxidizing particles after a metallic FB has
been removed. Metallic FBs may produce a surrounding rust or hemosiderin ring after 12-24 hours. Rust rings
appear orange to brown and may stain the epithelium and/or Bowman’s membrane. Rust ring removal is most
commonly performed immediately following FB removal.
Delaying rust ring removal for several days may result in permanent staining of Bowman's membrane. Permanent
staining may prevent proper corneal regeneration and lead to recurrent corneal erosion. Immediate removal will
therefore minimize the patient’s length of discomfort, extent of hemosiderosis and risk of recurrent corneal erosion.
Some practitioners prefer waiting a day or two after FB removal to remove the rust ring to allow the “rust” to soften
and possibly grow out towards the surface. This makes removal of the rust ring easier. Delayed rust ring removal is
preferred when the FB is deeply embedded.

Corneal Procedures
INSTRUMENTATION
• Alger brush
• Battery-powered drill
• Hand-held burr
• Golf club spud
• Hypodermic needle
ALGER BRUSH, BATTERY-POWERED DRILL, HAND-HELD BURR
The Alger brush and battery-powered drills produce a sound that may cause apprehension and occasional
resistance by the patient to the procedure. Therefore make the patient aware of the sound before starting and
assure them that the procedure is performed superficially, not deep in the cornea. The Alger Brush works by a
weak battery powered motor that spins a small metal drill-burr that will stop if too much pressure is applied. This
minimizes the risk of penetrating Bowman's membrane. The regular battery powered drill does not have this safety
mechanism. Therefore the Alger brush is preferred and used more commonly. The hand-held burr is rolled manually
tangential to the cornea and it acts like an Alger Brush to remove the rust ring.
Procedure

• Direct patient’s fixation to allow for easy access to rust ring
• Align the instrument tangential to the cornea
• Let the instrument lightly touch the epithelium
• Use a circular sweeping motion to remove stained cells & oxidizing particles
• With the hand-held burr, roll or twirl the burr between the thumb & index fingers
• The spinning tip of the drill-burr should gradually wipe away the rust & damaged epithelium
• Lavage the eye to remove loose debris

Corneal Procedures
Figure 6.9 Using the Alger brush, the battery powered drill or hand-held burr to remove rust rings.

Corneal Procedures
GOLF SPUD/NEEDLE
The golf spud or a needle may be used when other instruments are not available.
Procedure
• Direct patient’s fixation to allow for easy access to rust ring
• Let the instrument lightly touch the epithelium
• Make small sweeping motions over the corneal surface
• This lightly scrapes the epithelial surface and removes the hemosiderosis
• Lavage eye to remove loose debris
CORNEAL DEBRIDEMENT
Corneal debridement may be useful in the treatment of traumatic corneal abrasions, recurrent corneal erosions,
herpes simplex keratitis & corneal burns. In these conditions, the procedure is used to remove loose, jagged, flap-
like or sick corneal epithelium to smoothen the edges of the corneal defect & facilitate the growth & adherence of a
new healthy layer. In the case of herpes simplex keratitis, it is used to remove epithelium at the edge of a dendritic
ulcer that contains the replicating virus.
INSTRUMENTS
• Cotton-tipped applicator
• Alger brush
• Battery-powered drill
• Hand-held burr
• Golf Spud
• Jeweller’s forceps.

Corneal Procedures
COTTON-TIP APPLICATOR
Procedure
• Instill anaesthetic until cornea softens (Lidocaine 4.0% is best for an extensive debridement).
• Direct patient’s fixation to allow for easy access to the area of interest
• Gently pull epithelium toward the center of the epithelial defect
• Rub away the loose tissue
• Scrub the basement membrane to remove debris
• Lavage the eye to remove excess loose debris
Note:
• Following debridement for traumatic corneal abrasions, recurrent corneal erosion & chemical burns the resultant
“abrasion” is treated in the usual manner
• For HSV antiviral & “abrasion” therapy is given but patching is contra-indicated.
ALGER BRUSH, BATTERY-POWERED DRILL AND HAND-HELD BURR
Procedure
• Instill anaesthetic until cornea softens. (Lidocaine 4.0% is best for an extensive debridement)
• Align instrument tangential to the cornea
• Skim instrument across the epithelial surface
• Stop when all damaged cells are sloughed off

Corneal Procedures
Note:
• Following debridement for traumatic corneal abrasions, recurrent corneal erosion & chemical burns the resultant
“abrasion” is treated in the usual manner
• For HSV antiviral & “abrasion” therapy is given but patching is contra-indicated.
GULF SPUD / JEWELLER’S FORCEPS
Although not commonly used, it may be possible to debride loose epithelium using the golf spud &/or jeweller’s
forceps.
Procedure
• Instill anaesthetic until cornea softens (Lidocaine 4.0% is best for an extensive debridement)
• Gently scrub or pull epithelium toward the center of the epithelial defect
• Rub away the loose tissue
• Scrub the basement membrane with the blunt ends of the instruments to remove debris & promote better
adherence of new epithelium
SLIT LAMP CONSIDERATIONS
• Use right hand for left eye and left hand for right only if you are capable
• Otherwise use your dominant hand & crossover the patients face when necessary
• Have patient turn head as much as slit lamp headrest will allow to minimize nose interference
• Slit lamp hand rest posts are available to stabilize your hand during the procedure
• Alternatively rest your elbow on the table or place your elbow on a “cushion”
• Stabilize your hand by resting the 4th and 5th fingers against patients face
• Approach the FB removal instrument from an angle that the patient cannot see so as to diminish patient
apprehension.

Corneal Procedures
Figure 6.10 Foreign body removal at the slit lamp
INSTRUMENT MAINTENANCE & CLEANING
• Needles are already sterile if sealed in plastic

• Keep tools in a stainless steel tray of ZephiranHCl 1:750 with antirust tablets for prolonged storage
• Rinse the Zephiran or alcohol off with preserved saline irrigating solution
• With the instruments kept in sterile wrapping, autoclave sterilization is the best method to use
• Flame platinum coated instruments prior to use
• Hydrogen peroxide, bleach, alcohol or Cetylite chemical germicide are alternative to Zephiran HCl.
RECORDING
Draw and/or record the following:
• Location of the FB
• Size of epithelial defect
• Depth of penetration
• Edge quality (e.g. loose squamous epithelial edges, flaps or tags)
• Presence of edema with diameter, intensity & depth
• Instrument used
• Therapy initiated

Corneal Procedures
PRESSURE PATCHING
Pressure patching (PP) is performed following corneal FB removal, corneal rust ring removal and/or corneal
debridement. Therefore all pertinent testing has been performed prior to PP. The purpose of the PP is to promote
the healing process of the corneal epithelium by pressing the new cells down to the basement membrane. It also
provides symptomatic relief to the patient because constant blinking will cause irritation to the cornea and pain. At
this point, the issue of PP is controversial and its value is being questioned. PP may actually slows down the
healing process and provides little additional comfort to the patient. Therefore some practitioners will prefer not to
PP, especially in the case of small superficial abrasions.
The indications for pressure patching include:
• Abrasions with moderate to severe depth (up to basal cell layer or basal membrane)
• Loose epithelial edges
• Extremely large abraded area (> 4 to 6mm)
There are several ways to pressure patch but the intent is to tightly close the eyelids to prevent blinking. Besides
prolonging the FB sensation and discomfort to the patient, blinking tends to shear off new corneal cells and impairs
the healing process. If performed in an appropriate manner, the patch will press the basal layer of the epithelial cells
onto the basement membrane, increase cellular adherence & decrease corneal edema.
MATERIALS
• Pre-shaped sterile gauze eye pads

• Hypoallergenic paper, plastic or cloth adhesive tape
• Broad-spectrum topical ophthalmic antibiotic ointment
• Cycloplegic solution
• Hyperosmotic ointment (NaCl 5%).
PROCEDURE
• Lavage eye thoroughly with ophthalmic irrigating solution to reduce risk of secondary infection
• Instill cycloplegic the eye to reduce the pain & the risk of developing a secondary uveitis
• Instill broad-spectrum antibiotic ointment (~1cm ribbon) into the inferior cul-de-sac
• Place the patient’s head rests against headrest with eyes closed
• Wipe with alcohol swabs the forehead and cheek skin to remove skin oil
• This ensures proper tape adherence
• Push back hair from forehead and face (beard!?)
• Assess depth of orbit and prepare two to four pads in a stack
• Fold one in half and place it over closed lid
• Place two to four pads over folded pad at slight angle
• Using 15 to 18 cm strips of tape:
o Start at mid-forehead at an angle aiming directly over the middle of the pads
o Pull the skin of the cheek upward and pull the end of the tape tightly over it
o Start again at the mid-forehead a little closer to the nose bridge
o Curve this strip over the superior edge of the pads such that all are covered by the strip

Corneal Procedures
o Tape the end of strip tightly and firmly onto skin of cheek
o Start again at the mid-forehead but on the lateral side to cover the lower edges of the pads.
o Next place another strip over the first strip to cover the inner edge of the other strips & apply it tightly to the
cheek over the ends of all other strips.
• Advise the patient to take aspirin or ibuprofen if the pain persists
• Instruct the patient to leave patch in place until reexamination
• Reschedule the patient within 24-hour for follow-up.
Figure 6.11 How to apply and secure a pressure patch
Akorn Presspatch
In the case where the patient has a beard, the hypoallergenic tape does not adhere well, a patch can be held in
place with a specially designed plastic eye shield, held in place by an elastic and Velcro fastener.
Figure 6.12 Akorn presspatch

Corneal Procedures
Donaldson Natural Eye Patch
In a circumstance where a “light” or shorter duration patch is indicated or when medication must be applied
constantly applied to the eye, the conventional pressure patch is not the optimal method. For cases such as these,
the Donaldson Natural Eye Patch is available. The patch is T-shaped and it fastens to the cheek by a circular piece
of velcro and surgical tape. This design permits the patch to be lifted for instillation of medicine and re-fastened.
The Donaldson Natural Eye Patch is useful in cases of mild abrasions (e.g. lagophtalmos that present with
compromised abraded cornea) and cases of recurrent corneal erosions.
Figure 6.13 Donaldson natural eye patch
Inspired by Eskridge JB, Amos JF, Bartlett JD, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company,
1991.

Corneal Procedures
Contra-Indications
• Never apply a PP when a penetrating/perforating injury is suspected!

• Never apply a PP when mucopurulent, a sign of ocular infection, is present!
• Never apply a PP when the FB is organic in nature; the risk of fungal infection is present & would rapidly
deteriorate the cornea if patched!
• Never apply a PP on an abrasion that occurs in a CL wearer; the risk of Pseudomonas infection is present which
would rapidly ulcerate & perforate the cornea!
PP removal
• Gently remove the tape by pulling down on the skin of cheek & at the same time grasping with the other hand
the end of the first strip; lift it up from cheek to forehead
• Avoid adding skin irritation
• If an allergic reaction in the form of mild red erythematous patches under and around the taped areas appears,
treat with cold compresses or 1% hydrocortisone cream or nothing! It is usually self-limiting in a few days
• Assess the VA, the corneal abrasion and the associated ocular signs
• Mild to moderate striate keratitis (e.g. in Descemet’s membrane) may appear secondary to the mechanical
folding of the cornea; self-limiting within 2 to 3 days
• Mild to moderate abrasions usually heal in 24 -36 hrs
• Severe abrasions usually heal in 48 to 72 hours
• Re-patch if necessary & re-evaluate within 24 hrs.
Figure 6.14 Removing a presspatch
Inspired by Fingeret M, Casser L, Woodcome HT. Atlas of Primary Eyecare Procedures. Norwalk, Ct: Appleton & Lange; 1990.

Corneal Procedures
BANDAGE SOFT CONTACT LENSES (BSCL)
With the advancement of mid-high water and disposable SCL, an alternative to PP presents itself. Clinicians are
using mid-high water SCL with large diameters to cover the corneal abrasion. A low power or plano SCL with a base
curve on “K” or steeper is optimal. If the abrasion is too extensive to allow the reading of the corneal curvature of the
affected eye the curvature of the fellow eye can be used as reference. Medications must be instilled continuously
with this method. With the advent of disposable SCL and the controversy surrounding PP, bandage SCL may
become the optimal method for the treatment of abrasions. A comparison of advantages versus disadvantages
follows:
• Reduced corneal edema • Risk of pulling off epithelium (incomplete
• Reduced risk of infection (not a warm, healing)
moist environ) • Requires constant instillation of meds by
• Cosmesis patient
• Reduced risk of allergies to tape • Significantly less pressure is applied to
the eye
• Cost to practitioner
• Photophobia may present a problem
• Visual considerations (patient remains
binocular) • Cost to patient (may needs additional
Antibiotics)
• Visual considerations (monocular
dilation!)
Table 6.2 Comparison of advantages and disadvantages of bandage soft contact lenses
COLLAGEN SHIELDS
Collagen shields are recommended for use in cases of corneal abrasions or recurrent corneal erosions (RCE). They
are dissolvable contact-lens type patches. Collagen shields are very expensive when compared to the BSCL and
they are not as easy to handle.

EYELID PROCEDURES
AUTHOR
PEER REVIEWERS
TEAR MENISCUS (PRISM)
The measurement of the tear meniscus helps evaluate the tear volume.
PROCEDURE
• With the SL assess the height of the tear prism

• If possible measure using the reticule
• Compare the height between the two eyes
• Assess prior to manipulating the lids
• Use low lighting and high magnification
• Perform prior to instillation of medications
• Avoid bright light as it may stimulate reflex tearing.
INTERPRETATION
Average 0.4mm
Insufficient < 0.3mm
Ideal > 1.0mm
Gray Zone 0.3 – 1.0 (possible dry eye; consider patient’s symptoms)
Compare OD vs. OS
Normals: the border of the meniscus is straight or convex

Abnormal: the border may appear irregular or scalloped

Eyelid Procedures
NONINVASIVE BREAK UP TIME (NIBUT)
NIBUT evaluates tear film stability which is primarily a function of the mucin layer without the use of dye or any
device placed in the eye.
Keratometer or Xeroscope (an instrument that projects a grid pattern).
PROCEDURE
• No dye, no medication is placed in eye

• Instruct patient to blink several times
• Direct their gaze straight ahead
• Observe the mires or grid pattern
• Measure the time in seconds from the last blink to the development of the first discontinuity in the mires or grid
pattern.
INTERPRETATION
Abnormal < 5 seconds

Ideal > 10 seconds
Gray Zone 5-10 seconds (possible dry eye; consider patient’s symptoms)
TEARSCOPE
The tearscope is an instrument used in conjunction with a slit lamp to evaluate the pre-ocular tear film (POTF) and
pre-lens tear film (PLTF).
PROCEDURE
• Patient is seated at SL
• Turn off the SL illumination / turn on the tearscope illumination
• Magnification at least 20X
• Hold tearscope in front of the observation system close to the patient’s eye
• Focus on the POTF
• Measure the NIBUT and observe the tear film (TF) patterns
• To measure NIBUT, have patient blink and use the instrument’s digital timer to time the appearance of the first
dry spot.

Eyelid Procedures
INTERPRETATION
NIBUT
Marginal dry eye < 10 sec
Borderline dry eye 10- 20 sec
Stable tear film >20 sec
Tear Film Patterns (Compare to photos on Recognition Chart)

No apparent lipid layer: abnormal unstable tear film
Open meshwork: normal POTF with thin lipid coverage
Close meshwork: normal POTF with lipid coverage thicker than open meshwork
Wave (flow): normal POTF most common good lipid coverage
Amorphous: normal POTF most stable lipid coverage
Color-fringe: normal POTF with thick lipid coverage
INVASIVE TEAR BREAK UP TIME (TBUT)
TBUT evaluates the tear film stability which is primarily a function of the mucin layer.
PROCEDURE
• Place the fluorescein in the eye

• Avoid using excess fluid by shaking NaFl strip well before instillation
• Instruct patient to blink several times
• Direct them in the SL with their gaze straight ahead
• Observe the tear film using moderate magnification
• Measure the time in seconds from the last blink to the development of the first dark dry spot on the cornea
• Repeat 3 times and average.
INTERPRETATION
Abnormal < 5 seconds

Ideal > 10 seconds
Gray zone 5-10 seconds (possible dry eye; consider patient’s symptoms)

Eyelid Procedures
FLUORESCEIN STAINING
NaFl staining evaluates interpalpebral ocular surface integrity.
PROCEDURE
Fluorescein dye is instilled in the eye to assess the presence of staining erosions, abrasions or mucus.
INTERPRETATION
Fluorescein staining indicates the presence of eroded epithelial cells and mucus which commonly result from dry
eye. The staining pattern is characteristically, but not always, observed in the interpalpebral region where the eye is
most exposed.
ROSE BENGAL
Rose bengal (RB) helps evaluate ocular surface integrity by staining devitalized cells and mucus strands. In dry
eye assessment, this is more advantageous than NaFl because it stains cells at an earlier degenerative stage. Dry
eye may therefore be detected earlier.
PROCEDURE
With RB dye in the eye, note the presence of staining erosions, abrasions or mucus filaments especially in the
interpalpebral zone.
Note: Because RB may sting upon instillation, some sources recommend the use of anaesthetic. Instillation of
anesthetic, however, may disrupt the ocular surface and cause false positive staining. We therefore do not
recommend its use.
INTERPRETATION
RB staining indicates the presence of degenerated epithelial cells and mucus which commonly result from dry eye.
The staining pattern is characteristically, but not always, observed in the interpalpebral region where the eye is
most exposed.

Eyelid Procedures
LISSAMINE GREEN STAIN
The Lissamine green stain evaluates ocular surface integrity. Lissamine green is similar in function to RB because it
will stain degenerated cells and mucus strands/filaments. Lissamine green has the advantage over RB in that it does
not sting on instillation. Lissamine green is now commercially available.
PROCEDURE
With Lissamine green dye in the eye, note the presence of staining erosions, abrasions or mucus especially in the
interpalpebral zone. Grade the staining using the same scale as NaFl and RB and DRAW the location!
INTERPRETATION
Lissamine green staining indicates the presence of degenerated epithelial cells and mucus which commonly result
from dry eye. The staining pattern is characteristically, but not always, observed in the interpalpebral region where
the eye is most exposed.
Documentation of Staining
Clinically one can use available charts such as the CCLRU grading scale to grade the observed staining. In the
absence of these, however, one can use the following scale.
Grading Location
0 = No staining
1+ = Mild staining
DRAW!
2+ = Moderate staining
3+ = Marked/severe staining

Eyelid Procedures
SCHIRMER TEST
The Schirmer test measures the volume of the aqueous layer and the ability of the lacrimal glands to produce
aqueous. A special filter paper is inserted under the lids to collect and assess the tears produced by the eye. The
test can be performed in 3 ways:
Fig 7.1 Schirmer test
Inspired by Fingeret M, et al. Atlas of Primary Eyecare Procedures. Norwalk, CT: Appleton and Lange; 1990.
Schirmer # 1 Without Anaesthetic
• Bend paper strip at 5mm indent without touching strip directly (use instrument)
• Grasp end of paper with jeweller’s forceps to avoid oils from the fingers to alter test paper
• Bend at 5mm indent
• Place in inferior cul-de-sac at lateral edge of lid
• The patient can look straight ahead and blink normally
• The patient can also look down or gently close their eyes during test
• Leave in place for five minutes
• Remove paper strip
• Measure/record in millimeters the length of wetness from the bend.

Eyelid Procedures
Schirmer # 1 With Anaesthetic/Basal Secretion
• Anaesthetic is instilled several minutes prior to testing. This reduces reflex tearing.
• Grasp end of paper with jeweler’s forceps to avoid oils from the fingers to alter test paper
• Leave in place for five minutes
Schirmer # 2 With Anaesthetic and Nasal Mucosa Stimulation
• Anaesthetic is instilled several minutes prior to testing

• Grasp end of paper with jeweler’s forceps to avoid oils from the fingers to alter test paper
• Cotton swab inserted into nasal mucosa and gently rotated to stimulate reflex tearing
• Leave in place for two minutes
INTERPRETATION
#1 Without Anaesthetic #1 With Anaesthetic #2 Anaesthetic and Nasal Mucosa

Stimulation
Basal and reflex tear secretion Basal tear secretion only Separates basal and reflex tear
secretion
5 minute test time 5 minute test time 2 minute test time
Abnormal <10mm – 15mm Abnormal < 10mm Abnormal <15mm
Note: A variation of the Schirmer tear test is the Color Bar Schirmer Tear Test by Eagle Vision. The test paper is
impregnated with a dye which turns blue when it comes in contact with tears. Additionally a millimeter scale is
printed directly on the strip to facilitate readings.

Eyelid Procedures
MEIBOMIAN GLAND FUNCTION (MGF)
MGF is the last test to be performed because expressing lipids from the lid margin can alter other testing. In normal
functioning meibomian glands, lipid is released upon each blink. The lipid should be released along the entire lid
margin and it should appear clear like “baby oil”.
PROCEDURE
Gently express the glands digitally or with a cotton swab by applying pressure on the lid from base to margin. Note
signs of clogging or milky fluid expressed from glands.
INTERPRETATION
A clear oily fluid should emerge from the orifices of the gland. Apparent clogging of the glands or expression of a
“tooth paste” like material may indicate Meibomian Glands Dysfunction (MGD).
COTTON THREAD TEST
The Cotton Thread Test measures the volume of the aqueous layer. A special sterile yellow cotton thread is used
instead of a paper strip. The thread is impregnated with phenol red dye, which makes the yellow thread turns red
when wet by tears. Less invasive and irritating than the paper tear strip, it reduces the stimulation of reflex tearing.
The test may therefore be better to measure basal tear secretion. Recently FDA approved, it is now commercially
available.
PROCEDURE
• The cotton thread (70mm) is bent 3mm at the end using jewelers forceps
• The thread is placed in the inferior cul-de-sac temporally
• Test time is 15 seconds
• Remove thread
• Record in mm the length of red thread from the bend.
INTERPRETATION
Normal: 9 - 20mm
Symptoms of dryness correlate to measurements <9mm

Eyelid Procedures
TEAR FILM OSMOLARITY
Tear Film Osmolarity is performed to grade the osmolarity of the tear film. In patient’s with tear deficient dry eye
(TDDE) and evaporative dry eye (EDE), tear film osmolarity may be increased when compared to normals. This is
due to the fact that less aqueous content within the tears produces a higher concentration of electrolytes within the
tear film. Increased tear osmolarity usually occurs prior to Rose Bengal staining of the cornea and conjunctiva.
Unfortunately, this test is limited by availability of instrument.
PROCEDURE
• Tears are collected by capillary action into a glass micropipette

• The sample is then analyzed using an instrument termed an osmometer
• The osmometer correlates the freezing point of the sample to osmolarity.
INTERPRETATION
Normal: ~ 300 mOsm/kg

Abnormal: 312 - 330 mOsm/kg
TEAR PROTEIN ANALYSIS
Lysozyme Assay is an immunologic laboratory test of lacrimal gland function which measures the amount of
lysozyme within the tears. Lysozyme constitutes ¼ of the protein within the tear film. The amount of lysozyme may
be reduced in a patient TDDE compared to the normal population. This test is limited by the availability of laboratory
materials.
PROCEDURE
• A tear sample is taken by placing a filter paper disc in the inferior cul-de-sac
• The disc is placed on an agar plate which contains Micrococcus lysodeiktics
• The zone free of bacterial growth surrounding the disc is then measured.
INTERPRETATION
The measurement indicates the amount of lysozyme present in the tears. The quantity of lysozyme within the tears
decreases correspondingly with a decrease in lacrimal gland function.
The Lacoferrin Assay is an immunologic laboratory test of lacrimal gland function which is performed by the
lactoplate method and the lactocard method. It measures the amount of lactoferrin within the tears. Lactoferrin is a
protein found within the tear film. The amount of lactoferrin may be reduced in a patient with TDDE compared to the
normal population. The tests are limited by the availability of laboratory materials.

Eyelid Procedures
Lactoplate method
• A tear sample is taken by placing a filter paper disc in the inferior cul-de-sac
• The disc is placed on an agar plate containing rabbit anti-sera to human lactoferrin
• The ring of precipitate is then measured
INTERPRETATION
Normal 1.42 mg/ml

Abnormal <1 mg/ml
Lactocard method
• A tear sample is taken by using a glass capillary tube

• The sample is analyzed as a solid phase ELISA test
• The analysis instrument is a reflectance spectrometer
HISTOLOGIC TESTING
TDDE and EDE patients may suffer the effects of ocular surface disease which may include epithelial squamous
metaplasia or keratinization of the epithelial mucosa. Therefore, histologic tests have been developed to examine
these ocular manifestations.
Conjunctival Impression Cytology (CIC) is used to measure squamous metaplasia of epithelial and goblet cells of
the conjunctiva in patients with dry eye. The tissue sample is taken by placing a paper filter disc in the inferior
conjunctiva. The discs are then removed and placed on slides. With the use of histologic dyes the slides are then
examined microscopically . The test is limited by availability of laboratory materials.
Brush cytology measures the keratinized cell population of the conjunctiva in patients with dry eye. Samples are
taken from the temporal bulbar conjunctiva with a cytobrush. They are placed on a filter which is stained
histologically and examined microscopically. The test is limited by availability of laboratory.

CAROTID AND ORBITAL AUSCULTATION
AUTHOR
PEER REVIEWER
INTRODUCTION

• Loss of vision testing
• Carotid artery auscultation
• Orbital auscultation
LITERATURE REVIEW
PURPOSE
If a patient presents with a VA deficit that does not improve with refraction, it is necessary to pursue further testing.
The following tests are used to aid in the diagnosis for the non-refractive VA deficit:
Types of Diagnostic Tests

Amsler Grid Electroretinography (ERG)
Brightness & Color Comparison Visual-Evoked Potentials (VEP)
Photostress Recovery Electro-Oculography (EOG)
Contrast Sensitivity Function Carotid Artery Auscultation
Glare Evaluation Orbital Auscultation
Potential Acuity Assessment Deceptive Testing
Ultrasound
Table 8.1: Types of diagnostics tests that can be conducted to investigate non-refractive VA deficit

Carotid and Orbital Auscultation
CAROTID ARTERY AUSCULTATION
Carotid Artery Auscultation is usually performed when the patient is suspected of having carotid artery occlusive
disease caused by atherosclerosis. In carotid artery occlusion, the blood supply to the eye (Fig. 8.1) may be
decreased or be completely diminished, resulting in loss of vision. Carotid ausculation is usually done to complement
retinal findings associated to carotid artery disease, such as Hollenhorst plaque, venous occlusive disease, or
assymetric diabetic retinopathy. Symptoms of amaurosis fugax should also prompt carotid auscultation.
Figure 8.1: Anatomy of the blood supply to the eye from the carotid artery
Inspired by: Fingeret M, et al., Atlas of Primary EyeCare Procedures
AUSCULTATION
Auscultation is defined as using a stethoscope to listen to the physical signs of the body. Carotid auscultation
involves placing the stethoscope over the area of the carotid artery and listening to the sound of the blood flow
within. If a patient suffers from carotid occlusive disease the clinician may hear a bruit. A carotid bruit is heard as a
“swishing” sound that results from the turbulence of blood flowing through a partially occluded artery. Carotid bruits
are low-pitch sounds and are best heard with the bell of the stethoscope.
Procedure
• Perform in a room free of noise

• Turn the patient’s head slightly to one side
• Scan down the artery along the side of the trachea (Fig. 8.2a).
• Place the bell on the carotid artery just below jaw (Fig 8.2b).
• To intensify the noises, ask the patient to stop breathing.
• Listen for bruit or “swishing” sound.

Figure 8.2a Palpation of the carotid artery Figure 8.2b: Placement of the bell of the stethoscope
Inspired by: Fingeret M, et al., Atlas of Primary EyeCare Procedures
CLINICAL RELEVANCE
This technique is not very sensitive and often yields negative or incorrect results. Carotid occlusive disease may
have serious consequences if left untreated. One must therefore interpret carotid auscultation with utmost caution.
However, if a bruit is heard it may signify that the patient has carotid occlusive disease. There must be 50%
occlusion of the carotid artery to hear a bruit. If the bell is placed with too much pressure on the carotid artery, one
can partially occlude the vessel and induce a bruit sound, even on a healthy artery. If the bell is placed with too
much pressure over a vessel that is partially occluded, one may completely occlude the vessel. Therefore, one must
gently place the bell over the carotid artery to eliminate error and risk of complete artery occlusion.
If no bruit is heard, caution should be taken - if there is a 100% occlusion, a bruit will not be heard, because there is
no blood flow through the vessel. Ocular findings such as retinal plaques, rubeosis iridis, neovascular glaucoma,
venous stasis retinopathy, central and branch retinal artery occlusion, ischemic optic neuropathy or asymmetric
hypertensive retinopathy may indicate carotid artery disease and warrant a referral to general medicine. The patient
needs a cardiac and blood work up, as well as imaging of the carotid arteries with ultrasonography (carotid duplex
ultrasound).
ORBITAL AUSCULTATION
Orbital auscultation is indicated when a patient presents with a unilateral pulsating exophthalmos. Possible etiologies
of unilateral pulsating exophthalmous include orbital congestion due to space-occupying lesion, vascular anomaly
(Arterio-venous malformation), and edema (carotid-cavernous sinus fistula).
The patient may present with eyelid swelling, conjunctival injection and telangiectasia, chemosis, exophthalmos,
extra-ocular muscle restriction, diplopia, decreased visual acuity, and ocular discomfort.
Procedure

• Perform in a room free of noise

• Place the stethoscope bell over the closed eyelid (Fig. 8.3)
• Ask the patient not to breathe as the sound may obscure the vascular noise
• Listen for bruit or “swishing” sound for 10 seconds
• Ask the patient to listen for a swishing sound like running water (subjective response)
• Move the bell to the lateral canthus to enhance orbital sounds
• Auscultate the fellow eye for comparison of orbital sounds
Figure 8.3: Placement of the stethoscope over the eye

Source: Fingeret M, et al., Atlas of Primary EyeCare Procedures
CLINICAL RELEVANCE
If a bruit is heard, it may signify that the patient has one the above mentioned conditions. The patient should have a
neurological exam to differentiate between the various conditions in order for proper treatment to be initiated.

BRIGHTNESS, COLOR COMPARISON AND
PHOTOSTRESS RECOVERY TESTING
AUTHOR
PEER REVIEWER
INTRODUCTION

• Brightness and colour comparison
• Photostress recovery
BRIGHTNESS AND COLOUR COMPARISON
Comparison of brightness and comparison of colour are usually performed when the function of the optic nerve or
the visual pathway is questioned, especially in asymmetric cases. It is often used in complement to pupil testing,
colour vision and other neuro-ophthalmological tests.
BRIGHTNESS COMPARISON
Material needed
Light source (penlight, torch, transilluminator, ophthalmoscope, etc.).
Procedure
• Patient wears best Rx
• Occlude ‘affected’ eye
• Hold light source in front of patient, at near (20 - 40 cm)
• Ask patient to always look at light source
• Quickly change occlusion to healthy eye. Continue alternating occlusion, every 1-3 seconds.
• Ask patient to compare brightness between each eye
• If there is a difference, determine in which eye the light appears brighter
• Place a value on the difference.
E.g. If the “brighter light” eye = 100, how much is the intensity of the light in the other eye worth?

Brightness and Colour Comparison
COLOUR COMPARISON (AKA COLOUR DESATURATION, RED CAP TEST)
Material needed
• Red bottle caps (e.g. from mydriatic or cycloplegic drop bottle)

OR
• Ishihara or other pseudoisochromatic plate (preferred, as reflections from bottle caps may cause erratic results).
Procedure
• Patient wears best correction

• Present the ishihara plate or a red bottle cap at 40cm
• Alternate occlusion of eyes
• Ask patient to compare the colour between each eye
• If there is a difference, determine in which eye the colour appears brighter
• Place a value on the difference as above.
CLINICAL RELEVANCE
Any disorder that damages a portion of the visual pathway has the potential to affect brightness and colour
perception. The disorders include: inflammatory, infectious, vascular, neoplastic, idiopathic multisystem disorders
and retinal disease or detachment. Reliability may be affected by patient's interpretation of the test and lighting
conditions.
PHOTOSTRESS RECOVERY
Photostress recovery is usually performed when the integrity of the macula is in question. The test is used to
diagnose & monitor macular disorders & differentiate between macular and optic nerve (ON)disorders.
The photostress recovery test measures the amount of time needed for the macula to return to normal functioning
following exposure to an intense light source. When the macula is exposed to an intense light source, the
photoreceptors are bleached and are temporarily impaired, because the rhodopsin in the photoreceptors decreases.
If there is a disorder within the photoreceptors, RPE or choriocapillaris, the time it takes for the macula to regenerate
rhodopsin and recover is extended.
Procedure
• Record best VA (BVA) – for best results, should be above 6/24

• Dim room illumination
• Dark adapt eyes for 1 minute
• Occlude non-tested eye
• Place light source (penlight, transilluminator, ophthalmoscope) 2-3 cm from eye
• Tell patient to directly view light source for 10 seconds
• Remove light source and isolate the line of letters just above bva
• Record the time in seconds that it takes for the patient to read 1/2 the letters within the line.

Brightness and Colour Comparison
E.g. If BVA is 6/12, record the time it takes for the patient to read 1/2 of the letters of the isolated 6/15 line after
photostress.
CLINICAL RELEVANCE
The average normal recovery is less than 30 seconds; abnormal eyes recovery is usually greater than 60 seconds.
The test is an indication of macular function. Macular disorders may extend the time it takes to regenerate
rhodopsin. Such conditions are: Central Serous Retinopathy (CSR), Macular Edema, Wet and Dry ARMD, Serous
Detachment of RPE, Macular Cyst, Chloroquine Maculopathy, and various inflammatory or degenerative processes.
The test helps differentiate between loss of vision (LOV) that is due to ON causes from macular affections. A
macular disorder may impair recovery time. An ON disorder will not impair recovery time. Reliability of the
test may be affected by various factors. Patients over 40 will demonstrate a symmetric increase in their “normal”
recovery time. Finally, the validity of the test markedly decreases when the initial BVA is < 6/24.

DECEPTIVE TESTING
AUTHOR
PEER REVIEWER
INTRODUCTION
• Methods employed to investigate malingering or hysteria
INTRODUCTION
Deceptive Testing is usually performed when there exists a question of malingering or hysteria on the part of the
patient. If the patient complains of loss of vision (LOV) that is not proven diagnostically, it is necessary to
determine if the visual loss is due to malingering or hysteria.
Different methods are implemented to fool the malingerer or hysteric into seeing better than they are admitting to.
The procedures demonstrated are based on patient presentation.
PATIENT REPORTING NO LIGHT PERCEPTION
• Test the pupil reactions. If an eye truly has no light perception, the pupil will not react to the light (unless the
blindness is cortical in nature) and an afferent pupillary defect should be present.
PATIENT REPORTING VISION BETWEEN HAND-MOTION AND NO LIGHT PERCEPTION
• Test the pupils.

• Move a mirror slowly side to side in front of the eye in question and watch for eye movements. If there are eye
movements to fixate on the mirror, there is likely vision in that eye.
• Rotate an optokinetic drum or tape in front of the eye in question. Patch the non-tested eye. If a corresponding
optokinetic nystagmus is present, there is likely vision in that eye .

Deceptive Testing
PATIENT REPORTING VISION BETWEEN 6/12 AND 6/120
• Ask what time it is. Digital numbers on a watch are equivalent to a 6/12 - 6/18 target. If they look at their watch
and respond to the question, their vision is likely ranging from 6/12 to 6/18.
• Test near VA. If they report a normal level at near, then their distance VA should correspond.
• Retest the VA with a 3 meter chart. Compare the results to the Snellen projector recording.
• Start VA testing from the 6/3 (or smallest available) line. Offer the patient reassurance. Tell them that you will
show them an easier line. Then show the 6/4.5 (or second smallest) line and encourage them to read it. Proceed
up the chart in the same manner - you are likely to obtain a higher VA value (perhaps up to 6/9) than with the
traditional measurement.
• In a trial frame or in the phoropter, insert plano, very low power lenses or 2 powered lenses that cancel each
other out (e.g. a -3.00 D lens on top of a +3.00 D lens). Tell the patient that you are using very powerful lenses
that should correct their vision. Ask them to read the chart. VA will most likely improve. This is very useful with
malingering children.

CONTRAST SENSITIVITY FUNCTION
AUTHOR
PEER REVIEWER
INTRODUCTION
• Contrast sensitivity function (CSF)
CONTRAST SENSITIVITY FUNCTION (CSF)
CSF is usually performed when the integrity of the visual pathway is questionable or when media opacity is present.
CSF tests the patient's ability to differentiate between a light and dark stimulus by assessing the perception of black
on white. The test stimulus is usually an alternating light and dark stripe pattern. A number of CSF analyzers are
available: the Arden Contrast Sensitivity System, the Vision Contrast Test System (VCTS) 6000, the VCTS 700S,
the VCTS 6500 (Fig. 11.1), the B-VAT II-SG, the MCT 8000 and the Terry Vision Analyzer. The VCTS 6000 and
VCTS 6500 are the most commonly used.

Contrast Sensitivity Function
Figure 11.1: VCTS 6500
From Eskridge JB, et al, Clinical Procedures in Optometry
The contrast pattern or sinusoidal grating consists of alternating light (maximum luminance) and dark (minimum
luminance) stripes. The contrast equals the difference between the maximum and minimum divided by the sum of
the maximum and minimum.
Contrast = (Lmax − Lmin) / (Lmax + Lmin)
Multiplying the ratio by 100 gives the contrast percentage. The visual angle between the stripes equals the spatial
frequency.
The smaller the angle, the higher the spatial frequency and vice versa. In the normal population, as spatial
frequency increases, contrast sensitivity decreases (Fig. 11.3).

Figure 11.2: Fringe Pattern
Figure 11.3: Contrast Sensitivity Function (CSF): Spatial Frequency vs. Contrast Sensitivity
Procedure
• Patient wears best Rx

• Contrast chart is uniformly illuminated
• Patient positioned at distance indicated by test
• Ask patient to identify orientation of stripe patterns
• Identify circle pattern orientation from left to right

• Endpoint for each row is the first incorrect response

• Document responses on an evaluation form and compare results to normal CSF.
CLINICAL RELEVANCE
Any disorder that damages a portion of the visual pathway has the potential to affect the CSF. When a patient
manifests a high spatial frequency loss, it is closely related to a decreased VA. When a patient manifests a low
or medium spatial frequency loss, it is related to mobility deficits and/or facial recognition.

GLARE EVALUATION AND POTENTIAL
ACUITY TESTING
AUTHOR
PEER REVIEWER
INTRODUCTION
• Glare evaluation
• Potential acuity testing
GLARE EVALUATION
Glare Evaluation is usually performed when light scatter from media opacity negatively affects visual performance.
Light scatter is produced from sunlight, headlights of automobiles or highly reflective surfaces. Evaluation of the
disability imposed by glare is useful in the presence of corneal and lenticular opacities, following cataract surgery,
refractive surgery and/or keratoplasty.
Glare evaluation usually involves a source of light to induce light scattering. Visual performance is then measured in
terms of VA or contrast sensitivity. One can use a penlight, transilluminator, ophthalmoscope or an instrument
specifically designed for glare evaluation. Several devices are commercially available: Miller-Nadler Glare Tester,
Optec 1500 Glare Tester, Mentor Brightness Acuity Tester (BAT), MCT80000 and Terry Vision Analyzer (TVA). The
various devices are either hand-held or fixed and each varies slightly in procedure but the fundamental principal is
similar in all. The BAT and Miller-Nadler Glare Tester are the most commonly used. The general procedure
follows.

Glare Evaluation
PENLIGHT, TRANSILLUMINATOR OR OPHTHALMOSCOPE
• Record BVA
• Place light 30-40cm from the eye and 15-30°from the optic axis
• Allow patient to adapt to glare source for 30 seconds
• Ask patient to report smallest visible line on chart.
GLARE EVALUATION DEVICES
• Record BVA
• Seat patient in front of device
• Tell patient to view chart through aperture or screen
• Allow patient to adapt to glare source for 30 seconds
• Ask patient to report smallest visible line on chart or lowest contrast target visible
• Measurement is recorded as BVA or contrast sensitivity threshold.
CLINICAL RELEVANCE
Patients who have corneal, lenticular opacities or have a history of surgeries that affect the ocular media may suffer
disability from glare. Daily functioning such as being exposed to sunlight, headlights, streetlights or highly reflective
surfaces may impair visual performance. Various treatment options and support organizations are available to
patients impaired by glare. Reliability of results is affected by the type of instrument used for evaluation.
Procedures vary, glare sources vary (from a point source of light to a surrounding source of light), and recordings
vary (from a measurement of VA to a measurement of contrast sensitivity function). Overall, the lack of uniformity
among instruments is responsible for the low reliability of measurements.
POTENTIAL ACUITY TESTING
Potential acuity testing is usually performed when visualization of the retina is obscured by poor media clarity. The
procedure helps predict the potential retinal VA measurement “behind” the obstruction. Clinically, it is most useful in
the presence of cataracts, opacified capsule secondary to cataract surgery, keratoconus or amblyopia. There are
three types of potential acuity tests: the Potential Acuity Meter (PAM), the interferometer and the retinometer.
POTENTIAL ACUITY METER (PAM)
The PAM projects a Snellen chart or number chart of black optotypes on a white background onto the retina. The
light forming the chart is diffracted by Maxwellian View through a 0.1mm transilluminated aerial aperture and then
directed through a condensing lens within the system. Upon leaving the system, the light travels through the ocular
media and around opacities to converge onto the retina.
PROCEDURE
• The PAM is mounted on the slit lamp

• Room illumination is dim and slit lamp illumination is off
• Patient is dilated and positioned in the SL
Glare Evaluation
• The dioptric power control is set to account for refractive error

• The light projected is a red background with a white dot
• Instruct the patient to gaze 10° lower than the optic axis
• Focus the light into the pupil through a “window” in the opacity
• Ask to read the smallest line of the chart that is clearly visible
• The patient must correctly identify 3 characters on a line to reach an endpoint measurement. VA levels ranges
from 6/6 to 6/120.
INTERFEROMETER AND RETINOMETER
The interferometer and retinometer use a neon-helium or white incandescent bulb which emits two 0.1mm diameter
coherent light beams. By diffraction (Maxwellian view) the coherent beams pass through the ocular media, overlap
and produce a striped fringe pattern which focuses on the retina. The available instruments are the Randwal IRAS
interferometer and the Haag-Streit Lotmar Visometer and the Rodenstock Retinometer.
Procedure
• Room illumination is dim

• Patient is dilated and comfortably seated (at SL if indicated)
• Demonstrate stripe pattern to patient
• Ask patient to indicate orientation of stripe pattern
• Start at a low VA level and progress to finest grating visible
• Measurement is recorded from instrument in a reading display.
CLINICAL RELEVANCE
Potential acuity testing is an indication of retinal function. It is useful when considering cataract surgery, laser
capsulotomy, keratoplasty or visual therapy for amblyopia. The results from potential acuity assessment vary. The
PAM tends to give more falsely low predictions. Interferometers and retinometers tend to give more falsely high
predictive results. Insufficient dilation, severely dense cataracts, poor patient cooperation, fatigue, fixation and
posture can all adversely affect the reliability of the measurements.

OPTICAL COHERENCE TOMOGRAPHY (OCT)
AUTHORS
Mark Dunbar: Bascom Palmer Eye Institute, University of Miami
Sarah McGowan: Mzuzu University
PEER REVIEWER
Jean-Sébastien Dufour: University of Montreal
INTRODUCTION
Optical coherence tomography (OCT) imaging can be used in many biological tissues, but has gained significant
popularity amongst eye care providers for imaging structures of the eye, including the retina, optic nerve head, and the
retinal nerve fiber layer (RNFL), for the purposes of clinical diagnosis and monitoring of human retinal and optic nerve
disease. OCT technology, when applied for ophthalmic clinical use, offers a non-contact, non-invasive, qualitative,
quantitative and repeatable imaging option to make diagnoses, as well as observe and monitor in vivo details of
biological tissues in the eye that are otherwise invisible to the clinician during standard ophthalmoscopy and slit lamp
examination. While OCT is not intended to make a diagnosis in lieu of a clinical exam, OCT technology has provided
new insights into the pathology of ocular diseases and has rapidly become a component of the clinical management of
certain disease processes.
Figure13- 1. OCT Spectralis (Heidelberg Engineering). Retinal scan, foveal cross-section superimposed over a 2-D false colour
retinal image. Spectralis OCT has the software to produce video-style images through consecutive areas of retina as well as 3-D
images of retinal anatomy and topography. With OCT technology, the retinal layers can be differentiated and retinal thickness can
be measured.

Ocular Coherence Tomography
PRINCIPLES OF OCT
The image recovered with the OCT is similar to ultrasound B-scan imaging. Cross-sectional images of the retina are
produced using the optical backscattering of light in a fashion analogous to B- scan ultrasonography, except that light
is used instead of sound waves to formulate the image. The image is created by a superluminescent diode light laser
(810 nm) that is scattered, reflected and absorbed by the tissue. The resultant cross-sectional image is made up of
thousands of A-scans (one-dimensional images). The resolution of OCT systems is set by the coherence properties of
the light source. A spatially uniform, low-coherent (white light) beam of light is generated from a superluminescent
diode or laser diode to obtain high resolution images. Low coherence light allows for a propagation speed nearly one
million times faster than sound.
Figure 13-2. Basic optical principles of a modern OCT setup. Light is transmitted into the eye via fiber optic delivery system. Prior
to ocular transmission, the near infrared beam of light is split at a coupler into 2 separate paths. One beam is directed into a
reference mirror (reference beam). The other is directed into the eye (probe beam). Light from both beams are then reflected back
from the eye and recombined within a fiber-optic interferometer. The temporal (time or echo delay) information contained in the
resulting interference pattern is the basis by which OCT images are constructed.
The image is displayed by using a logarithmic “false colour” scale, in which the log of the backscattered light intensity
corresponds to a colour scale. The intensity of the light is dependent upon the optical properties (index of refraction) of
the tissue layer being imaged. Highly reflective (eg. pigment, blood) layers are shown in red. Although the OCT image
can be displayed in colour, many clinicians prefer to use the black and white image because it often offers a greater
perception of the details.
Figure 13-3. Stratus OCT. Normal foveal pit and macula.

CHOICE OF CLINICAL INSTRUMENT
OCT OR ULTRASOUND?
There are different factors involved in determining whether OCT or ultrasonography is of better clinical usage.
OCT
 Detailed imaging, 10 to20X higher resolution compared to ultrasound
 Image tissues that are optically accessible – if you can’t see through it, neither can the OCT
o Dense cataract, vitreous hemmorrhage, corneal opacity
 No corneal contact
Ultrasound
 Imaging through opaque media
 Direct corneal contact
 Tissue differentiation and dynamic properties, i.e. vascularity
BENEFITS TO OCT / ADVANTAGES OVER OPHTHALMOSCOPY
 Objective
 Quantitative
 Non-contact to patient (ophthalmoscopy is also a non contact technique)
 Operable by technician with minimal training
 Larger field of view
 Detailed imaging of retinal layers and abnormalities missed in ophthalmoscopy
 Repeatable and reproducible results
 Software for monitoring progression
 Optic disc, RNFL and retina can be imaged through an undilated pupil
Quantification combined with reproducibility and reliability of results allows for better/earlier determination of
progression, earlier intervention, and determination of resolution of a disease. This can also be beneficial in a clinical
context of monitoring efficacy of treatment with an unaltered visual acuity.
MEASUREMENT AND IMAGING ERRORS IN OCT
 Poor fixation
 Movement (less of a problem with SD-OCT)
 Blinking
 Improper placement in the machine (e.g. head not against forehead rest)
 Cloudy media
 Vitreous opacities
 Staphyloma,
 ONH and RNFL edge of retinal pigment epithelium (RPE) may be altered - peripapillary atrophy, degenerative
myopia, high refractive error
 Tilted optic nerve
 Optic disc drusen
 Peripapillary sectoral pigmentary changes
POSTERIOR SEGMENT OCT
The original design of OCT was based on time and distance measurements and is identified as time-domain
technology or a time-domain OCT (TD-OCT). The machine was setup to determine the echo time delay and intensity
of reflected light (Hee et al 1995). Developed in the early 1990’s (Huang 1991), OCT technology has developed into
powerful imaging technology that can produce in vivo, real time imaging of tissues with a resolution between 3 and 15
µm.

Current devices
 Time domain OCT – 5-10 µm resolution
o OCT Stratus (Carl Zeiss, Meditec, Dublin, CA)
o Mechanical moving reference mirror performs each A-scan
 Fourier/Spectral/High speed/High Definition OCT– 3-5 µm resolution (Wojtkowski et al 2005) (diameter of a
red blood cell is 7 µm)
o Cirrus High Definiton OCT (HD-OCT) (Carl Zeiss, Meditech, Dublin, CA)
o RTVue 100 (Optovue, Fremont, CA)
o Spectralis HRA+OCT (Heidelberg Engineering, Vista, CA)
o Optical Coherence Tomography RS-3000 Advance (Nidek, Japan)
o OCT/SLO Combination Imaging System (Optos, Inc Dunfermline, UK)
o 3D OCT-2000 Spectral Domain OCT (Topcon Medical Systems, Tokyo, Japan)
COMPARISON OF TD AND FD OCT
With TD-OCT, information accumulates along the longitudinal direction of the retina, one pixel at a time, and 1024
pixels per A-scan. In 1.28 seconds, 512 A-scans (1D) are collected and a B-scan (2D) image is created.
With FD-OCT, the reference mirror is stationary and the image is captured using a fast transfer rate CCD camera. A
spectrometer analyses the signal by wavelength and the resulting spectral interferogram is converted by Fourier
transform to a typical A-scan image. With new commercially available SD OCT, the speed of acquisition can go up to
68 000 A-scans per second, enabling higher resolution compared to time domain OCT. The speed is faster than eye
movement so eye movement does not degrade the image quality to the same extent.
Technology is rapidly advancing with new manufacturers on the market. Competition is lowering the cost and
increasing the accessibility and usage of OCT in optometry clinics.
New technology in SD-OCT

 Improving software
 Noise reduction/over sampling technology that provides higher resolution imaging
 Improvements in 3D rendering
 Enhanced depth imaging – imaging choroid
 Automatic Fovea Finding
 Progression analysis software
 Expanded normative data bases
It is important to remember that due to different imaging characteristics between OCT’s (namely time domain versus
spectral domain machines), the clinician must establish a new baseline data set if switching machinery when
managing or following progression of disease on a patient.
CLINICAL APPLICATION
Posterior pole scanning using the “Fast Macular Scan” in which a 6 mm area is scanned (6 line scans), thereby
providing a 2-D 360 degree thickness map divided into three circular macular sectors, 1mm, 3mm, and 6 mm from the
fovea. Quantification of the retinal thickness is depicted in the parameter display. Thicker areas of retina are in
red/yellow while thinner retinal areas are shown in blue. The normal fovea is 200 ± 20 um thick and displayed in blue.
A difference of more than 30 um between the two eyes is often considered suspicious. This scan provides a rapid
assessment of the entire macular area. A shortcoming of this, however, is that should a lesion fall between the six
scanned line areas, it may be missed. In addition, the information between line scans is extrapolated, which leaves
room for error.

Figure 13- 4. Retinal photo with overlay of macular scan as performed by Stratus OCT. Line scans in 6 directions in a circle
centred on the fovea.
Figure 13- 5. (1) Stratus OCT line scan through fovea with incomplete macular hole OD. (2) Corresponding macular thickness
map.

Figure 13- 6. Stratus OCT. Labeled retinal layers.
Figure 13-7. Macular cube scan as seen with Cirrus HD-OCT centered on the fovea. Cirrus scans the entire area within the larger
box.
Figure 13-8. Cirrus HD-OCT. Normal retina with layers labeled.

Figure 13-9. 50 µm histological section of retina. SD-OCT image indicating corresponding layers image.
Figure 13-10: Retina layer (Cirrus HD OCT)
Figure 13-11. Cirrus HD-OCT printout Macular cube OS. Image is centered on fovea with adjacent retinal thickening.

Another clinical application of high resolution OCT is visualization of the interface between the inner segments (IS)
and outer segments (OS) of the retinal photoreceptor layer. The IS/OS line is termed the photoreceptor integrity layer
(PIL), and, as such, an intact PIL imaged with OCT is an indication that the photoreceptor layer has maintained
integrity in the presence of any ongoing pathological process. This interface is affected in disease of the outer retina
and, intact or not, is invisible to the clinician with ophthalmoscopy.
GENERAL CLINICAL USE OF OCT

 High resolution evaluation of retinal anatomy
 Diagnosis of macular conditions difficult to establish with biomicroscopy
 Quantitative assessment of retinal and vitreoretinal anatomic alterations
 Objective means for monitoring disease progression and/or therapeutic response
o For example, resolution of oedema following treatment, progression, repeatability. Oedema and
thickness cannot be calculated with ophthalmoscopy,
COMMON PATHOLOGIES THAT ARE OBSERVED OR MONITORED WITH OCT
 Vitreomacular traction
 Optic neuropathies that affect the RNFL
 Outer retinal dystrophies (PIL)
 Retinal tumors
 Retinal detachment
 Retinoschisis
 Diabetic retinopathy
 Macular oedema
 Macular hole
 Central serous chorioretinopathy (CSCR)
 Macular degeneration
 Occult choroidal neovascular membranes (CNVM)
 Retinitis
 Choroiditis
 Choroidal degeneration.

CLINICAL EXAMPLES WITH CIRRUS HD-OCT
Figure 13-12: Epi-retinal membrane. Note the fine hyper-reflective layer on the surface of the retina. Epi-retinal membrane is often
associated with an important thickening of the retina.
Figure 13-13: Epi-retinal membrane associated with an irregularity of the IS/OS layer

Figure 13-14: Full thickness macular hole with operculum over the hole. Note the important oedema at the edge of the hole.
Figure 13-15: Full thickness macular hole with retinal atrophy around the hole

Figure 13-16: Stage 1 macular hole
Figure 13-17: Pigment epithelial detachment (PED)

Figure 13-18: Central serous retinopathy
Figure 13-19: Small pigment epithelial detachment with an overlying neurosensory retinal detachment, associated with central
serous retinopathy

Figure 13-20: Macular degeneration: drusen
Figure 13-21: Macular degeneration: RPE atrophy

Figure 13-22: Pseudo-vitelliform degeneration
Figure 13-23: Macular degeneration: CNVM with sub-retinal and intra-retinal fluid

Figure 13-24: Cystoid macular oedema (CME) following cataract surgery
Figure 13-25: Serous detachment and CME secondary to Central Retinal Vein Occlusion (CRVO)

Figure 13-26: Macular oedema in a patient with diabetic retinopathy
Figure 13-27: Hydroxychloroquine maculopathy with loss of the IS/OS junction

Figure 13-28: Foveoschisis in a patient with staphyloma
Figure 13-29: Foveoschisis in a patient with myopia

Figure 13-30: Retinitis pigmentosa. Note the lost of the IS/OS junction line
Figure 13-31: Drusen with pigment epithelial detachments showing Bruch’s membrane
Figure 13-32: Choroidal neovascular membrane

Figure 13-33: Branch Retinal Vein Occlusion (BRVO) with cystoid macular oedema
OCT IN GLAUCOMA
Compared to standard methods for diagnosis and monitoring of glaucoma (visual field, intraocular pressure (IOP),
subjective evaluation of optic nerve), there is a need for objective testing that can reliably detect those patients who
may have glaucoma and/or are at risk of developing glaucoma. Advanced software on newer OCT’s allows for
glaucoma progression analysis as well as analysis of the ganglion cell layer.
The Stratus OCT RNFL analysis uses a series of 4 mm long radial line scans at 12 clock hours around the disc
allowing for topographic measurement of the optic disc as well as quantification of the RNFL thickness in four
quadrants around the disc. The instrument uses the termination of Bruch’s membrane to determine the edge of the
disc. Disc parameters include cup volume, disc area, cup and rim area, and cup to disc ratios. RNFL thickness data
are collected in a circular area 3.37 mm in diameter around the ONH. A peripapillary cross sectional image is obtained
and displayed as a temporal-superior-nasal-inferior-temporal (TSNIT) curve. Using this scan protocol, the patient’s
curve is displayed within a 5-95% confidence interval of normative data for that patient’s age group. The statistical
significance of any abnormal areas is depicted in yellow (borderline) and red (outside) normal limits.
The protocol for ONH and RNFL analysis on the Cirrus OCT is similar with data collected in a 6 mm X 6 mm square
area centred on the optic nerve head. The scan performed with Cirrus, as with the retinal scanning, covers the entire
area of the disc with 200 A-scans performed to accumulate the data set. The Cirrus, like Stratus, offers detailed
information about the ONH and RNFL and comparisons between eyes.

Figure 13-34. Stratus OCT glaucoma RNFL analysis
Figure 13-35. Cirrus OCT Glaucoma protocol

Figure 13-36. Cirrus OCT combined RNFL and ONH information printout with more detailed disc information in the box at the top of
the printout.
OCT also enables the practitioner to measure the complex formed by the ganglion cell and the inner plexiform layers
in the macular area. Recent studies have shown that early glaucoma damage often takes place in the macular area
and that the measurement of the ganglion cell and inner plexiform layer can help in the diagnosis and follow-up of
patient with glaucoma.
Figure 13-37: Measurement of the complex formed by the ganglion cell and inner plexiform layers in the macula can help in the
diagnosis and follow-up of glaucoma.

Figure 13-38: Ganglion cell analysis perform by Cirrus OCT
Regarding glaucoma, clinical research has shown the following:

 OCT has the ability to detect early glaucoma change by measuring NFL thickness
o Particularly inferior quadrant
o Often before visual field (VF) loss
 The nasal side of the optic nerve is affected earlier and more than what is usually considered
 Average and quadrant NFL thickness have good correlation with associated mean deviation and visual field
findings.

ADDITIONAL RESOURCES
Schuman JS, Puliafito CA, Fujimoto JG. Ocular coherence tomography of ocular disease. 2004. 2 nd ed. Slack, Inc.
Thorofare, NJ.
REFERENCES
 Hee MR, Izatt JA, Swanson EA et al. Optical coherence tomography of the human retina. Archives of
Ophthalmology, 1995. 113(3):325-332
 Horn FK, Mardin CY, Laemmer R, et al. Correlation between local glaucomatous visual field defects and loss
of nerve fiber layer thickness measured with polarimetry and spectral domain OCT. Invest Ophthalmol Vis Sci.
2009 May;50(5):1971-7.
 Huang D, Swanson EA, Lin CP et al. Optical coherence tomography. Science; 1991, 254(5035):1178-1181
 Lan YW, Henson DB, Kwartz AJ. The correlation between optic nerve head topographic measurements,
peripapillary nerve fiber layer thickness, and visual field indices in glaucoma. Br J Ophthalmol. 2003
Sep;87(9):1135-41
 Lee EJ, Kim TW, Park KH, et al. Ability of Stratus OCT to detect progressive retinal nerve fiber layer atrophy
in glaucoma. Invest Ophthalmol Vis Sci. 2009 Feb;50(2):662-8.
 Leung CK, Cheung CY, Weinreb RN, et al. Evaluation of retinal nerve fiber layer progression in glaucoma: A
study on optical coherence tomography guided progression analysis. Invest Ophthalmol Vis Sci. 2010
Jan;51(1):217-22.
 Mardin CY, Horn FK, Jonas JB, Budde WM. Preperimetric glaucoma diagnosis by confocal scanning laser
tomography of the optic disc. Br J Ophthalmol. 1999 Mar;83(3):299-304.
 Medeiros FA, Zangwill LM, Alencar LM. Detection of glaucoma progression using Stratus OCT retinal nerve
fiber layer, optic nerve head, and macular thickness measurements. Invest Ophthalmol Vis Sci. 2009
Dec;50(12):5741-8.
 Wojtkowski M, Srinivasan VJ, Fujimoto JG et al. Three-dimensional retinal imaging with high-speed ultrahigh
resolution optical coherence tomography. 2005. Ophthalmology 112 (10):1734-1746.
 Wolf-Schnurrbusch UE, Ceklic L, Brinkmann CK, et al. Macular thickness measurements in healthy eyes
using six different optical coherence tomography instruments. Invest Ophthalmol Vis Sci. 2009 Jul;50(7):3432-
 Yüksel N, Altintas O, Ozkan B, et al. Discriminating ability of optical coherence tomography data in staging
glaucomatous damage. Can J Ophthalmol. 2009 Jun;44(3):297-307.

ULTRASONOGRAPHY
(OCULAR ECHOGRAPHY)
AUTHOR
PEER REVIEWER
INTRODUCTION
• Introduction
• Theory
• Instrumentation
• Clinical indications and contra-indications
• Procedure
• Normal findings
• Abnormalities
• Orbital diagnosis
ULTRASONOGRAPHY
Ocular echography, or ultrasonography, is a commonly utilized technique to measure intraocular distances, including
axial length, in clinical situations. In addition, ultrasound has become an important tool because it can be used to
detect and characterize the soft tissue of the eye and orbit, even in the presence of intervening opacities.
Diagnostically, it can also be used to detect, visualize and differentiate masses or foreign bodies within the
structures of the eye.
Ultrasound is advantageous in comparison to other available imaging techniques in that it is non-invasive, produces
no tissue irradiation or known side effects, is quick, convenient, and relatively inexpensive. It is also particularly well
suited for soft tissue imaging. However, it has low resolution when compared to other techniques (e.g. magnetic
resonance imaging or computed tomography) and is very dependent on examiner skill.

Ultrasonography
THEORY
Ocular echography involves the use of high frequency acoustic energy (sound waves) that is generally above the
audible frequencies (usually above > 20 000 Hz). The typical frequencies used in diagnostic ophthalmic ultrasound
are in the range of 1 to 25 MHz.The higher frequencies have shorter wavelengths and provide better spatial
resolution than lower frequencies. However, the lower frequencies (and longer wavelengths) penetrate deeper into
tissues before the energy is absorbed. The exact frequency used in ophthalmic work depends on the desired
assessment. In general, high frequency ultrasound is used for measurements of the anterior segment while lower
frequencies are used to determine axial length and to evaluate retrobulbar structures.
Acoustic (sound) waves penetrate through opaque tissues at varying speeds depending on the acoustic density of
the tissue (Table 1). Acoustic impendence refers to the resistance of sound flow through a media and is dependent
on acoustic density.
At the borders of density changes, the waves are reflected (echoes) or transmitted (refracted) according to the
properties of the acoustic interface, namely its size, shape, smoothness and acoustic impedance. The acoustic
impedance is a direct function of the density of the adjacent substances. The higher the acoustic density of a tissue,
the greater is the impedance of the transmitted waves as well as the greater the reflection of echoes.
Ultrasonography makes use of the resulting echoes and wave changes to determine the location and characteristics
of the different tissues under examination.
Media Sound Velocity (m/sec)

Water 1480
Aqueous (aqueous and vitreous) 1532
Cornea 1550
Soft Tissue 1550
Lens 1640
Bone 3500
Table 14.1: Velocity at which sound waves penetrate through various tissues
Adapted from: Eskridge JB, Amos JF and Bartlett JD. Clinical Procedures in Optometry. Lippincott, USA. 1991.
When ultrasound travel across different media, it can be reflected (echoes) and transmitted (refracted) in a manner
similar to light, according to the properties of the interface (size, shape, smoothness) and the differences in acoustic
impedances. For example, sound waves are directed at an interface between two tissues that have different acoustic
impedances, the boundary between the two tissues acts as an acoustic mirror and an acoustic refracting surface. As
a result, some of the ultrasound will be reflected (according to the Law of Reflection, i.e., the angle of reflection will
be equal to the angle of incidence) and some will be transmitted. Ultrasonography makes use of the resulting echoes
and wave changes to determine the location and characteristics of the different tissues under examination.
To measure the position of a given interface within the eye, ultrasound is transmitted to the eye from a transducer
that contains a piezoelectric crystal. Piezoelectric crystals possess two important properties. First, the surfaces of
these crystals are deformed (thus producing acoustic vibrations) when an electrical current is passed through the
material. Second, when acoustic waves strike the crystal, they produce an electrical charge that can be recorded.
Thus, if the transducer is positioned in such a manner that the acoustic waves intersect tissue interfaces in the eye
in a perpendicular manner, sound is reflected and echo back to the transducer in proportion to the differences in the
acoustic impedances of the different tissues.

Ultrasonography
Ultrasound instruments do not continuously emit sound waves. Instead, a procedure referred to as the "pulse-echo"
technique is usually employed. With this technique a brief pulse of sound (typically 1 microsecond in duration) is
emitted periodically. Between pulses, the instrument records the time that transpires between when the pulse was
emitted and when the returning echoes produce a charge on the crystal. The elapsed times can be converted to
distances between various interfaces and the probe simply by multiplying the measured time by the velocity of sound
in the respective media.
Ultrasound does not travel at a constant velocity in the eye. It travels faster in the denser structures (e.g., the lens;
1640 m/sec) than it does in the less dense structures (e.g., the vitreous; 1530 m/sec). However, when an ultrasound
instrument is used to measure axial length, it is generally assumed that sound travels at a constant velocity in the
eye. In order to take into account the variations in intraocular acoustic velocity, a weighted "average" value for the
velocity of sound within the eye is typically employed (e.g., 1540 m/sec). In aphakic patients (i.e., patients without a
crystalline lens) it is necessary to assume a slightly lower velocity for sound than that employed with normal patients.
Most commercially available ultrasound instruments now include, as an option, alternative operational settings for
aphakic individuals.
For ophthalmic use, the time between echoes and the strength of the returning echoes are displayed in one of three
ways: A-mode, B-mode or M-mode.
A-mode (A-scan, Amplitude mode) or biometry: the A-mode is the simplest and most commonly used ultrasound
technique. With this technique the strength of the echo produced by a given interface is displayed as a vertical
deflection (Y axis) relative to its position (time, X axis) along the path of the ultrasound beam.
The strength of the echo, which is related to the angle of the incident sound beam and the differences in acoustic
impedance at the interface, is reflected in the height of the display deflection. A normal A-scan echograph obtained
when the transducer is aligned with the optical axis is illustrated in Figure 14.1b.
Figure 14.1a: Performing A-scan biometry
Photo courtesy of: International Centre for Eye Health (ICEH), Photographer: B Ramamurthy.
The deflections associated with the anterior and posterior surfaces of the cornea and lens and the vitreoretinal
interface allow measurements of corneal thickness, anterior chamber depth, lens thickness, vitreous chamber depth,
and axial length. The aqueous and the vitreous should appear acoustically clear since they are normally
homogenous structures.

Ultrasonography
Figure 14.1b: A-Mode Biometry
Photo courtesy of: International Centre for Eye Health (ICEH), Photographer: B Ramamurthy.
B-mode (B-scan, Brightness mode). The B-mode is essentially composed of many bright echo spots resulting
essentially from hundreds of A-scans. In the B-scan mode, the strength of the returning echo is indicated by an
increase in the display brightness as a function of time or distance. Structures that produce tall echoes on A-scan
(i.e. high reflecting tissues) will produce bright spots on B-scan.
In the B-mode, the spatial orientation of the transducer is systematically changed. The transducer orientation and the
display orientation are coordinated so that a B-scan echograph looks like a cross section of the globe (two-
dimensional image). The figure below shows a B-scan obtained along the vertical meridian of a normal eye. In the
more sophisticated B-scan systems, the probe is oscillated in 2 dimensions allowing a 3 dimensional echograph of
the eye to be constructed.
Figure 14.2: B-Mode
Photo courtesy of: LV Prasad Eye Institute.
Although the B-scan is a more involved procedure, it provides the most graphic representation of the relative
positions of ocular structures and as a result, it is rapidly overtaking the A-scan as the most commonly utilized
display technique. However, in comparison to the A-scan, the B-scan has historically been a much more complicated
procedure. For example, instead of simply holding the transducer in contact with the eye or lids (as is typical with the
A-scan) an immersion technique is sometimes required where the patient, usually in the supine position, is fitted with
a set of adapted goggles that resemble a scuba diver mask with the plastic visor removed. The goggles are filled
with a saline solution and the probe is placed in the solution. The liquid interface between the probe and the eye
allows the probe to be moved (usually by a programmable mechanical device) without losing acoustic contact with
the eye. More recently, B-scan probes have been manufactured so that the transducer is completely sealed within
the probe (about 1.5 cm in diameter) and rotates about a point inside the probe so that a large scan of the posterior
globe is possible simply by placing the probe in direct contact with the patient's lids.

Ultrasonography
M-mode (M-scan, Movement mode). In the M-mode the position and strength of the echoes are displayed as bright
dots on the display. However, in contrast to the B-scan, the transducer is held stationary and the oscilloscope
display (or film or light sensitive graph paper) is moved in "real time". With this display technique, movement of the
tissues associated with accommodation, vascular pressure changes, etc., can be observed over time. It is often
used in determining the magnetic properties of intraocular foreign bodies
INSTRUMENTATION
The ultrasound unit consists of a transmitter, a transducer, a receiver and a video unit. The transmitter produces the
short electrical pulses that are sent to the transducer which contains a piezoelectric element, a polarized material
(e.g. crystal) that can change shape and mechanically vibrate under an electrical stimulus thus generating
ultrasound waves. Conversely, returning echoes deform the element which produces and electrical signal which is
sent to the receiver.
The receiver is a radio-like device which essentially captures and amplifies the received sound frequencies.The
video unit consists of an oscilloscope which allows the visualisation of the recorded signal.The B-scan unit has in
addition a motor drive unit which moves (oscillates) the transducer along an axis (in order to generate multiple A-
scans).
The ultrasonograms of interest are “frozen” or recorded when dynamic viewing is necessary and generally stored
electronically.
Most ultrasound systems allow the examiner to perform A-mode and B-Mode simultaneously.A vector scan usually
allows the selection of an axis of interest. The system contains a vector scan dial, which can be used to select any
axis on the 2-dimensional image so as to assess specific areas and determine the spike amplitude or reflectivity of
that tissue.
The amplitude or ‘gain’ of the ultrasound can be adjusted to increase or reduce the intensity of the returning echoes.
Increasing the gain returns very low sound signals; this raises the sensitivity of the procedure but increases ‘noise’
levels or artefacts. Decreasing the gain will “remove” less acoustically dense tissue from the scan and enhance the
visibility of the more acoustically dense tissues (which remain bright). The gain adjustment is different from the
brightness or gray scale adjustment which modifies the overall contrast of the image.
CLINICAL INDICATIONS AND CONTRA-INDICATIONS
Ultrasound provides an accurate description of normal and abnormal structures even when the structure in question
cannot be optically evaluated using visible light. While each procedure can be carried out alone, the A-mode and B-
mode used in conjunction appear to provide the most complete ultrasonic evaluation. The A-mode provides the best
means of evaluating the differences in acoustic impedances between tissues to provide accurate measurements of
intraocular structures and lesions.
The B-mode provides a two-dimensional view of the eye and allows the topographic and kinetic assessment of
ocular structures and lesions.Topographic echography reveals and documents the location, shape, borders and
geographical relationships of lesions whereas various types of kinetic echography determine the vascularity, mobility
and consistency of lesions.

Ultrasonography
Indications Contra-indications
A-Mode B-Mode A-Mode & B-Mode
Assess axial length of the eye Assess fundus through cloudy media Recent intraocular surgery
Assess anterior chamber depth Assess fundus through non-dilatable pupil Perforating injury
Assess corneal thickness Assess ocular & orbital lesions Corneal disruption (+/-)
Intraocular lens power calculation Assess optic nerve head disease (elevation)
View surrounding orbital tissues
Differentiation of intra-ocular tumours
(e.g. muscles)
Detect & differentiate ocular tumours
Locate intraocular foreign bodies
Characterize retinal detachments
Assess traumatized eyes
Table 14.2: Indications and contra-indications for A-mode and B-mode ultrasonography
PROCEDURE
A-MODE
The patient is seated at an instrument similar to a slit lamp. A probe similar to a Goldmann tonometer is placed on
the cornea or a hand held probe is applied directly to the cornea. Preliminary adjustments to the instrument include
inputting patient data and keratometry readings, choosing biometry or pachymetry automatic mode and identifying
phakia status.
Figure 14.3: A-mode in a “Hand-held” set-up
Photo courtesy of: International Centre for Eye Health (ICEH), Photographer: B Ramamurthy
The eye is first anaesthetized, and the probe sterilised in the usual manner. A drop of saline may be used on the
probe tip, but the tear film is generally an acceptable coupling medium, which allows the transmission of acoustic
waves from one surface to another. The patient is asked to fixate a distant target as the examiner brings the probe in
contact with the central cornea. Care must be taken to avoid excessive force on the globe and to assure that the
probe lies perpendicular to the plane of the central cornea. Once the probe is properly aligned, the sound waves
traverse ocular contents and are reflected back at surface interfaces.

Ultrasonography
If the A-Mode is set at automatic, the system will sound when alignment is correct, indicating that a reading has been
taken. The examiner should remove the probe and record the reading. Five readings should be taken on each eye.
The system will average the readings of axial length, anterior chamber depth or corneal thickness. Keratometry
readings and axial length measurement can be mathematically manipulated to calculate the power of the intra-ocular
lens.
B-MODE
The patient is seated comfortably, or in a lying position. The probe may be applied either to the open or closed eye.
Since high frequency sound waves are not transmitted through air, the probe must be coupled to the lid with a
coupling agent, a thick and non-drip solution (usually methyl-cellulose). The patient should experience no discomfort
during this procedure when performed through the closed lid. For the open eye procedure, anaesthetic is instilled
prior and if necessary during the testing. The initial examination is performed at the highest decibel gain (sensitivity),
so that even weak echoes from objects with low acoustic densities will be detected.
Performing B-Scan ultrasonography requires that the examiner perform axial, transverse and longitudinal scans of
the globe to fully scan and map out the eye or lesions. The scanning probe has a marker near its tip, which
designates the area represented on the upper portion of the B-Scan display. For the axial views, the patient fixates
in primary gaze and the probe is placed with the marker superiorly for vertical sections and nasally for horizontally
sections. In the transverse views, the probe is placed on the limbus and directed posteriorly. In a single smooth arc
movement, it is moved from limbus to fornix, scanning the opposite globe wall from the posterior pole to the ora
(postero-anteriorly). The scanning is repeated around the limbus (360°) to insure full coverage of the globe. The
longitudinal views produce an antero-posterior slice of the opposite ocular wall along one meridian only, from
ciliary body to optic nerve.The marker is oriented towards the cornea.
Figure 14.4: Graphic representation of a transverse view showing probe position on the globe and the ocular area examined

Ultrasonography
Figure 14.5: Graphic representation of a longitudinal view showing probe position on the globe and the ocular area examined
NORMAL FINDINGS
A-MODE
The characteristic display shows the left most echoes from the cornea and the next two echoes from the anterior and
posterior lens surfaces. The echoes seen to the right are from the retina-choroid-sclera complex. The axial length
and anterior chamber depth are noted in the upper right corner of the screen.
B-MODE
In the scan of the normal eye, the anterior portion of the eye is not clearly visualised (fig 14.2). The posterior lens
capsule may be observed at the extreme left of the screen. The vitreous and optic nerve tissues reflect sound poorly
and are termed sonolucent or echolucent. These structures appear black in contrast to structures that reflect
sound well, which appear white or as shades of gray. The black horizontal V-shaped optic nerve is an important
landmark in B-Mode ultrasonography. The retina appears as a smooth concave surface, which becomes
indiscernible from the echoes arising from the choroid and sclera.
The acoustic properties of different tissue aid in diagnosis of abnormalities. Acoustically denser substances (e.g.
calcium) will produce reflections even at low gain.
• Calcium
• Retina, Choroid, Sclera
• Haemorrhage
Increasing Acoustic
• Vitreous tissue Density (brighter echo)

Ultrasonography
ABNORMALITIES
VITREOUS ABNORMALITIES
The vitreous is normally sonolucent and will therefore appear dark and clear on ultrasonography especially in young
patients. In older individuals, scattered opacities and posterior vitreous detachment will show up on A & B-scans with
low reflectivity. Abnormal findings in the vitreous such as fibro-proliferative tissue, haemorrhages, membranes and
inflammatory debris will appear as irregular white or gray areas. Acoustically denser findings such as asteroid
hyalosis (calcium soaps) or foreign bodies will continue to appear on the scan as sensitivity is decreased.
Figure 14.6a: Vitreous haemorrhage Figure 14.6b: Asteroid Hyalosis
Photos courtesy of: LV Prasad Eye Institute.
RETINAL ABNORMALITIES
Retinal detachment (RD) will appear as a thin white continuous folded membrane separate from the choroid and
sclera (Fig.14.7). Many scans in serial planes are necessary to obtain the full three-dimensional extent of the RD.
Flat RD is difficult to see because of the narrow space between the RD and the choroid. Bullous RD is convex in
shape and extends into the anterior vitreous with attachments at the optic nerve head, nasal and temporal ora
serrata. Fresh RD will move with eye movements, whereas long-standing RD will not because of associated fibrous
tissue proliferation. The detached retina appears with very high reflectivity while the underlying space is generally
sonolucent unless an haemorrhage exists underneath.
With classic retinoschisis, B-scan will differentiate an isolated “blister” from one with an underlying RD (Fig.14.8).
Figure 14.7: Typical Retinal detachment
Photo courtesy of: LV Prasad Eye Institute.

Ultrasonography
Figure 14.8: Typical Retinoschisis
Photo courtesy of: LV Prasad Eye Institute
INTRAOCULAR TUMOURS
Retinoblastoma in children is often concealed ophthalmoscopically by an overlying retinal detachment, inflammation

or vitreous haemorrhage. The retinoblastoma which is acoustically dense will have high reflectivity and can be
differentiated using B-scan. Osseous choristoma, a rare bone tumour of the choroid, is also acoustically diagnostic
by its high reflectivity.
Choroidal tumours can be differentiated from choroidal detachments with underlying serous fluid or blood. Certain
characteristics differentiate malignant melanomas from metastatic carcinoma, haemangioma, & subretinal
haemorrhage.
Internal Structure Internal Sound

Lesion
(Cells) Reflectivity Attenuation
Melanoma Small & Regular Low to Medium Significant
Metastasis Irregular Variable Variable
Haemangioma Large & Regular High Minimal
Table 14.3: Response of various lesions when performing ultrasonography
OPTIC NERVE HEAD ABNORMALITIES
Conditions that result in elevation of the optic nerve head, such as papilloedema, papillitis and drusen of the optic
disc can be appreciated ultrasonically. Drusen bodies often give the appearance of grape clusters (Fig. 14.9 a and
b). However, buried drusen are not visible to the eye and is the most common cause of pseudo-papilloedema.
Ultrasonography will show the high reflectivity of the calcium within the drusen and the continued reflection of sound
as sensitivity is decreased.
Papillitis and papilloedema are difficult to differentiate ultrasonically although a clear subretinal fluid level may be
seen with papilloedema. Peripapillary staphyloma will be seen as a concave depression at the position of the optic
nerve head.

Ultrasonography
A B
Figure 14.9a. and b.: Optic nerve head drusen
INTRAOCULAR FOREIGN BODY
Ultrasonography is used to locate foreign bodies and to assess their magnetic properties. Localisation requires
decreasing the decibel gain to differentiate the high amplitude echoes produced by most foreign bodies from lower
amplitude echoes emanating from surrounding tissue. Magnetic foreign bodies can be identified by using an
ultrasonic display of the motion of the foreign body when a magnet is applied to the globe, placed in a position over
the pars plana. The finding of metallic intraocular foreign bodies is an obvious contraindication to performing
magnetic resonance imaging.
LENS DISLOCATION OR SUBLUXATION
Subluxated or dislocated lenses secondary to trauma or associated systemic disorders are difficult to view
ophthalmoscopically. Ultrasonography is a useful tool in these cases.
GLOBE SHAPE AND SIZE VARIATION
Eyes with opaque media and especially low intraocular pressures are suggestive of phthisis bulbi. Ultrasonography
will show disorganized tissue of high reflectivity.

Ultrasonography
ORBITAL DIAGNOSIS
Ultrasonography of the orbit is useful when there is proptosis or exophthalmos, choroidal folds or retinal striae,
unexplained optic atrophy or papilloedema, palpation of a cyst or mass, microphthalmic eye, and suspected orbital
foreign body. In the orbit, the abnormal appears dark against the white bright background of highly acoustic dense
orbital fat (versus in the globe where the abnormal is white or gray on a black background).Abnormalities that appear
black include mass lesion, foreign body and inflammatory change.
Extra-ocular muscles in the orbit are sonolucent and normally appear black.Enlargement and infiltration of the
muscles will render them abnormally white on ultrasonography.
BIBLIOGRAPHY
• Eskridge JB, Amos JF and Bartlett JD.Clinical Procedures in Optometry.Lippincott, USA. 1991.

FLUORESCEIN ANGIOGRAPHY
AUTHOR
PEER REVIEWER
INTRODUCTION
• Definition
• Purpose
• Indications
• Contra-indications (relative)
• Technique principle
• Procedure
• Factors affecting visualization
• Interpretation
• Terminology
• Interpretation steps of Fluorescein Angiography
• Indocyanine green angiography
DEFINITION
Fluorescein Angiography (FA) is a technique used to dynamically evaluate vascular conditions of the eye by
photographing Sodium Fluorescein (NaFl) dye in the vasculature following intravenous (IV) injection. FA allows the
visualisation of the normal passage of blood (dye) from the arterial to the venous systems in both the retinal and
choroidal circulations of the eye. Pathological changes on blood vessels which affect the vascular circulation and the
inner or outer blood-retinal barrier can also be viewed with FA.

Fluorescein Angiography
PURPOSE
• Advanced understanding of ocular vasculopathies reveals that earlier disease diagnosis and treatment
yields better clinical results.
• Progress in laser therapeutics permits very early intervention in disease conditions.
• FA permits earlier and more effective detection of disease processes that may be otherwise subclinical and
not observable ophthalmoscopically. FA enables viewing retinal details as small as 5 microns compared to
direct ophthalmoscopy which permits viewing of details > 72 microns even with 15X magnification.
INDICATIONS
1. Suspected or possible Sub-Retinal Neovascular Membranes (SRNVM)

2. Proliferative vascular changes (e.g. diabetes mellitus)
3. Suspected “leaking” problems of the retina or choroid (e.g. macular oedema))
4. Unexplained visual loss
5. Unidentified Fundus Observation (Tumours, Drusen, etc.)
6. Suspected diseases of the RPE/Bruch Membrane complex (e.g. dystrophies).
OCULAR DISEASE CONDITIONS INDICATING THE NEED FOR FA
• Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)

• Angiomatosis retinae
• Anterior ischemic optic neuropathy
• Behcet’s disease
• Branch retinal vein occlusion
• Cavernous haemangioma of the retina
• Choroidal rupture (when developing choroidal neovascularisation)
• Coat’s disease
• Cystoid maculopathy (Irvine-Gass syndrome)
• Diabetic retinopathy
• Eales disease
• Fuch’s spot
• Hemicentral retinal vein occlusion
• Idiopathic central serous choroidopathy
• Iris neovascularisation
• Maculopathy of angioid streaks
• Malignant choroidal melanoma
• Preretinal macular fibrosis
• Presumed ocular histoplasmosis (macular changes)
• Proliferative peripheral retinal disease
• Retinal capillary haemangioma
• Retinal microaneurism
• Retinal pigment epithelial dystrophies (central)
• Retinal pigment epithelial detachment
• Retinal tumours
• Sensory retinal detachments
• Tumours of iris and ciliary body.

CONTRA-INDICATIONS
• Frail Health
• Cardiac/Bronchial Disease
• Renal Diseases
• Hypersensitive Status
• Asthma (poorly controlled)
• Severe diabetes mellitus
• Hypertension
• Hypersensitivity to NaFl
• Pregnancy / Lactating mother.
TECHNIQUE PRINCIPLE
Sodium Fluorescein (NaFl) is a pharmacologically inactive substance which fluoresces when stimulated by an
exciting light source. The substance may be available in solution concentrations of 5%, 10% and 25%. Absorbing
light maximally at 485nm (blue), it emits maximally (peak transmission) at 520nm (green). In the bloodstream, when
IV injected or orally ingested, it can be visualised at the ocular level by several methods:
• Direct with a BIO equipped with special filters

• Video-based system equipped with special filters permitting live recording of the Fluorescein flow
• Photography on standard 35mm negatives or positives viewed on a lighted box.
Photography is the usual method of performing FA. The procedure requires a special fundus camera which includes
a high intensity flash with rapid recycle time delay (1 - 1,5 sec) to allow “rapid fire” serial photographs and a timer to
register interval from injection time to picture time. A 36 exposure black and white film (200-400 ASA or Kodak Tri-X
film) is usually used.
The camera is adapted to contain two special filters. The excitation filter is a blue filter of wavelength 465-490 nm
[Baird Atomic B4 470 or Kodak Wratten 47]. Placed between the illumination system of the camera and the retina, it
serves to excite and raise the NaFl electrons to a higher energy level causing them to fluoresce. The barrier filter is a
yellow-green filter of wavelength 525-630nm [Iford 109 Delta Chromatic 3 or Kodak Wratten g15]. Placed between
the light reflected from the retina and the camera film plane, it blocks the emitted light except the light from the
excited NaFl (λ ~ 525nm) to allow the viewing and imaging of fluorescing tissues and blood.

Figure 15.1: Optics of the camera used in FA
PROCEDURE
INTRA-VENOUS
• Have a crash cart (cardiopulmonary resuscitation unit) and emergency protocol on site
• Educate patient and obtain consent signature
• Maximum pupillary dilation required
• Seat patient comfortably and appropriately at fundus camera
• Direct patient fixation, which must be maintained throughout the procedure
• Obtain colour fundus photos (stereo pairs preferable)
• Obtain baseline red-free (green or Wratten 57) photos on black/white film through system filters
• Check for pseudofluorescence as a result of poor filter quality
• Ensure that proper filters and flashes are in place
• Set appropriate IV line on antecubital vein or hand vein and maintain with heparinised saline.
• Set 5ml NaFl 10% (preferred dosage) ready in a syringe for injection (or 10ml of 5% or 3ml of 25%)
• Locate and focus area of interest in the fundus
• Inject bolus of NaFl regularly over 10-15sec.
• Start photo shoot 10-15 sec later (time for NaFl to reach ocular circulation)
• Shoot rapid sequence photos first minute: 1 per 1-2 sec. first 15 sec.\ 1 per 10-15 sec. next 45 sec.
• Next 10-20 minutes shoot intermittently at regular time intervals (e.g. 1 per minute)
• Shoot photos of fellow eye after primary eye is done
• Shoot stereo pairs when possible

SIDE-EFFECTS
The procedure is relatively safe with a clinical dose of 100 X less than the lethal dose of NaFl but complications arise
in ~ 5% of IV procedures (Table 1). Occurring during the first 30 sec. of the procedure, these are usually minor and
transient. However cardiac arrest and even death can occur.
Common (in 5% of procedures within 30 sec) Less Common

Nausea Cardiac arrest
Warm flush Respiratory reactions
Vomiting Acute pulmonary oedema
Urticaria and pruritus (hives and itching) Seizures
Skin discolouration (yellowing for ~1 hour) Extravasation
Urine discolouration (yellow-orange for ~24 hours)
Syncope
Table 15.1: Complications of IV procedures
ORAL FLUOROGRAPHY
Oral Fluorography provides similar results but is not as good or as clear as IV FA. As such, it is not so valuable for
the observation of fine details but it is especially useful when expected late dye leakage is of interest. With minimal
to no side-effects, it is much safer than IVFA and may be used for children and patients with cardiovascular
compromise. The procedure includes similar observation elements but with the following technical changes:
• Patient must fast 8 hours before exam

• NaFl is given orally: 15ml of 10% NaFl with citrus solution over crushed ice
• Dentures must be removed to avoid staining
• Red-free photos are taken before ingestion
• Photo shoot starts 15-30 min. after ingestion - must look for 1st sign of fluorescence in the fundus
• Late phases are ~ 1 hour after ingestion.
FACTORS AFFECTING VISUALISATION
• Clarity of media
• Dilation level
• Quality of camera
• Skill of examiner
• Patient cooperation
• NaFl concentration reaching the eye (depends most on injection quality)
• Quality of film processing
• Quality of filters (need regular changes) which can cause pseudofluorescence.

INTERPRETATION
The interpretation of FA is based on basic anatomical and physiological principles. Good knowledge of these is
crucial to the understanding of FA.
Inner blood-retinal barrier - Healthy retinal vessels are impermeable to NaFl and are not leaky.
Fenestrated choriocapillaris - Healthy choriocapillaris is a sponge-like tissue whose vessels are fenestrated
(porous). Hence blood and NaFl freely leak from it.
Outer blood-retinal barrier - Healthy RPE-Bruch complex with the tight “zonula occluden” junctions between RPE
cells keeps blood (and NaFl) of the choroid and choriocapillaris away from the retina.
RPE filter - the RPE acts like an optical filter. The “choroidal glow” that results from the NaFl freely leaking within it
only shows through partially, giving a typical ground-glass appearance.
Macular hypofluorescence - Dense cuboidal RPE and xantophyll mask the “choroidal glow” across healthy
maculae.
TERMINOLOGY
Hyperfluorescence indicates more glow (NaFl) than would be normally expected (e.g. leakage, pooling, RPE
faults...)
Hypofluorescence indicates less glow (NaFl) than would by normally expected (e.g. non-perfusion, blockage,...)
Autofluorescence refers to the ability of certain retinal components to fluoresce naturally without the presence of
NaFl. The pre-injection as well as the black and white control photo through the camera filters allows the
differentiation of autofluorescent elements (e.g. ONH drusen, myelinated NF,...)
Pseudofluorescence results from the overlap of the transmission curves of exciter and barrier filters that may result
in apparent fluorescence. The pre-injection as well as the black and white control photo through camera filters also
allows the detection of pseudofluorescence.
Transit refers to the time of the first passage of fluorescing blood in the eye (arm-retina cycle). Although it varies
with the dynamics of blood circulation factors such as cardiac output, blood volume, etc., it is usually from 10-20 sec.
Recirculation Phase refers to subsequent passages of fluorescing blood in the eye. Recirculation phases are less
intense.
Phases refer to specific physiological intervals in the FA cycle. Phases occur quite rapidly and may overlap with one
another.

Figure 15.2: Phases of the FA cycle
Adapted from Eskridge JB, et al, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.
1. Choroidal Flush (7-10 sec. after injection)

The choroidal flush corresponds to the rapid “patchy” filling of the choroidal system (long and short ciliary arteries)
with fluorescing blood (Fig. 15.3). Because of the fenestrated vessels of the choroid, the NaFl quickly leaks in the
choroidal swamp and the choroidal glow becomes somewhat uniform. The RPE partly masks the choroidal flush to
give it a “ground-glass” appearance; this stage occurs first as the choroidal circulatory route is slightly shorter than
the retinal route. The Cilio-retinal artery fills at this stage because it originates from the choroidal vasculature.
Figure 15.3: Choroidal phase of FA cycle
Photo Courtesy of Priyashangu Chandra: LV Prasad Eye Institute.
2. Arterial Phase (11-12sec. after injection)
The arterial phase corresponds to the filling of the Central Retinal Artery and retinal arteries. Laminar flow becomes
observable (Fig. 15.4 and 15.5): blood flow dynamics make the arterial core glow before the arterial walls. This is
followed by complete filling of the arteries (Fig. 15.6).

Figure 15.4: Black indicates non-fluorescence; white area indicates fluorescence
Figure 15.5: Early arterial phase of FA cycle showing laminar flow
Photo Courtesy of LV Prasad Eye Institute.
Figure 15.6: Arterial phase of FA cycle

3. Arterio-Venous (A-V) Phase (13-15sec. after injection)
The A-V phase corresponds to the filling of capillaries in the interval between arterial and venous circulation (Fig.
15.7).
Figure 15.7: Arteriovenous phase of FA cycle
Photo Courtesy of LV Prasad Eye Institute
4. Venous Phase (16-20sec. after injection)
The venous phase corresponds to the filling of retinal veins. The laminar flow is initially observable but this time the
venous wall glows before the venous core (Fig. 15.8 and 15.9). Laminar flow ceases at ~ 18-20sec. in the late
venous phase when the veins are fully filled (Fig. 15.10).
Figure 8. Black indicates non-fluorescence; white area indicates fluorescence
Figure 15.9: Early venous phase of FA cycle showing laminar flow

Figure 15.10: Late venous phase of FA cycle
5. Late Phase (~ 10minutes post-injection)
The late phase is the recirculation stages when the arteries and veins are empty of NaFl. The choroidal flush is
minimised and the ONH hyperfluoresces because NaFl adheres to the scleral rim and nervous tissue (this glow is
constant throughout the procedure and does not diffuse if the tissue is normal) (Fig. 15.11).
Leakage and Pooling become more apparent as NaFl diffuses into surrounding tissues. Leakage occurs with the
extravasation or escape of fluorescing blood and indicates retinal vascular abnormality. Pooling represents
accumulation of fluid and generally indicates a break in the RPE-Bruch barrier.
Note: Some authors prefer to use “Arterio-Venous Phase” to speak of stages 2,3,4 jointly.

INTERPRETATION STEPS OF FLUORESCEIN ANGIOGRAPHY
1. Study the colour photographs

2. Study the red-free photos (see everything)
3. Note the time, phase, location at all times
4. Look for hyper and hypofluorescence
5. Study frame by frame changes in size and intensity.
E.g. At 17 seconds, late choroidal filling phase, the OD shows 1 spot of hyperfluorescence in the inferior
paramacular area. It is observed to percolate upward increasing in size and intensity throughout the test.
INTERPRETATION OF FLUORESCEIN ANGIOGRAPHY
Broadly two things need to be considered:
1. Hypofluoresce versus hyperfluoresce

2. Timing or delay in fluorescence.

Hypofluorescence Hyperfluorescence Angiographic Features

Transmission defects
Vascular filling defect ⇐ atrophy of RPE revealing choroidal
fluorescence
Window defects
Vascular occlusion
Age-related macular degeneration pigment
Emboli
changes ⇐ Hyperfluorescence increases and
Arteriosclerosis decreases in phase with the FA
Retino-choroidal dystrophies
Vascular nonperfusion
Choroidal Rupture
Things that leak
Blocked fluorescence
⇐ breakdown of inner retinal barrier
Haemorrhages
Microaneurisms
Exudates
Neovascularization
Cotton wool spots ⇐ Early intense leakage increasing
Intra-retinal microvascular abnormalities throughout the FA
Glial tissue
Disruption of vessel integrity e.g. wet
Retinal Pigment
ARMD
Masses
Things that pool
⇐ breakdown of outer retinal barrier
Cystoid Macular Oedema
Idiopathic Central Serous Choroidopathy ⇐ Slowly increasing
hyperfluorescence throughout the FA
Serous detachment of the RPE and after
Papilloedema
Things that stain
⇐ uptake of NaFl into tissues
Optic nerve head drusen
Retinal Drusen
⇐ Slow staining that does not diffuse
Optic nerve head scleral rim and tissues
or increase in size throughout the FA
Sclera
Vessel Walls
Table 15.2: Interpretation of FA

INDOCYANINE GREEN ANGIOGRAPHY (ICG)
Indocyanine Green (ICG) is a relatively new procedure. ICG is advantageous over FA in that the ICG dye fluoresces
near the infrared spectrum with peak absorption at 805nm and peak fluorescence at 835nm. This enhances the
fluorescence through exudates, haemorrhages and normal ocular pigment (RPE). Being 98% protein-bound in the
blood, the dye does not readily leak through the fenestrations of the choriocapillaris or neo-vessels. Therefore it
does not obscure the underlying choroidal vasculature.
An improved visualization of the choroid is obtained with ICG because it permits a longer and uninterrupted view of
the choroidal circulation. As such, it is primarily used to expose or define sub-retinal neo-vascular membranes
(SRNVM) when they are suspected but not seen with NaFl angiography. ICG can however be used for all the same
clinical applications as NaFl.
The only contra-indication to ICG is an allergy to shell fish or to iodine.

FLUORESCEIN ANGIOGRAPHY
AUTHOR
PEER REVIEWER
INTRODUCTION
 Definition
 Purpose
 Indications
 Contra-indications (relative)
 Technique principle
 Procedure
 Factors affecting visualization
 Interpretation
 Terminology
 Interpretation steps of Fluorescein Angiography
 Indocyanine green angiography
DEFINITION
Fluorescein Angiography (FA) is a technique used to dynamically evaluate vascular conditions of the eye by
photographing Sodium Fluorescein (NaFl) dye in the vasculature following intravenous (IV) injection. FA allows the
visualisation of the normal passage of blood (dye) from the arterial to the venous systems in both the retinal and
choroidal circulations of the eye. Pathological changes on blood vessels which affect the vascular circulation and the
inner or outer blood-retinal barrier can also be viewed with FA.

PURPOSE
 Advanced understanding of ocular vasculopathies reveals that earlier disease diagnosis and treatment
yields better clinical results.
 Progress in laser therapeutics permits very early intervention in disease conditions.
 FA permits earlier and more effective detection of disease processes that may be otherwise subclinical and
not observable ophthalmoscopically. FA enables viewing retinal details as small as 5 microns compared to
direct ophthalmoscopy which permits viewing of details > 72 microns even with 15X magnification.
INDICATIONS
1. Suspected or possible Sub-Retinal Neovascular Membranes (SRNVM)

2. Proliferative vascular changes (e.g. diabetes mellitus)
3. Suspected “leaking” problems of the retina or choroid (e.g. macular oedema))
4. Unexplained visual loss
5. Unidentified Fundus Observation (Tumours, Drusen, etc.)
6. Suspected diseases of the RPE/Bruch Membrane complex (e.g. dystrophies).
OCULAR DISEASE CONDITIONS INDICATING THE NEED FOR FA
 Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)

 Angiomatosis retinae
 Anterior ischemic optic neuropathy
 Behcet’s disease
 Branch retinal vein occlusion
 Cavernous haemangioma of the retina
 Choroidal rupture (when developing choroidal neovascularisation)
 Coat’s disease
 Cystoid maculopathy (Irvine-Gass syndrome)
 Diabetic retinopathy
 Eales disease
 Fuch’s spot
 Hemicentral retinal vein occlusion
 Idiopathic central serous choroidopathy
 Iris neovascularisation
 Maculopathy of angioid streaks
 Malignant choroidal melanoma
 Preretinal macular fibrosis
 Presumed ocular histoplasmosis (macular changes)
 Proliferative peripheral retinal disease
 Retinal capillary haemangioma
 Retinal microaneurism
 Retinal pigment epithelial dystrophies (central)
 Retinal pigment epithelial detachment
 Retinal tumours
 Sensory retinal detachments
 Tumours of iris and ciliary body.

CONTRA-INDICATIONS
 Frail Health
 Cardiac/Bronchial Disease
 Renal Diseases
 Hypersensitive Status
 Asthma (poorly controlled)
 Severe diabetes mellitus
 Hypertension
 Hypersensitivity to NaFl
 Pregnancy / Lactating mother.
TECHNIQUE PRINCIPLE
Sodium Fluorescein (NaFl) is a pharmacologically inactive substance which fluoresces when stimulated by an
exciting light source. The substance may be available in solution concentrations of 5%, 10% and 25%. Absorbing
light maximally at 485nm (blue), it emits maximally (peak transmission) at 520nm (green). In the bloodstream, when
IV injected or orally ingested, it can be visualised at the ocular level by several methods:
 Direct with a BIO equipped with special filters

 Video-based system equipped with special filters permitting live recording of the Fluorescein flow
 Photography on standard 35mm negatives or positives viewed on a lighted box.
Photography is the usual method of performing FA. The procedure requires a special fundus camera which includes
a high intensity flash with rapid recycle time delay (1 - 1,5 sec) to allow “rapid fire” serial photographs and a timer to
register interval from injection time to picture time. A 36 exposure black and white film (200-400 ASA or Kodak Tri-X
film) is usually used.
The camera is adapted to contain two special filters. The excitation filter is a blue filter of wavelength 465-490 nm
[Baird Atomic B4 470 or Kodak Wratten 47]. Placed between the illumination system of the camera and the retina, it
serves to excite and raise the NaFl electrons to a higher energy level causing them to fluoresce. The barrier filter is a
yellow-green filter of wavelength 525-630nm [Iford 109 Delta Chromatic 3 or Kodak Wratten g15]. Placed between
the light reflected from the retina and the camera film plane, it blocks the emitted light except the light from the
excited NaFl ( ~ 525nm) to allow the viewing and imaging of fluorescing tissues and blood.

Figure 15.1: Optics of the camera used in FA
PROCEDURE
INTRA-VENOUS
 Have a crash cart (cardiopulmonary resuscitation unit) and emergency protocol on site
 Educate patient and obtain consent signature
 Maximum pupillary dilation required
 Seat patient comfortably and appropriately at fundus camera
 Direct patient fixation, which must be maintained throughout the procedure
 Obtain colour fundus photos (stereo pairs preferable)
 Obtain baseline red-free (green or Wratten 57) photos on black/white film through system filters
 Check for pseudofluorescence as a result of poor filter quality
 Ensure that proper filters and flashes are in place
 Set appropriate IV line on antecubital vein or hand vein and maintain with heparinised saline.
 Set 5ml NaFl 10% (preferred dosage) ready in a syringe for injection (or 10ml of 5% or 3ml of 25%)
 Locate and focus area of interest in the fundus
 Inject bolus of NaFl regularly over 10-15sec.
 Start photo shoot 10-15 sec later (time for NaFl to reach ocular circulation)
 Shoot rapid sequence photos first minute: 1 per 1-2 sec. first 15 sec.\ 1 per 10-15 sec. next 45 sec.
 Next 10-20 minutes shoot intermittently at regular time intervals (e.g. 1 per minute)
 Shoot photos of fellow eye after primary eye is done
 Shoot stereo pairs when possible

SIDE-EFFECTS
The procedure is relatively safe with a clinical dose of 100 X less than the lethal dose of NaFl but complications arise
in ~ 5% of IV procedures (Table 1). Occurring during the first 30 sec. of the procedure, these are usually minor and
transient. However cardiac arrest and even death can occur.
Common (in 5% of procedures within 30 sec) Less Common

Nausea Cardiac arrest
Warm flush Respiratory reactions
Vomiting Acute pulmonary oedema
Urticaria and pruritus (hives and itching) Seizures
Skin discolouration (yellowing for ~1 hour) Extravasation
Urine discolouration (yellow-orange for ~24 hours)
Syncope
Table 15.1: Complications of IV procedures
ORAL FLUOROGRAPHY
Oral Fluorography provides similar results but is not as good or as clear as IV FA. As such, it is not so valuable for
the observation of fine details but it is especially useful when expected late dye leakage is of interest. With minimal
to no side-effects, it is much safer than IVFA and may be used for children and patients with cardiovascular
compromise. The procedure includes similar observation elements but with the following technical changes:
 Patient must fast 8 hours before exam

 NaFl is given orally: 15ml of 10% NaFl with citrus solution over crushed ice
 Dentures must be removed to avoid staining
 Red-free photos are taken before ingestion
 Photo shoot starts 15-30 min. after ingestion - must look for 1st sign of fluorescence in the fundus
 Late phases are ~ 1 hour after ingestion.
FACTORS AFFECTING VISUALISATION
 Clarity of media
 Dilation level
 Quality of camera
 Skill of examiner
 Patient cooperation
 NaFl concentration reaching the eye (depends most on injection quality)
 Quality of film processing
 Quality of filters (need regular changes) which can cause pseudofluorescence.

INTERPRETATION
The interpretation of FA is based on basic anatomical and physiological principles. Good knowledge of these is
crucial to the understanding of FA.
Inner blood-retinal barrier - Healthy retinal vessels are impermeable to NaFl and are not leaky.
Fenestrated choriocapillaris - Healthy choriocapillaris is a sponge-like tissue whose vessels are fenestrated
(porous). Hence blood and NaFl freely leak from it.
Outer blood-retinal barrier - Healthy RPE-Bruch complex with the tight “zonula occluden” junctions between RPE
cells keeps blood (and NaFl) of the choroid and choriocapillaris away from the retina.
RPE filter - the RPE acts like an optical filter. The “choroidal glow” that results from the NaFl freely leaking within it
only shows through partially, giving a typical ground-glass appearance.
Macular hypofluorescence - Dense cuboidal RPE and xantophyll mask the “choroidal glow” across healthy
maculae.
TERMINOLOGY
Hyperfluorescence indicates more glow (NaFl) than would be normally expected (e.g. leakage, pooling, RPE
faults...)
Hypofluorescence indicates less glow (NaFl) than would by normally expected (e.g. non-perfusion, blockage,...)
Autofluorescence refers to the ability of certain retinal components to fluoresce naturally without the presence of
NaFl. The pre-injection as well as the black and white control photo through the camera filters allows the
differentiation of autofluorescent elements (e.g. ONH drusen, myelinated NF,...)
Pseudofluorescence results from the overlap of the transmission curves of exciter and barrier filters that may result
in apparent fluorescence. The pre-injection as well as the black and white control photo through camera filters also
allows the detection of pseudofluorescence.
Transit refers to the time of the first passage of fluorescing blood in the eye (arm-retina cycle). Although it varies
with the dynamics of blood circulation factors such as cardiac output, blood volume, etc., it is usually from 10-20 sec.
Recirculation Phase refers to subsequent passages of fluorescing blood in the eye. Recirculation phases are less
intense.
Phases refer to specific physiological intervals in the FA cycle. Phases occur quite rapidly and may overlap with one
another.

Adapted from Eskridge JB, et al, Clinical Procedures in Optometry, Philadelphia, PA: J.B.Lippincott Company, 1991.
1. Choroidal Flush (7-10 sec. after injection)

The choroidal flush corresponds to the rapid “patchy” filling of the choroidal system (long and short ciliary arteries)
with fluorescing blood (Fig. 15.3). Because of the fenestrated vessels of the choroid, the NaFl quickly leaks in the
choroidal swamp and the choroidal glow becomes somewhat uniform. The RPE partly masks the choroidal flush to
give it a “ground-glass” appearance; this stage occurs first as the choroidal circulatory route is slightly shorter than
the retinal route. The Cilio-retinal artery fills at this stage because it originates from the choroidal vasculature.
Figure 15.3: Choroidal phase of FA cycle
Photo Courtesy of Priyashangu Chandra: LV Prasad Eye Institute.
2. Arterial Phase (11-12sec. after injection)
The arterial phase corresponds to the filling of the Central Retinal Artery and retinal arteries. Laminar flow becomes
observable (Fig. 15.4 and 15.5): blood flow dynamics make the arterial core glow before the arterial walls. This is
followed by complete filling of the arteries (Fig. 15.6).

Figure 15.4: Black indicates non-fluorescence; white area indicates fluorescence
Figure 15.5: Early arterial phase of FA cycle showing laminar flow
Figure 15.6: Arterial phase of FA cycle

3. Arterio-Venous (A-V) Phase (13-15sec. after injection)
The A-V phase corresponds to the filling of capillaries in the interval between arterial and venous circulation (Fig.
15.7).
Figure 15.7: Arteriovenous phase of FA cycle
Photo Courtesy of LV Prasad Eye Institute
4. Venous Phase (16-20sec. after injection)
The venous phase corresponds to the filling of retinal veins. The laminar flow is initially observable but this time the
venous wall glows before the venous core (Fig. 15.8 and 15.9). Laminar flow ceases at ~ 18-20sec. in the late
venous phase when the veins are fully filled (Fig. 15.10).
Figure 8. Black indicates non-fluorescence; white area indicates fluorescence
Figure 15.9: Early venous phase of FA cycle showing laminar flow

Figure 15.10: Late venous phase of FA cycle
5. Late Phase (~ 10minutes post-injection)
The late phase is the recirculation stages when the arteries and veins are empty of NaFl. The choroidal flush is
minimised and the ONH hyperfluoresces because NaFl adheres to the scleral rim and nervous tissue (this glow is
constant throughout the procedure and does not diffuse if the tissue is normal) (Fig. 15.11).
Leakage and Pooling become more apparent as NaFl diffuses into surrounding tissues. Leakage occurs with the
extravasation or escape of fluorescing blood and indicates retinal vascular abnormality. Pooling represents
accumulation of fluid and generally indicates a break in the RPE-Bruch barrier.
Note: Some authors prefer to use “Arterio-Venous Phase” to speak of stages 2,3,4 jointly.

INTERPRETATION STEPS OF FLUORESCEIN ANGIOGRAPHY
1. Study the colour photographs

2. Study the red-free photos (see everything)
3. Note the time, phase, location at all times
4. Look for hyper and hypofluorescence
5. Study frame by frame changes in size and intensity.
E.g. At 17 seconds, late choroidal filling phase, the OD shows 1 spot of hyperfluorescence in the inferior
paramacular area. It is observed to percolate upward increasing in size and intensity throughout the test.
INTERPRETATION OF FLUORESCEIN ANGIOGRAPHY
Broadly two things need to be considered:
1. Hypofluoresce versus hyperfluoresce

2. Timing or delay in fluorescence.

Hypofluorescence Hyperfluorescence Angiographic Features

Transmission defects
Vascular filling defect  atrophy of RPE revealing choroidal
fluorescence
Window defects
Vascular occlusion
Age-related macular degeneration pigment
Emboli
changes  Hyperfluorescence increases and
Arteriosclerosis decreases in phase with the FA
Retino-choroidal dystrophies
Vascular nonperfusion
Choroidal Rupture
Things that leak
Blocked fluorescence
 breakdown of inner retinal barrier
Haemorrhages
Microaneurisms
Exudates
Neovascularization
Cotton wool spots  Early intense leakage increasing
Intra-retinal microvascular abnormalities throughout the FA
Glial tissue
Disruption of vessel integrity e.g. wet
Retinal Pigment
ARMD
Masses
Things that pool
 breakdown of outer retinal barrier
Cystoid Macular Oedema
Idiopathic Central Serous Choroidopathy  Slowly increasing
hyperfluorescence throughout the FA
Serous detachment of the RPE and after
Papilloedema
Things that stain
 uptake of NaFl into tissues
Optic nerve head drusen
Retinal Drusen
 Slow staining that does not diffuse
Optic nerve head scleral rim and tissues
or increase in size throughout the FA
Sclera
Vessel Walls
Table 15.2: Interpretation of FA

INDOCYANINE GREEN ANGIOGRAPHY (ICG)
Indocyanine Green (ICG) is a relatively new procedure. ICG is advantageous over FA in that the ICG dye fluoresces
near the infrared spectrum with peak absorption at 805nm and peak fluorescence at 835nm. This enhances the
fluorescence through exudates, haemorrhages and normal ocular pigment (RPE). Being 98% protein-bound in the
blood, the dye does not readily leak through the fenestrations of the choriocapillaris or neo-vessels. Therefore it
does not obscure the underlying choroidal vasculature.
An improved visualization of the choroid is obtained with ICG because it permits a longer and uninterrupted view of
the choroidal circulation. As such, it is primarily used to expose or define sub-retinal neo-vascular membranes
(SRNVM) when they are suspected but not seen with NaFl angiography. ICG can however be used for all the same
clinical applications as NaFl.
The only contra-indication to ICG is an allergy to shell fish or to iodine.

ELECTRODIAGNOSTIC TESTS
AUTHOR
PEER REVIEWER
INTRODUCTION

• Electroretinography (ERG)
• Visual evoked potential (VEP)
• Electro-oculography (EOG)

Electrodiagnostic Tests
ELECTRORETINOGRAPHY (ERG)
ERG is a method to record the electrical signals (field potential) generated by visual function from the surface of the
cornea. ERG records the sum of electrical potentials that originate from the various layers of the retina. The ERG is
a useful diagnostic tool when a patient's visual status is reduced because it provides a measure of retinal integrity. In
certain pathological conditions, abnormalities on the ERG may present prior to VA reduction or prior to visible
ophthalmoscopic signs.
The retinal components, the photoreceptors (Fig. 16.1a), horizontal and bipolar cells, Muller cells and the RPE,
respond to changes in the concentration gradient of extracellular potassium and therefore contribute to retinal
electrical activity. The neuronal activity generated by the retinal components creates a complex waveform pattern
(Fig. 16.1b) that can be recorded using electrical equipment.
Figure 16.1a Figure 16.1b
The typical ERG is formed by 3 different waves: the A wave, B wave and C wave (Fig. 16.1b). The A wave
originates from activity within the inner segment of the photoreceptors. The A wave can be separated into two
parts, one from the cones and one from the rods. The B wave originates from a passive reflection of the Muller
cells responding to the Potassium liberated by the bipolar cells. Its cellular origin is from the bipolars, but when the
ERG is measured at the plane of the cornea it is a measure of the Muller cell’s reflection of the bipolar activity. The C
wave originates from the RPE In order to generate the C wave, the receptors must be intact. If they are not, the C
wave parallels the response of melanin, not the visual pigment rhodopsin.
There are two minor components of the ERG waveform. The first is the Early Receptor Potential (ERP) which occurs
just before the A wave. The ERP originates in the outer segments of the photoreceptors. The second is the
oscillatory potential (OP) which appears on the ascending portion of the B wave. The OP is thought to be derived
from neuronal activity between the bipolar cells and the amacrine cells. These portions of the waveform are less
relevant clinically than the A, B and C wave components.
The first analysis of the ERG was performed in a research setting by R. Granit. Granit isolated 3 major processes
which he termed PI, PII and PIII. PI corresponds to the C wave, PII to the B wave and PIII to the A wave.
Anatomical Origin Wave Component Process

Photoreceptors A PIII
Muller cells B PII
RPE C PI
Table 16.1: Summary of anatomical region with ERG processes

INSTRUMENTATION
The most ideal testing device is the Ganzfeld which provides a very bright full field dome of diffuse strobe light. The
Standard Bright Flash (SBF) illuminance must be at least 1.5-3.0 cd/m2. The response to the light flash is recorded
through the use of electrodes. Many different electrodes are available including the Henkes (hard contact lenses),
the Jet (disposable contact lens), the DTL (silver-coated nylon thread), the Foil (gold foil), Polyvinyl Alcohol Gel
(polyvinyl immersed carbon fibers) or skin electrodes (useful when testing infants, small children or uncooperative
patients). Reference or ground electrodes may be part of the contact lens assembly or a separate skin electrode
attached to the forehead, cheek or orbital rim. Ground electrodes are usually in the form of an ear clip.
Procedure
The standard protocol for testing the ERG is to perform 5 different measurements:
1. The maximum response in the dark adapted eye

2. A response developed by the rods
3. A response developed by the cones
4. A response to flicker and
5. The oscillatory potentials.
To begin testing the scotopic ERG, the patient is dilated and dark adapted for at least 30 minutes. Scotopic
conditions are necessary in order to maximize the response of the rods and minimize input from the cones. A dim
background is used and the white SBF is used. A 30 Hz flicker response is then recorded. This ERG is a scotopic
response from the rods and cones. In order to measure a response developed by the rods, the ERG is recorded at
the same frequency, but the stimulus illumination is changed to a white or blue light flash that is set at 2.5 log units
below the SBF. Finally, while under scotopic conditions the OP is measured with the white SBF stimulus at a
frequency between 100-1000-Hz.
The photopic ERG is then recorded. The patient is light adapted for 10 minutes to a bright background of
approximately 17-34 cd/m2. The ERG is recorded using a single light flash of the SBF illumination which is used to
maximize the response of the cones and minimize the input from the rods. Finally, the flicker response is recorded
under photopic conditions, using SBF illumination and a light flash of 30-Hz.
Figure 16.2a: ERG response to SBF b: Scotopic Response c: Photopic Response
CLINICAL RELEVANCE
Certain ocular conditions may affect the typical waveform pattern of the ERG. ERG measurement is particularly
useful to aid in the diagnosis of retinal dystrophies which tend to affect different layers of the retina and thus affect
the ERG in characteristic manners. Retinitis Pigmentosa, Pseudo Retinitis Pigmentosa, Inverse RP, Stargardt's,

Leber's Congenital Optic Neuropathy, Congenital Stationary Night Blindness, Rod Monochromatism, and Cone
Degeneration are examples of some conditions that may be investigated using the ERG.
Since many dystrophies are hereditary, familial studies using “electrical” tests may help in the diagnosis of other
family members with the condition. Because changes encountered on the ERG often present prior to visual
symptoms and fundus lesions, ERG is also useful in the early detection of conditions. Early recognition of visually
impairing condition allows for counseling on career choices and for better preparation with low vision training for
example, in face of a potential handicap. Finally, genetic counseling may also be provided given the diagnosis and
hereditary pattern of particular conditions.
The following pathological examples demonstrate how the ERG is affected and how it can be used clinically for the
differential diagnosis of ocular conditions.
Retinitis Pigmentosa (RP)
RP is a progressive retinal degeneration in which there is virtually no rod function. Signs of fundus abnormalities
include bilateral bone spicule pigment proliferation, attenuated arterioles reduced tapetoretinal sheen. Symptoms
include loss of night vision, poor peripheral vision & problems with mobility. The scotopic ERG shows a
considerably reduced wave amplitude. The photopic ERG displays decreased amplitudes & b-wave implicit
time delays.
Pseudoretinitis Pigmentosa
The ERG allows the differentiation of conditions that resemble RP. Persons that suffer insult to the retina through
trauma, chorioretinitis, chloroquine toxicity, or central retinal artery occlusion may present pigment aggregation
within the retina that resemble those in RP. These conditions are not hereditary and therefore may only present
unilaterally as a non-progressive course. Visual function in such cases is generally preserved and the ERG tends to
be unremarkable.
Leber's Congenital Optic Neuropathy (LCON)
Patient's with Leber's suffer an overall retinal dysfunction with signs and symptoms of reduced visual function
centrally and peripherally and a nystagmus which begins at birth and follows a non-progressive course. The fundus
evaluation is generally unremarkable. The ERG exhibits severely reduced amplitudes on both the scotopic and
photopic responses.
Congenital Stationary Night Blindness (CSNB)
CSNB is an inherited retinal disease in which the retina has a partial or complete absence of rods. Present at birth, it
is non-progressive with patients presenting normal VA, normal daylight visual fields, but a severely diminished dark
adaptation. CSNB must be differentiated from empty field myopia and vitamin deficiency which are both associated
to dark adaptation problems. An ERG from a patient with CSNB will exhibit implicit times from the scotopic
response that are almost analogous to the photopic response. In a normal individual, the implicit time of the B
wave is twice as long in the scotopic response when compared to the photopic response. The ERG also
demonstrates a reduction in the amplitude of the B wave. The resultant B wave is recorded as an electronegative
response. This may occur more in the scotopic response and it is a result of a poor electrical transmission from the
photoreceptors to the bipolar cells.

Rod Monochromatism
A patient with typical rod monochromatism has a complete absence of cones within the retina. It is present at birth
and is non-progressive. Vision will be severely reduced and patients will have abnormal color vision and the
presence of a congenital nystagmus. The scotopic ERG response is unremarkable however, the photopic and
flicker ERG responses are nonexistent due to the absence of cones. In atypical rod monochromatism in which
only 1 photopigment is present, vision will be severely reduced and congenital nystagmus is present. However, the
color vision may be normal. The scotopic ERG is unremarkable while the photopic ERG may be present but
reduced.
Cone Degeneration
Cone degeneration has a progressive course. Patient's may have a color vision deficit and/or VA loss. The foveal
cones are affected last therefore VA may not be affected until the later stages of the disease. The scotopic ERG
response is unremarkable and the photopic ERG response is severely reduced.
VISUAL EVOKED POTENTIAL (VEP)
VEP measures the electrical output of the occipital lobe during the presentation of visual stimuli. The test uses
electrodes placed at the surface of the occipital lobe to record the sum of electrical potentials that mainly originate
from the macula. The VEP is a useful diagnostic tool when a patient's visual status is reduced because it provides a
measure of macular & ON integrity. In certain pathological conditions, VEP abnormalities may be present after VA
recovers.
The stimulus presented to the patient is a checkerboard reversal pattern which has a constant luminance (Fig.
16.3). The pattern of black and white checks alternates and evokes a potential that is recorded from the occipital
cortex. It is mainly a reflection of the macular integrity for two reasons. First, the electrodes are placed over the
occipital lobe. The receptors for central vision are on the tips of the occipital lobe. The peripheral vision receptors are
represented deeper within the calcarine fissure. Therefore the electrodes are physically placed in closer proximity to
the area for central vision. Second, the macula which constitutes 5 ° of the retina accounts for 50% of the visual
fibers in the occipital lobe. Therefore, the occipital lobe fibers are devoted more to high resolution of detail.

Figure 16.3: Checkerboard Reversal Pattern
The typical VEP recording displays a single wave or major positive peak which represents the photopic response
(Fig. 16.7a). The amplitude of the wave differs depending on the stimulus check size. The implicit time for a normal
individual is 100msec. For that reason, the wave occurring at this time is called the P100 or P1 wave. In the
presence of an organic abnormality, the P100 wave will be delayed or its amplitude may be reduced (Fig. 16.4b).
Figure 16.4a: Standard VEP pattern Figure 16.4b: VEP Composition (noises and actual response)

INSTRUMENTATION
Various systems are available to record VEP. The most refined instrument, manufactured by Nicolet Biomedical
Instruments, is called the Pathfinder II Electrodiagnostic System. There are 3 fundamental components to VEP
systems (Fig. 16.4a and b):
1. The supplier of visual stimuli

2. A device to record electrical output from the occipital lobe and
3. A method to analyze the information.
Procedure
The patient is seated in front of the visual stimuli terminal. The surface electrode is placed over the inion (bony
protuberance in the occipital region). The reference electrode is clipped onto the left ear and the ground electrode is
clipped onto the right ear. The patient is fully corrected and instructed to fixate on the center of the screen. The test
is performed monocularly and the response is recorded for 4 different check sizes (Fig. 16.5).
Figure 16.5: Standard VEP response (4 different check sizes)
CLINICAL RELEVANCE
Certain ocular conditions may affect the major peak amplitude and the implicit time of the P100 wave. VEP
measurement is useful to aid in the diagnosis of macular disease, optic nerve disorders, orbital disease and
amblyopia. The VEP also provides an objective measure of VA. The acuity measurement is dependent on check
size and the generation of a major peak in response to the stimulus.

Macular Disease
In conditions such as Idiopathic Central Serous Choroidopathy (ICSC) and Age Related Macular Degeneration
(ARMD), the integrity of the macula is compromised. Since the major peak recorded is mainly a reflection of macular
function, the amplitude of the may be reduced and the implicit time may be delayed.
Optic Nerve Disease
In Demyelinating Optic Neuropathy (DON) the myelin sheath responsible for conduction velocity of neural impulses
is damaged. The VEP therefore displays an implicit time delay. The P100 may not occur until 150msec or more.
Following VA improvement from DON, the P100 frequently remains delayed. Anterior Ischemic Optic Neuropathy
(AION) affects the nerve fibers. The VEP demonstrates reduced major peak amplitude. A slight delay in implicit time
is also possible.
Orbital Disease
In conditions such as carotid cavernous sinus fistula, ocular pseudotumor and dysthyroid orbits, VA and VF testing
may or may not be affected, but the VEP will certainly demonstrate an abnormality. The VEP in such cases displays
a reduction in the major peak amplitude.
Amblyopia
The VEP is useful in determining a prognosis for VA improvement through visual therapy. Amblyopia may reduce the
major peak amplitude. A mildly reduced amplitude indicates a good prognosis for VA improvement while a severe
reduction is less positive for improvement through visual therapy.
Objective VA measurement
With non-verbal or uncooperative patients or in patients with dense media opacity, the VEP can provide an objective
VA measurement. If a patient is able to see the check pattern then a major peak will be generated. The amplitude of
the peak can be correlated to the check size (angle subtended by the stimulus), hence VA.
ELECTRO-OCULOGRAPHY (EOG)
The EOG is a measure of the standing potential between the cornea and the fundus. The standing potential
between the cornea and fundus is termed the battery. The battery is recorded as an electrical response to eye
movements, therefore, it is not constant. The size of the battery is dependent on the state of light adaptation. The
battery is larger under photopic conditions and smaller under scotopic conditions. The test functions by the use of
electrodes placed at the temporal and nasal canthus of each eye. Fixation is shifted between two stimuli that are
separated by 30° of visual angle (Fig. 16.6). The EOG is a useful diagnostic tool because it is a reflection of the
integrity of the RPE. In certain conditions abnormalities on the EOG are present while the ERG is normal.
Figure 16.6: Standing potential shifts with eye movements

The test is performed under scotopic conditions and photopic conditions. The eye movement potential under
photopic conditions displays a maximum Light Peak which reflects fast oscillations. The eye movement potential
under scotopic conditions displays a minimum Dark Trough which reflects slow oscillations. The ratio between the
maximum Light Peak and minimum Dark Trough is clinically relevant and is referred to as the Light-Dark ratio or
Arden Ratio (Fig. 16.7a).
Light peak (LP)

Arden ratio
Dark trough (DT)
Figure 16.7a: Expected Arden Ratio ≥ 2.0 Figure 16.7b: Abnormal Arden Ratio ≤ 1.8
Procedure
Electrodes are placed at the temporal and nasal canthi. The subject is asked to alternate fixation between 2 dimly
illuminated red-cross targets. The test is performed over 35 minutes. The first 5 minutes are recorded under photopic
conditions. The next 15 are recorded under scotopic conditions. The final 15 minutes are recorded under photopic
conditions (Fig. 16.7b).
CLINICAL RELEVANCE
Few ocular conditions may give a normal ERG and an abnormal EOG. Best's Vitelliform Macular Dystrophy and
Fundus Flavimaculatus demonstrate an abnormal EOG and a normal ERG. The EOG is most useful when these
specific conditions are suspected.

RADIOLOGICAL EXAMINATION OF THE VISUAL
SYSTEM
AUTHOR
PEER REVIEWER
John Pula: NorthShore University Health System, Pritzker School of Medicine Clinician Educator, University of
Chicago
RADIOLOGICAL EXAMINATION
Radiological examination refers to procedures that employ the use of imaging techniques to visualize the human
body non-invasively for diagnostic or therapeutic purposes. The most common techniques used in ocular care are
Magnetic Resonance Imaging (MRI) and Computed tomography (CT)
PROJECTIONS
Images are 2 dimensional pictures which can run in any of three planes.
• Axial (or transverse) plane - a horizontal plane of view. This is the only slice seen on most head CT scans. Orbit
CT scans usually include coronal or sagittal scans as well. Axial images account for the majority of sequences in
a brain MRI as well.
• Coronal plane - a vertical plane, named from the ‘corona‘ or ‘crown‘ as seen in many paintings displaying saints
or holy men. The optic nerves, superior and inferior recti muscles, paranasal sinuses, orbital floor and roof, and
optic chiasm are all seen in this plane.
• Sagittal plane - a vertical plane of view running anterior to posterior.

Radiological Examination of the Visual System
Figure 18.1. Diagram showing sagittal, coronal and transverse planes of the head
I. MAGNETIC RESONANCE IMAGING
Within the body, hydrogen nuclei (protons) act as small magnets when placed in a strong magnetic field. Each proton
can exist in one of two states - parallel or antiparallel. When a magnetic field is activated, in an MRI machine for
example, all protons are affected, and are aligned in a similar direction (i.e. parallel). At this point, a pulse of energy
can be sent to the protons, and their reaction to the pulse (time constant) produces a signal that is captured by an
imager, decoded and represented as a gray scale in a scan (the MRI images). The images are essentially imaged
"slices".
The most commonly used time constants are T1 and T2. T1 is the time needed for 63% of protons to recover their
former position after a pulse is given (relaxation time). Different types of tissue (i.e. extraocular muscle, optic nerve)
have different T1 relaxation times, and this is represented by having different intensity (brightness) on MRI. T1-
weighted imaging is the best sequence on MRI to evaluate normal anatomy.
T2-weighted imaging uses different imaging parameters (relaxation) than T1-weighted imaging to change the relative
intensity of the signal coming from certain tissues. Specifically, pathologic lesions are usually visualized better with T2-
weighted imaging.
Other relevant techniques include diffusion-weighted MRI which allows the visualization of water diffusion in biological
tissues and gradient imaging which allows finer tuning to allow imaging of blood. In the orbits, a special sequence, fat
suppression, is used to eliminate signal from the orbital fat, in order to better visualize the intra-orbital contents.
Evaluations thus consist of several sequences of images from the same slice of tissue. These usually include T1-
weighted (for anatomy), T2-weighted (for pathology), diffusion-weighted (for ischemia), and gradient imaging (for
blood).

Figure 18.2. Coronal fat-suppressed T1-weighted imaging of the orbits. Short arrows point to the rectus muscles. Long arrow
shows the superior oblique muscle. Curved arrow shows an ophthalmic vessel.
II. COMPUTED TOMOGRAPHY
The principles of X-ray are used for CT scans. X-rays refer to the use of an electromagnetic wave of high energy and
very short wavelength which is able to pass through many opaque materials including the human body. X-rays are
absorbed to different degrees by materials of varying composition and physical density. Therefore if an X-ray beam is
passed through a portion of matter (body, globe, etc.) it will be attenuated according to the density of the area.
Sensitive detectors can then capture and record the residual X-rays on a photographic or digital image.
Tomography means imaging a number of (X-ray) sections together. Scanning cross-sectionally will provide a "slice" of
the anatomy. A series of these "slices" are then repeated at various levels. An image representing tissues and
structures can be computer generated.
CT scans are better for the detection of denser tissues. Substances which appear bright on CT are therefore tissues
such as bone and acute blood. In the orbit, drusen are also dense (Figure 18.3).
Figure 18.3. Axial CT image through the orbits, showing the dense appearance of optic disc drusen (arrowhead).
III. CONTRAST
Contrast agents or media may or may not be given as part of the imaging sequences. Given orally or intravenously,
contrast agents alter the relaxation times of atoms within body tissues where they are present. They thus accentuate

the appearance of certain structures, namely those which have either physiologic or pathologic breakdown of the
blood-brain barrier. Common pathologic examples of these are tumors or abscesses.
The contrast used for CT is an iodine-based dye. The contrast used for MRI is an element called gadolinium which is
iodine free. Neither MRI nor CT contrast is used in patients with renal failure, either because it can worsen renal
function (iodine), or cause a skin problem (gadolinium). For MRI, gadolinium is given with T1-weighted imaging.
Figure 18.4. T1-weighted gadolinium contrast evaluations of the chiasm, showing a normal, non-enhancing chiasm (left image),
and a pathological, demyelinating chiasm lesion (right image), which appears hyperintense on MRI.
IV. ADVANTAGES/DISADVANTAGES OF CT VERSUS MRI
CT
• Shorter examination scanning time
• Quieter procedure
• Larger open area decreases claustrophobia
• May be utilized in patients with intra-ocular metallic foreign bodies
• Pacemakers are unaffected
• Bone and small fractures more easily seen
MRI
• No radiation
• Orbital muscles and fat easier to distinguish
• Superior evaluation of most orbital and intracranial lesions
V. STUDY OF CHOICE: CT VERSUS MRI
Area of suspected pathology CT MRI
Blow-out fracture •
Extraocular muscles •
Fracture (craniofacial) •

Lacrimal gland mass • •
Mass (craniofacial) • •
Optic nerve •
Chiasm •
Cerebral lesions (figure 4) •
Cerebral hemorrhage (acute) •
Cerebral hemorrhage (chronic) •
Vascular malformation •
Figure 18.5. Axial non-contrast MRI of the brain showing pathological lesions in the occipital lobes (arrows), resulting in cortical
blindness. Ocular examination and orbital imaging in this case would be normal, accentuating the need for correct localization prior
to image ordering.
VI. GENERAL GUIDELINES FOR IMAGING OF VISUAL PROBLEMS
• First localize the lesion, then the suspected pathology

• Choose the study (CT versus MRI) and location (brain versus orbit) based on above
• Order contrast based on indications and contraindications
• Discuss the case with radiology/neuro-radiology to increase yield of discovering pathology.
• A normal imaging result does not necessarily mean that there is no pathology (lesions may be too small to be
seen, may be iso-intense or iso-dense to surrounding tissues, or may be too short lived to yet be present on
imagine (for example, a small stroke on MRI).

REFERENCES
1. Johnson M, Policeni BA, Lee AG, Smoker WR. Neuroimaging in Ophthalmology. Oxford University Press,
New york, 2011.
2. Lee AG, Brazis PW, Garrity JA, White M. Imaging for neuro-ophthalmic and orbital disease. Am J
Ophthalmol 2004;138(5):852-862.

OPHTHALMIC LASER THERAPY:
MECHANISMS AND APPLICATIONS
AUTHOR
Daniel Palanker: Department of Ophthalmology and Hansen Experimental Physics Laboratory, Stanford University
PEER REVIEWER
David A. Cockrell: President, American Optometric Association, Stillwater, Oklahoma
DEFINITION
The term LASER is an abbreviation which stands for Light Amplification by Stimulated Emission of Radiation. The
laser is a source of coherent, directional, monochromatic light that can be precisely focused into a small spot. The
laser is a very useful tool for a wide variety of clinical diagnostic and therapeutic procedures.
COMMON OPHTHALMIC LASER PROCEDURES
PATTERN SCANNING LASER PHOTOCOAGULATION
The first attempts to make photocoagulation a completely automated procedure involved rather complex equipment,
including image recognition software and eye tracking[13]. The complexity of such systems prevented their
commercial introduction and acceptance in clinical practice.
A semi-automatic pattern scanning photocoagulator (PASCAL, Topcon Medical Laser Systems Inc.) was introduced
by OptiMedica Corp. in 2005[14]. It delivered patterns of laser spots ranging from a single spot to 56 spots applied in a
rapid sequence with a single depression of a foot pedal. The control of laser parameters was performed by means of a
touch screen graphic user interface, facilitating selection of the different patterns of photocoagulation. The laser was
activated by pressing a foot pedal, which was kept depressed until the entire pattern was completed, although it was
possible for the physician to release the foot pedal and stop the laser at will, prior to completion of the pattern, if
clinically indicated.
Patterns included square arrays with up to 5x5 spots, arcs with the number of concentric rows varying from 1 to 3,
circular patterns for photocoagulation of small holes and other lesions in the retinal periphery. Patterns for macular
photocoagulation included rings and arcs with adjustable central exclusion zone of up to 2 mm in diameter to allow for
laser application reducing the risk of inadvertent damage to the foveal avascular zone.
Note: this chapter contains excerpts from the full chapter by Daniel Palanker, which can be found here.

Ophthalmic Laser Therapy
To deliver the whole pattern within the eye fixation time and avoid beam movement due to the ocular muscles, each
exposure was required to be shorter than in conventional photocoagulation: 10-20 ms instead of 100-200 ms,
traditionally applied with single spot exposures. Reduced heat diffusion into choroid during shorter exposures also
resulted in patients experiencing less pain [15-17]. Short pulse lesions appear smaller and lighter than conventional
burns produced with the same beam size, and therefore a larger number of them are required to treat the same total
area[18].
An automatic laser delivery, guided by diagnostic imaging and stabilized using eye tracking, has been recently
introduced in a NavilaseTM system (OD-OS GmbH). This system includes retinal image acquisition, annotation of the
images to create a detailed treatment plan, and then automated delivery of the laser to the retina according to the
treatment plan.
CLINICAL INDICATIONS: TREATMENT OF DIABETIC RETINOPATHY
Photocoagulation has proven safe and effective in the treatment of proliferative diabetic retinopathy. In this disorder
the retina becomes ischemic and releases a variety of chemical messengers, most importantly vascular endothelial
growth factor (VEGF) that stimulates the growth of new blood vessels and also markedly increase retinal vascular
permeability. The abnormal new vessels, and associated fibrous tissue and macular oedema are major causes of the
sight-threatening complications in diabetic eye disease. By destroying a portion of the peripheral retina with laser, it
has been hypothesized that retinal metabolic demands and available nutrients are better balanced and the stimulus
for growth of the new blood vessels is decreased. This treatment has been termed panretinal photocoagulation (PRP)
and significantly reduces the risk of vision loss due to neovascularization. The side effects of panretinal
photocoagulation – mild nyctalopia and constriction of visual field- are felt to be outweighed by the preservation of the
central vision, and have been confirmed in multiple large randomized clinical trials[19]. Similarly, the focal laser
photocoagulation to actively leaking microaneurysms, and the grid photocoagulation to areas of diffuse retinal
permeability have been shown to reduce clinically significant macular oedema associated with diabetic retinopathy
and slow the rate of vision loss. These effects have been confirmed in large randomized multicenter clinical trials[20].
AGE RELATED MACULAR DEGENERATION: EXTRAFOVEAL NEOVASCULAR LESIONS
Another application for laser photocoagulation in the past was for the treatment of extrafoveal CNV membranes that
occur in AMD. Intense photocoagulation destroyed the invading vascular membrane usually leaves a chorioretinal
scar, and a blind spot or scotoma, but if the lesions treated were outside the center of the macula, the treatment was
typically well tolerated by the patients. Currently, many physicians have elected to use PDT as an alternative to
intense focal photocoagulation, or to use anti-VEGF therapy, because of later recurrences and eventual spread of
lesions into the macula.
Additional applications of retinal photocoagulation include grid and focal treatment of leaking microvascular
abnormalities, in branch-vein occlusion and radiation retinopathy; and treatment of retinal breaks and lattice
degeneration to prevent retinal detachment.
SELECTION OF OPTIMAL WAVELENGTH FOR COAGULATION
A number of important factors must be considered when choosing the best wavelength for a particular
photocoagulation application. The first consideration is to determine what absorbers are present in the site to be
photocoagulated. Wavelengths that are highly absorbed by macular yellow (such as 488 nm) are relatively contra-
indicated when treating in or near the macula. Absorption of these wavelengths in macular pigments may cause
heating and destruction of the nerve fiber layer, resulting in loss of vision. As shown in Figure 3B, in the macular
region, wavelengths longer than 500 nm should be chosen, such as the green argon (514 nm) or the frequency
doubled YAG (532 nm) or semiconductor yellow (577nm) laser. Melanin provides good absorption at most
photocoagulation wavelengths. Wavelength selection is therefore less important when melanin is the primary
absorber. To minimize scattering loss in cataract or in vitreous opacities the longer wavelengths (yellow - 577nm or
red - 640 to 680 nm) are preferable. If scattering by the ocular tissues is not significant, the argon green (514nm) or
doubled YAG (532nm) continue to serve well.

When hemoglobin is the primary absorber (see Figure 17.3B), as in the treatment of vascularized tumors, a
wavelength shorter than 600 nm is preferable. Treatment of CNV may be effective using red light through indirect heat
transfer from the surrounding melanin. Tunable lasers may provide the flexibility to select a wavelength of choice for
required photothermal procedure. However, tunable lasers are more costly, require more maintenance, and are now
less commonly employed clinically than previously.
LASER TRABECULOPLASTY
Argon Laser Trabeculoplasty (ALT) is usually applied to patients with open-angle glaucoma whose intraocular
pressure (IOP) cannot be controlled by maximum pharmacological therapy. Safety and efficacy of ALT in treatment-
naive subjects with newly diagnosed primary open-angle glaucoma has been demonstrated in large multicenter
prospective clinical trial (POAG) in 1995 [21]. ALT provided longer control of intraocular pressure (IOP) without the
need for additional therapy, and greater stability of visual field and optic nerve status, as compared with timolol
monotherapy[22]. ALT lowers IOP by 6-10 mmHg, usually within 4-5 weeks, and lower IOP is usually maintained for
several years. ALT is reported to have 70-75% success rate of clinically significant improvement.
With Argon laser (514 nm) or more recently, with the equivalent 532nm Nd:YAG laser, 50 spots of 50 µm in diameter
are applied to the 180 degrees on trabecular meshwork (TM) with pulses of 100 ms in duration (Figure 17.1). The
mechanisms of action leading to reduction in IOP are not well established. One theory is that the thermal burns
created in the trabecular meshwork contract the tissue and open spaces within trabecular meshwork, thus increasing
the aqueous outflow and lowering IOP. Another possible theory states that the thermal stress induced by laser therapy
causes an increase in metabolic activity of the endothelial cell in the trabecular meshwork, which improves the
aqueous outflow.
Figure 17.1: Laser trabeculoplasty: laser beam is directed onto the trabecular meshwork via gonioscopic lens. For ALT, laser is
typically focused into 50 µm spots. For SLT, the laser spots are 400 µm in diameter.
Selective Laser Trabeculoplasty (SLT) was introduced in 1995[23, 24]. The commercially available SLT laser systems
(Lumenis Inc., Santa Clara, CA; and Ellex Inc., Adelaide, Australia) include a Q-switched, frequency-doubled, 532-nm
Nd:YAG laser, that delivers 3 ns pulses in a 400 μm diameter treatment spot. Typical SLT pulse energy ranges from
0.4 to 1.2 mJ, about hundred times lower than ALT. With 400 µm beam diameter, 100 spots per 360 degrees provide
practically complete coverage of the TM (Figure 17.9). SLT has been shown to be an effective alternative to LT [23,
25, 26], in the treatment of patients with Open Angele Glaucoma. SLT leaves the Trabecular Meshwork intact with
minimal damage to the endothelial cells lining the meshwork beams[23], in contrast to the ALT, which results in
extensive scarring of the meshwork[27]. This observation has led to significant speculation that SLT may be more
repeatable than ALT. SLT is easier to perform than ALT due to its larger spot size, and is better tolerated by patients
due to reduced pulse energy. Like ALT, the IOP-lowering effect of SLT lasts for several years, but does tend to
diminish over time. SLT is effective as primary therapy, can reduce the pharmaceutical burden in medically controlled
eyes, and can prevent or delay the need for surgery in eyes poorly controlled, but on maximally tolerated medical
therapy. Both 180 and 360-degree treatments appear to be reasonable as initial therapy, and there seems to be no
contraindication to initial 360 degrees treatment. The majority of procedures are performed as 180 degree treatments,
with the second 180 degrees done typically 14 days after the first treatment.
Much lower energy requirements in SLT compared to ALT is due to different mechanisms of cellular damage
produced by nanosecond and millisecond pulses. Millisecond hyperthermia of pigmented cells leads to cellular
damage due to denaturation of proteins and other cellular macromolecules[28]. Nanosecond exposures though are
too short to produce thermal denaturation below the vaporization threshold, and cells are damaged by cavitation
bubbles forming around melanosomes[28]. With sub-microsecond pulses the heat does not diffuse beyond one
micrometer, and thus the damage can be confined within a cell. With 100 ms exposures in ALT the heat diffusion zone
can reach 220 µm, covering practically the whole width of TM.
LASER IRIDOTOMY
Laser iridotomy (LI) also called PI (peripheral iridotomy) is performed on the eye to treat angle closure glaucoma, a
condition of increased intraocular pressure caused by blockage of the angle of the anterior chamber by the iris. LI is a
procedure in which the laser creates a hole in the iris to allow fluid to flow through and relieve pressure in the eye.
This typically results in resolution of the forwardly bowed iris and thereby an opening up of the angle of the eye (Figure
17.2). It is also used prophylactically with anatomically narrow angles, in the fellow eye of a patient with primary pupil
block angle closure, a patient with primary open angle glaucoma and coincidentally narrow angles, and
nanophthalmos. LI is performed ~3mm from iris root under the superior lid to prevent monocular diplopia. Power and
pulse duration vary with iris color of the patient. Pulses (100-300 ms) of argon laser (514nm) or 532nm YAG laser
focused into 50 µm spot are applied to create a depression. A “smoke signal” or aqueous plume, is seen when the
posterior pigment epithelial layer is reached. The process is continued until penetration is complete. A combination of
millisecond pulses of Argon laser and nanosecond pulses of Q-switched YAG is often used to perform the procedure.
The Argon is used first to initiate tissue removal and photocoagulate vessels to prevent hemorrhages and then the ns
YAG is used to complete the iridotomy[29]. The ns YAG laser does not coagulate tissue, and used alone can cause
hemorrhages.
Figure 17.2: Laser iridotomy providing an alternative route for the aqueous flow from posterior to anterior chamber of the eye.

POSTERIOR CAPSULOTOMY
Posterior lens capsule opacification (PCO) is the most common late complication occurring in approximately third of
the cataract surgery cases[30]. Laser is used to create an opening in the hazy central part of the posterior capsule
situated behind the intraocular lens (IOL) implant. The slit lamp-coupled nanosecond Nd:YAG laser focused into a
tight spot can produce extremely high light intensities – in excess of 1010 W/cm2. At these irradiancies photons can
ionize even transparent materials via several different mechanisms[6], producing plasma in a focal spot. Plasma
energy converting into heat results in rapid vaporization of the focal volume, producing shock waves and cavitation
bubbles. Rapidly expanding and collapsing vapor bubbles can rupture (a process called photodisruption) the adjacent
opacified posterior lens capsule, providing a clear window for central vision. To avoid damage to the intraocular lens
implant, the laser is focused slightly posterior to the capsule in the vitreous (Figure 17.3).
Figure 17.3: Posterior capsulotomy
REFRACTIVE SURGERY
Laser-Assisted In Situ Keratomileusis (LASIK) includes 2 steps: 1) cutting of a flap in the cornea (by mechanical
microkeratome or a femtosecond laser) to pull it back and expose the corneal stroma for laser ablation; 2) ablation of
the corneal stroma with 193nm excimer laser [31]. ArF excimer laser radiation is absorbed in a very shallow layer of
the cornea (~200nm), and short pulse duration (10-20 ns) prevents heat diffusion from the light absorption zone during
the pulse, by more than a few nanometers. These features enable very precise ablation of the cornea by ArF laser,
ejecting the overheated surface material layer by layer, with the steps of about 200nm per pulse. Such precise tissue
scalping with very shallow residual tissue damage zone allows precise reshaping of the corneal surface to correct
refractive errors. After the laser reshaping of the stroma, the corneal flap is placed back over the treatment area, and
its adhesion to the surrounding tissue improves over time due to natural healing.
Development of the femtosecond laser for corneal flap cutting, based on dielectric breakdown of the tissue in the
tightly focused laser beam [32], enabled further improvements. Unlike mechanical microkeratome, laser cutting
allowed the formation of vertical walls around the planar flap, which enabled better positioning of the corneal flap back
into original location after ablation. This improved the consistency of refractive outcomes, and led to wide acceptance
of the fs laser in refractive surgery[33, 34]. Ultrafast lasers also enabled refractive surgical procedures based on

intrastromal cutting, without excimer laser ablation: extraction of lenticules[35] and producing pockets for intrastromal
rings[36]. The same laser systems have been applied to transplantation of the whole cornea or corneal
endothelium[37], so called Endothelial Keratoplasty.
In Laser Thermal Keratoplasty (LTK) long pulses of the mid-infrared laser (Holmium YAG, 2.1mm wavelength) are
applied in a ring pattern of 6-7 mm in diameter. Heating of the upper third of the corneal stroma results in collagen
shrinkage, thereby steepening it to correct hyperopia[38]. Similar effect can be produced by electric current, the
procedure called conductive keratoplasty[39]. This effect may regress somewhat over time.
CATARACT SURGERY
Conventional cataract surgery involves manual formation of an opening in the anterior lens capsule, fragmentation
and evacuation of the lens tissue using ultrasound probe, and implantation of a plastic intraocular lens into the
remaining capsular bag. The size, shape and position of the anterior capsular opening (one of the most critical steps
in the procedure) is controlled by a freehand pulling and tearing the capsular tissue. Recently developed new laser-
based technique greatly improves the precision and reproducibility of cataract surgery by performing anterior
capsulotomy, lens segmentation and corneal incisions with a femtosecond laser[11]. Exact placement of the cutting
patterns in tissue is determined by imaging the anterior segment of the eye using integrated Optical Coherence
Tomography[12], as illustrated in Figure 17.4. Femtosecond laser produces 3-dimentional patterns of cutting to soften
the crystalline lens and to cut a round opening in the anterior capsule. Three-dimensional cutting of the cornea based
on diagnostic imaging can improve safety by creating multi-planar self-sealing cataract incisions, and can reduce
residual astigmatism by exact placement of the limbal relaxing incisions.
Figure 17.4: Left: system diagram, including the OCT and femtosecond laser combined by a common scanner. Right: Side and top
views of the eye, with overlay of the planned laser patterns.

OTHER PROCEDURES (LESS COMMON OR UNDER INVESTIGATION)
• Anterior Stromal Puncture for traumatic recurrent corneal erosion.

• Laser Suture Lysis for post-filtration or cataract surgery.
• Oculoplastic Surgery (CO2 or Argon laser): port-wine stain, capillary hemangioma, basal cell carcinoma,
trichiasis, xanthelasma, phthiriasis palpebrarum.
• Photomydriasis ( to enlarge pupil )
• Anterior Synechiolysis for iris incarceration, adhesions involving anterior and posterior capsule, and vitreous
body strands.
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1. Kramer, M., et al., Liposomal benzoporphyrin derivative verteporfin photodynamic therapy. Selective
treatment of choroidal neovascularization in monkeys. Ophthalmology, 1996. 103(3): p. 427-38.
2. Schmidt-Erfurth, U., et al., Photodynamic therapy of subfoveal choroidal neovascularization: clinical and
angiographic examples. Graefes Arch Clin Exp Ophthalmol, 1998. 236(5): p. 365-74.
3. Woodburn, K.W., C.J. Engelman, and M.S. Blumenkranz, Photodynamic therapy for choroidal
neovascularization: a review. Retina, 2002. 22(4): p. 391-405; quiz 527-8.
4. Sramek, C., et al., Dynamics of Retinal Photocoagulation and Rupture. J. Biomedical Optics, 2009. 14.(3): p.
034007-1-13.
5. Simanovskii, D.M., et al., Cellular tolerance to pulsed hyperthermia. Phys Rev E Stat Nonlin Soft Matter Phys,
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6. Vogel, A. and V. Venugopalan, Mechanisms of pulsed laser ablation of biological tissues (vol 103, pg 577,
2003). Chemical Reviews, 2003. 103(5): p. 2079-2079.
7. Vogel, A., et al., Mechanisms of intraocular photodisruption with picosecond and nanosecond laser pulses.
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8. Krueger, R.R., et al., Ultrastructure of picosecond laser intrastromal photodisruption. Journal of Refractive
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9. Yen, K.G., et al., Histopathology of femtosecond laser intrastromal refractive surgery in rabbits. Investigative
Ophthalmology & Visual Science, 1999. 40(4): p. S621-S621.
10. Cohen, B.Z., K.J. Wald, and K. Toyama, Neodymium:YLF picosecond laser segmentation for retinal traction
associated with proliferative diabetic retinopathy. American Journal of Ophthalmology, 1997. 123(4): p. 515-
523.
11. Palanker, D.V., et al., Femtosecond laser-assisted cataract surgery with integrated optical coherence
tomography. Sci Transl Med, 2010. 2(58): p. 58ra85.
12. Friedman, N.J., et al., Femtosecond laser capsulotomy. J Cataract Refract Surg, 2011. 37(7): p. 1189-98.
13. Wright, C.H.G., et al., Initial in vivo results of a hybrid retinal photocoagulation system. Journal of Biomedical
Optics, 2000. 5(1): p. 56-61.
14. Blumenkranz, M.S., et al., Semiautomated patterned scanning laser for retinal photocoagulation. Retina-the
Journal of Retinal and Vitreous Diseases, 2006. 26(3): p. 370-376.
15. Nagpal, M., S. Marlecha, and K. Nagpal, Comparison of laser photocoagulation for diabetic retinopathy using
532-nm standard laser versus multispot pattern scan laser. Retina, 2010. 30(3): p. 452-8.
16. Muqit, M.M., et al., Pain responses of Pascal 20 ms multi-spot and 100 ms single-spot panretinal
photocoagulation: Manchester Pascal Study, MAPASS report 2. Br J Ophthalmol, 2010. 94(11): p. 1493-8.
17. Muqit, M.M., et al., In vivo laser-tissue interactions and healing responses from 20- vs 100-millisecond pulse
Pascal photocoagulation burns. Arch Ophthalmol, 2010. 128(4): p. 448-55.
18. Palanker, D., et al., THE IMPACT OF PULSE DURATION AND BURN GRADE ON SIZE OF RETINAL
PHOTOCOAGULATION LESION: Implications for Pattern Density. Retina, 2011.

19. DRS_Study_Group, Photocoagulation Treatment for Proliferative Diabetic Retinopathy. Clinicial Application
of DRS findings, DRS Report Number 8. Ophthalmology, 1981. 88: p. 583-600.
20. ETDRS_Study_Group, Early Photocoagulation for Diabetic Retinopathy. ETDRS Report Number 9.
Ophthalmology, 1991. 98: p. 766-785.
21. The Glaucoma Laser Trial (GLT) and glaucoma laser trial follow-up study: 7. Results. Glaucoma Laser Trial
Research Group. Am J Ophthalmol, 1995. 120(6): p. 718-31.
22. Kass, M.A., et al., The Ocular Hypertension Treatment Study: a randomized trial determines that topical
ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch
Ophthalmol, 2002. 120(6): p. 701-13; discussion 829-30.
23. Latina, M.A., et al., Q-switched 532-nm Nd:YAG laser trabeculoplasty (selective laser trabeculoplasty): a
multicenter, pilot, clinical study. Ophthalmology, 1998. 105(11): p. 2082-8; discussion 2089-90.
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25. Nagar, M., et al., A randomised, prospective study comparing selective laser trabeculoplasty with latanoprost
for the control of intraocular pressure in ocular hypertension and open angle glaucoma. Br J Ophthalmol,
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26. Melamed, S., G.J. Ben Simon, and H. Levkovitch-Verbin, Selective laser trabeculoplasty as primary treatment
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28. Schuele, G., et al., RPE damage thresholds and mechanisms for laser exposure in the microsecond-to-
millisecond time regimen. Invest Ophthalmol Vis Sci, 2005. 46(2): p. 714-9.
29. He, M., et al., Laser peripheral iridotomy in primary angle-closure suspects: biometric and gonioscopic
outcomes: the Liwan Eye Study. Ophthalmology, 2007. 114(3): p. 494-500.
30. Apple, D.J., et al., Posterior capsule opacification. Surv Ophthalmol, 1992. 37(2): p. 73-116.
31. Pallikaris, I.G., et al., A corneal flap technique for laser in situ keratomileusis. Human studies. Arch
Ophthalmol, 1991. 109(12): p. 1699-702.
32. Kurtz, R.M., et al., Lamellar refractive surgery with scanned intrastromal picosecond and femtosecond laser
pulses in animal eyes. Journal of Refractive Surgery, 1998. 14(5): p. 541-8.
33. Ratkay-Traub, I., et al., Ultra-short pulse (femtosecond) laser surgery: initial use in LASIK flap creation.
Ophthalmol Clin North Am, 2001. 14(2): p. 347-55, viii-ix.
34. Nordan, L.T., et al., Femtosecond laser flap creation for laser in situ keratomileusis: six-month follow-up of
initial U.S. clinical series. J Refract Surg, 2003. 19(1): p. 8-14.
35. Heisterkamp, A., et al., Photodisruption with ultrashort laser pulses for intrastromal refractive surgery. Laser
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36. Ertan, A. and M. Bahadir, Intrastromal ring segment insertion using a femtosecond laser to correct pellucid
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Global Optometry Resources

Clinical Optometric Procedures 2

Luigi Bilotto: Brien Holden Vision Institute

Mark Dunbar: Bascom Palmer Eye Institute, University of Miami

Sarah McGowan: Mzuzu University

Benoit Tousignant: Université de Montréal, School of Optometry

James Loughman: Dublin Institute of Technology

Dr Cédric Yansouni: McGill University

Patricia Hrynchak: University of Waterloo

Timothy Wingert, University of the Incarnate Word Rosenberg School of Optometry

Maureen Hanley, The New England College of Optometry

Meng Meng Xu, The New England College of Optometry

Iqbal Ike Ahmed, MD, FRCS

Jean-Sébastien Dufour: University of Montreal

EDITORS AND GRAPHICS

Brien Holden Vision Institute Staff – Public Health Division

COPYRIGHT © 2014 Brien Holden Vision Institute. All rights reserved.

By the end of the module the student should be able to:

STANDARD OCULAR HEALTH ASSESSMENT

VISUAL FIELDS ASSESSMENT AND INTERPRETATION

Learning and Teaching Methods & Resources

Suggested equipment for teaching includes:

STANDARD OCULAR HEALTH ASSESSMENT

VISUAL FIELDS ASSESSMENT AND INTERPRETATION

Copyright © 2015 Brien Holden Vision Institute

STANDARD OCULAR HEALTH ASSESSMENT

VISUAL FIELDS ASSESSMENT AND INTERPRETATION

Luigi Bilotto: Brien Holden Vision Institute

Dr Cédric Yansouni: McGill University

• Chronic open angle glaucoma

2013 Clinical Optometric Procedures 2, Chapter 1-1

Pressure in the arterial system during single cardiac cycle

125 Systolic pressure

mmHg Mean pressure

2013 Clinical Optometric Procedures 2, Chapter 1-2

Figure 1.2: Set up and phases of a blood pressure measurement

Figure 1.3: Instrumentation used for blood pressure measurement

• If not your own, clean earpieces of the stethoscope with alcohol

SYSTOLIC / DIASTOLIC; ARM USED; PATIENT POSITION; TIME

E.g. 150/90 RAS 13:45

2013 Clinical Optometric Procedures 2, Chapter 1-4

Falsely Low Readings:

Falsely High Readings:

2013 Clinical Optometric Procedures 2, Chapter 1-5

BP Range (mmHg) Category Recommended Follow-up

Adults (> 18)

≤ 95/60 Hypotension Routine unless symptomatic

< 85 Normal BP Recheck within 2 years

Systolic (when diastolic < 90)

< 140 Normal BP Recheck within 2 years

< 135/90 Ages 14-18 years Routine

2013 Clinical Optometric Procedures 2, Chapter 1-6

Luigi Bilotto: Brien Holden Vision Institute

Benoit Tousignant: Université de Montréal, School of Optometry

Clinical Optometric Procedures 2, Chapter 2-1

LIDS & LASHES

Definition: A drooping or abnormally low position of the upper eyelid.

Clinical Optometric Procedures 2, Chapter 2-2

A: Primarily due to the aging process.