MACULAR FUNCTION TEST

D R . P U S H PA N J LI A

macula
• The International ARM Epidemiological study group, defined macula as the posterior part of retina centered on the foveola. • 5.5-6 mm diameter. • Comprises of fovea centralis(1.5mm), foveola(0.35mm) and FAZ(0.4-0.6mm).

Fovea differs from retina in that it has only the following 6 layers :
• • • • • •
 

Retinal pigment epithelium, Photoreceptors (cones only), External limiting membrane, Outer nuclear layer, Outer plexiform (Henle) layer, & Internal limiting membrane.

FUNCTIONAL DISTINCTION • highest discriminative ability(VA), • colour perception and

Specific anatomic configuration • Densest concentration of cones and a one to one photoreceptor-ganglion cell relationship. Cones more elongated and slender. • Absence of rods - fovea and foveola. • RPE more deeply pigmented. • Presence of xanthophyll. •  Imparts certain properties  …MFTs.

USES of macular function tests:
• Diagnosis; • Follow up of macular diseases & • For evaluating the potential macular function in eyes with opaque media such as cataract and dense vitreous hemorrhage.

Macular function tests
methods
• Psychophysical tests 1. Visual acuity 2. Contrast sensitivity 3. Photostress test 4. Amsler grid 5. Two point discrimination test* 6. Entoptic phenomenon 7. Tests dependent on macular pigment* 8. Maddox rod test* 9. Color vision 10. Foveal flicker sensitivity 11. Dark adaptation 12. Perimetry/Scanning laser ophthalmoscopy* • Electrophysiologic tests 15. Electroretinography (ERG)* 16. Electrooculography (EOG)* 17. Visually evoked response(VER)*

Visual Acuity
• A guide to the functioning of the entire visual pathway i.e. the visual axis, the macula and the optic pathways once the eye has been corrected for refractive errors. • The best-corrected visual acuity is a measure of actual foveolar function. • Visual acuity is measured by the visual resolution of a letter, symbol or a pattern under conditions of maximal contrast.

Visual acuity testing

The Snellen Chart
• The Snellen score = test distance/size of the smallest letter correctly identified. • The numerical value of the denominator is the distance at which the height of this smallest identified  test letter subtends 5 minutes of visual angle  on the retina. • Each component of this letter subtends 1 min  at this distance. LANDOLT C CHART : NAS-NRC recommended.

• Bailey-Lovie chart (ETDRS study) • Illiterate E chart (used with illiterate patients) • Sheridan-Gardiner cards (children>3 yrs) • Cat ford Drum - Based on Oscillatory movements • Teller’s acuity cards (useful in case of children from 6 months to 2 years). • Cardiff vision chart ( useful for children from 2-3 years). • Angular visual acuity cards (to avoid crowding phenomenon). • Near vision - by near vision charts for each eye separately.

Teller’s Acuity Cards (with Black & White strips)

Caradiff vision charts (diminishing optotypes)

Pin-hole test
• In pts with macular disease VA  is frequently worse when pt looks through a pin-hole.

Pu p i l ry re a cti n s la o • The pupillary reactions are usually normal in eyes with macular diseases. • The defect usually indicates either a lesion of the optic nerve(APD) or extensive retinal disease.

Contrast sensitivity
• Contrast sensitivity is a measure of the minimum amount of contrast needed to distinguish a test object & indirectly assesses the quality of vision. • Unlike VA, it is a measure of visual function under

 Uses : 1. To detect early/subtle visual loss esp when VA is Normal. 2. To detect retinal conditions like DR, ARMD and other retinal, macular and optic nerve diseases. 3. Optical conditions like refractive error, refractive surgery, cataract and intraocular lens implantation and normal aging of the eye.  In macular diseases, there is a marked impairment for the intermediate and higher

Sinusoidal gratings

Functional acuity contrast test

CONTRAST SENSITIVITY GRATINGS

L E T T E R C O N T R A S T S E N SI TI VI T Y

T h e H a m i to n -ve a l l e C o n tra st S e n si vi ti ty C h a rt

T h e Pe l iR o b so n C h a rt l
developed in 1988 is the accepted gold standard for measuring contrast sensitivity.

Laser interferometer
• Useful subjective test of the resolving power of eye by using Laser generated interference fringes. • Rodenstock interferometer. • Dilated pupil. • Coarse to fine fringes, change orientation.



Small heliumneon laser  collimated beam  optically divided  2 beams Overlap at/post. to plane of lens
 

 Brightness increased in pts with dense cataracts.  The laser interferometer resolving power converted to standard V.A.  Fringes not dependent on optical components of eye, except large r.e. uncorrected aphakia.  Limitations : 1. subjective,  2. Laser fringe vision>> vision of letter  acuity.  3. overpredicts visual potential in  amblyopes,

Potential acuity meter
• GUYTON and MINKOWSKI. • It consists of a slit lamp attachment that can project an entire V.A. chart on the macula. • Emits 0.1mm beam into windows of pt’s cataract. • Focusing with a slide scale  ranging from +13 to-10D. • Dilated pupil, relaxed pt. • Easier than laser interofermetry, does not overpredict V.A. in macular diseases.

Amsler Grid TEST
• Evaluates the 20* of visual field centered on fixation.  Used in screening and monitoring macular diseases like 1. Maculopathy – congenital, stargardt, ARMD. 2. Retinopathy – diabetic, CSR, chloroquine related. 3. Macular holes and 4. Optic neuropathies. GRID : square 10*10 cm divided into 400 5*5 mm squares to be held at 28-30 cm. Chart subtends angle Of 20*,each small square 1*.

Amsler Grid Testing
 Procedure : reading glasses, cover 1 eye.  SIX standard questions to be asked :
1. Ability to see the central spot. 2. Ability to see the 4 corners and sides of the grid. 3. Presence of any interruptions in the network of small squares by holes or blurry areas. 4. Ability to see all the horizontal and vertical lines straight and parallel to each other. 5. Presence of abnormalities like blurred areas, holes, distortions, movement of certain lines, vibrations or waning, something shining or an abnormal colour or tint. 6. Distance of above abnormalities from the fixation point and the presence of any intact square between the central point and the CHART 1 abnormal areas.

CHART 2

CHART 3

CHART 4

CHART 5

CHART 6

CHART 7

Central Scotoma

Arcuate Scotoma

Positive/Absolute Paracentral Scotoma

Macropsia

Micropsia

Metamorphopsia

Colour vision
• The central 30-60 degree of visual field processes trichromatic color vision. • Hereditary dystrophies of posterior pole, nonhereditary maculopathies & certain optic nerve conditions often result in acquired color defects. • Congenital:not particularly rare, affect males, symmetric, involve red-green color & occur as isolated visual defect. • Acquired: asymmetric, accompanied by other visual dysfunctions, most commonly show irregularity in color testing not usually seen in congenital variety. Eg.

COLOR CONFUSION TESTS

1. ISHIHARA CHART

2. Farnsworth panel D-15 3. The American Optical Hardy-Rand-Rittler pseudoisochromatic plates. 4. Sloan Achromatopsia Test.

• HUE DISCRIMINATION TEST : Farnsworth-Munsell 100 Hue test. • SPECTRAL TEST : Nagel Anomaloscope : the

best method for accurate classification of red-green defects.

Two Point Discrimination Test
• The ability to distinguish two illuminated points of light suggests good retinal function. • “Rule of 2” : Two illuminated points of 2 mm diameter size and 2 inches apart are placed 2 feet away from the patient’s eye. The patient is then asked to indicate whether he can perceive the two points

Maddox rod test
• Simplest, most reliable test(opaque med). • Rod consists of several cylinders of glass placed side by side in a frame.  Pt is asked to fixate light at a distance of 1/3 m through M.R. with opposite eye occluded.  Image formed is a straight line(vertical/horizontal streak) running perpendicular to the axis of rods.  Any breaks/holes; discoloration/distortion indicates a macular lesion.  RED: more sensitive, tells us about color perception.  Test various meridians by rotating : may

Photostress test:
• Bailliart in 1954. • Methods of assessing macular function by timing the recovery of visual acuity after adaptation to an intense light source have been called macular photostress tests. • PRINCIPLE : The test involves exposing the macula to a light source bright enough to bleach a significant proportion of the visual pigments. • Return of normal retinal function and sensitivity depends on the regeneration of the visual pigments.

• As the rate and extent of this regeneration is determined by anatomical and physiological apposition of photoreceptors and RPE, pathological states that affect the photoreceptors, Bruchs membrane, chorio- capillaris or choroid can prolong visual recovery time. • In contrast no such prolongation is observed in diseases affecting the neural conducting pathways.

• USES

: 1. to quantify subtle maculopathies,

2. discriminate between optic neuropathy & maculopathy, 3. to plot the recovery or progression of

TECHNIQUE
• The patient's pre-stress BCVA is noted. • The patient is asked to cover or occlude one eye while the other eye is subjected to a bright light from fully charged ophthalmoscope directed onto the macula for 15 seconds/indirect ophthalmoscope light held 3cm away for 10 seconds. • Photostress recovery time (PSRT) is the time it takes for the patient to read the line just above its pre-test best acuity line backwards. • Normal PSRT ranges from 8-70 seconds. •

CONDITIONS WITH PROLONGED PSRT
• • • • • • • • • Central serous retinopathy, Age related maculopathy, Macular edema, Retinal detachment, Diabetic retinopathy, Systemic hypertension, Retinal pigmentary degeneration, Chloroquine retinopathy, Alcohol or marijuana ingestion.

Dark adaptation
• Dark adaptation refers to the ability of the visual system,(both rods and cones mechanisms) to recover sensitivity following exposure to light. • Most primitive model-photometer of Richard Forster. • Hemispherical adaptometers are used nowadays (Goldman-Weekes by Haag Streit). • Useful in pts presenting with c/o night blindness as in hereditary macular degenerations. • Normally the whole process of dark

PROCEDURE: 1.Subject exposed to intense light that bleaches photoreceptors. 2.Then Suddenly placed in dark. 3.Threshold at which sub just perceives light is plotted. 4.Flashes repeated at regular intervals; sensitivity of eye to light gradually increases. 5.By taking a threshold reading every min a curve of changing threshold Vs time of dark adaptation is obtained.  Sensitivity curve : a. cone branch  b. rod-cone break

Dark Adaptation Curve

Clinical applications
1. Disorders of pigment degeneration a. Vitamin A deficiency; b. Fundus albipunctatus 2. Disorders of neural adaptation a. Oguchi’s disease b. Congenital stationary night blindness (CSNB) 3. Chloroquine toxicity, 4. Retinitis pigmentosa Type II, 5. Tapetoretinal degenerations, 6. High myopia,

The entoptic phenomenon (or Scheerer's phenomenon)
• visual perceptions that are produced or influenced by the native structures of one’s own eye. • Structures producing – N anatomic parts/Media opacities. 1.PURKINJE VASCULAR E.P. : Visual elements underlying bld vsls become adapted to this pattern of illumination. Focal source(at an unusual angle), pressed firmly against globe, retinal blood vessel pattern transiently. -Useful in pts with media opacities.

2. The blue field Entoptic Phenomenon (Flying spots)

• series of fast moving, luminous points or spots seen on looking at a bright and diffusely illuminated surface with no contrasting features. • Best seen in background illuminated by blue light in spectral region of 350-450nm. • Capillaries full of RBCs too close to each other, too far away from retina; so normally invisible. WBCs large act like gaps.

5/> - normal. Abnormal:  (a) failure to see any, (b) partial loss in 1 part of the field, (c) less no., (d) slow movement.  More accurate than : Two light discrimination,  color perception &  purkinje vascular entoptic phen.  Disadvantage : subjective, poorly quantifiable.  Little use in significant vitreous opacity.  D/d : FLOATERS : variable appearance, almost stationary or drift slowly, dont follow welldefined paths & are due to debris floating in vireous.

Haidinger’s Brushes
• Subject looks at a surface illuminated with blue light through a polarizer. • N – hourglass shaped yellowish brushes seen radiating from the pt of fixation. On rotating polarizer, brushes rotate. • Phenomenon - caused by variations in absorption of plane polarized light by oriented molecules of xanthophyll pigment in foveal retina. • Screening test for retinal or macular pathology in strabismus patients with amblyopia.

Maxwell’s Spot
• Subject looks at a brightly illuminated white surface through blue filter. • N - dark/greyish spot in the visual field corresponding to fovea surrounded by a dark ring is seen that gradually fades with time. • Now used clinically to detect eccentric fixation by placing a fixation pt in the diffusely illuminated field. • Perception is related to the arrangement of the yellow pigment in the inner retinal layers of the macula. • Thus, both these tests utilise the

erg
• The clinical ERG is the recording of the electrical potential waveform generated by the total (preganglionic) retina in response to a diffuse light stimulus.
• Test-performed in dark adaptation using a corneal contact lens(active) electrode which records changes in the corneoretinal potential with each

Negative ‘a wave’ – activities of rods & cones. Positive (composite)‘b-wave’ – from Muller cells in the bipolar region(inner retinal layers). c-wave – retinal metabolism (RPE). Peak amplitudes and latencies as well as waveform shape are considered in the interpretation of the ERG. Monitors preganglionic retinal activity so optic atrophy – N ERG. ERG - mass retinal response; an isolated lesion of the macula would not be

The Multifocal ERG
• Produces topographical maps of retinal function. • Stimulus is scaled for variation in photoreceptor density across the retina; at fovea where receptor density is high smaller stimulus element is used than in periphery. • The information can be summarised in form of a 3-D plot, resembling hill of vision.

Clinical applications

1. Vitamin A deficiency & xerosis. 2. Retinitis pigmentosa & allied diseases e.g.(a) Congenital Night Blindness. (b) Oguchi's Disease. (c) Retinitis punctate albicans. 3. Prognosis in Cataract. 4. Prognosis in Glaucoma. 5. Detachment of retina. 6. Systemic & retinal vascular conditions. 7. Macular diseases.

Eog
• Measures changes in corneoretinal potential of the eye under varying conditions of illumination.
• 2 electrodes are placed on the skin, 1 at lateral canthus & other at medial canthus. Pt is asked to shift fixation back & forth between 2 red lights that turn on & off sequentially in an alternating fashion. • Several measurements are taken every min for total of 15 min in darkness & then 15 min in light. • Plot of average amplitude value for each min against time normally shows a

• • • • • •

Dark trough - integrity of pigment epithelial outer segment region. Light rise - function of mid-retinal layers + outer retina-pigment epithelial complex. Light peak/dark trough ratio - reliable parameter of retinal function. N - >185%. Arden ratio : calculated by taking ratio of(max light adapted to min dark adapted response)*100. EOG is a reflection of generalized retinal responsiveness. So, abnormal in most of those conditions in which ERG is abnormal. Except Best’s Vitelliform macular dystrophy, Butterfly dystrophy, fundus flavimaculatus & generalized drusen. Here, ERG -N, EOG -abnormal.

v.e.r.
• Measure of the electrical potential generated in response to a visual stimulus.
 It is recorded with scalp electrodes placed over occipital lobe region, a cortical area with primarily a macular representation. • Diffuse light stimulus flashes intermittently-in suspected monocular pathology.

 Checkerboard pattern stimulator with alternation of dark and light checks. Then average potential is calculated by a computer. USES: monitoring of visual function in babies, macular pathway function & inv of optic neuropathy(demyelination). Though VER is predominantly a foveal response, it represents integrity of entire visual pathway from retina to occipital lobe. Limitation : cant differentiate macular from an optic n/cortical pathology.

Foveal Flicker Sensitivity
• A small flickering test light (0.5-2*) is superimposed on a constant background luminance. • The luminance of the flickering test light is so modulated; that the mean luminance of the test light is equal to that of the surround. • For a given frequency value, minimum modulation depth at which test spot is barely perceived to be flickering is defined as threshold modulation, reciprocal of which is sensitivity. • Comparison with normal patients yields information about presence

Flicker sensitivity curve is then plotted for a given point on retina as a function of flicker frequency.

perimetry
• Perimetry can also test the retinal function. • N useful for defects of peripheral visual fields careful STATIC of central 2-4* - early maculopathy. • FLICKER PERIMETRY . • Scanning Laser ophthalmoscope. • Macular disease is sometimes part of a generalized pathologic process & in such cases

SCANNING LASER OPHTHALMOSCOPE

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