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• 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.
• highest discriminative
• colour perception and
Specific anatomic configuration
• Densest concentration of cones and a one
to one photoreceptor-ganglion cell
relationship. Cones more elongated and
• Absence of rods - fovea and foveola.
• RPE more deeply pigmented.
• Presence of xanthophyll.
Imparts certain properties
USES of macular function
• Follow up of macular diseases &
• For evaluating the potential macular
function in eyes with opaque media
such as cataract and dense
Macular function tests
• Psychophysical tests
1. Visual acuity
2. Contrast sensitivity
3. Photostress test
4. Amsler grid
5. Two point discrimination
6. Entoptic phenomenon
7. Tests dependent on
8. Maddox rod test*
9. Color vision
10. Foveal flicker sensitivity
11. Dark adaptation
12. Perimetry/Scanning laser
17. Visually evoked
• 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
• 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
test letter subtends 5 minutes of visual
on the retina.
• Each component of this letter subtends 1 min
at this distance.
LANDOLT C CHART :
• Bailey-Lovie chart (ETDRS study)
• Illiterate E chart (used with
• Sheridan-Gardiner cards
• Cat ford Drum - Based on
• 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
• In pts with macular disease VA
is frequently worse when pt looks
through a pin-hole.
Pu p illa ry re a ctio n s
• The pupillary reactions are usually
normal in eyes with macular
• The defect usually indicates either a
lesion of the optic nerve(APD) or
extensive retinal disease.
• Contrast sensitivity
is a measure of
contrast needed to
distinguish a test
object & indirectly
quality of vision.
• Unlike VA, it is a
measure of visual
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
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
Functional acuity contrast test
T h e H a m ilto n -ve a le
C o n tra st S e n sitivity
C h a rt
T h e Pe lliR o b so n C h a rt
developed in 1988 is the
accepted gold standard for
measuring contrast sensitivity.
• Useful subjective test of
the resolving power of
eye by using Laser
• Dilated pupil.
• Coarse to fine fringes,
Small heliumneon laser
Overlap at/post. to
plane of lens
Brightness increased in pts with dense
The laser interferometer resolving power
converted to standard V.A.
Fringes not dependent on optical
components of eye, except large r.e.
Limitations : 1. subjective,
2. Laser fringe vision>>
vision of letter
3. overpredicts visual
Potential acuity meter
• GUYTON and MINKOWSKI.
• It consists of a slit lamp attachment that
can project an entire V.A. chart on the
• Emits 0.1mm beam into windows of pt’s
• Focusing with a slide scale
ranging from +13 to-10D.
• Dilated pupil, relaxed pt.
• Easier than laser interofermetry, 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,
2. Retinopathy – diabetic, CSR,
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
SIX standard questions to be
1. Ability to see the central spot.
2. Ability to see the 4 corners and sides of the
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
Positive/Absolute Paracentral Scotoma
• 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
• 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
4. Sloan Achromatopsia Test.
100 Hue test.
• SPECTRAL TEST :
Anomaloscope : the
best method for
of red-green defects.
Two Point Discrimination
• 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
Test various meridians by rotating : may
• 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
• PRINCIPLE : The test involves exposing the
macula to a light source bright enough to
bleach a significant proportion of the
• 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
: 1. to quantify subtle maculopathies,
2. discriminate between optic neuropathy &
3. to plot the recovery or progression of
• 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
• Normal PSRT ranges
from 8-70 seconds.
CONDITIONS WITH PROLONGED
Central serous retinopathy,
Age related maculopathy,
Retinal pigmentary degeneration,
Alcohol or marijuana ingestion.
• 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
• Hemispherical adaptometers are used
nowadays (Goldman-Weekes by Haag
• Useful in pts presenting with c/o night
blindness as in hereditary macular
• Normally the whole process of dark
1.Subject exposed to intense light that
2.Then Suddenly placed in dark.
3.Threshold at which sub just perceives light is
4.Flashes repeated at regular intervals;
sensitivity of eye to light gradually
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
1. Disorders of pigment degeneration
a. Vitamin A deficiency; b. Fundus
2. Disorders of neural adaptation
a. Oguchi’s disease
b. Congenital stationary night blindness
3. Chloroquine toxicity,
4. Retinitis pigmentosa Type II,
5. Tapetoretinal degenerations,
6. High myopia,
The entoptic phenomenon (or
• visual perceptions that are produced or
influenced by the native structures of one’s
• Structures producing – N anatomic parts/Media
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
• series of fast moving, luminous points or
spots seen on looking at a bright and diffusely
illuminated surface with no contrasting
• 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
5/> - normal.
(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 &
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
• 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.
• 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
• 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
• The clinical ERG is the
recording of the
by the total (preganglionic) retina in
response to a diffuse
• Test-performed in dark
adaptation using a corneal
electrode which records
changes in the corneoretinal potential with each
Negative ‘a wave’ – activities
of rods & cones.
– from Muller cells in the
bipolar region(inner retinal
c-wave – retinal metabolism
Peak amplitudes and
latencies as well as
waveform shape are
considered in the
interpretation of the ERG.
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
• The information can be
summarised in form of a 3-D
plot, resembling hill of
1. Vitamin A deficiency & xerosis.
2. Retinitis pigmentosa & allied
diseases e.g.(a) Congenital Night
(b) Oguchi's Disease.
(c) Retinitis punctate
3. Prognosis in Cataract.
4. Prognosis in Glaucoma.
5. Detachment of retina.
6. Systemic & retinal vascular
7. Macular diseases.
• Measures changes in corneoretinal 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 &
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
Light rise - function of mid-retinal layers + outer retina-pigment
Light peak/dark trough ratio - reliable parameter of retinal
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
Except Best’s Vitelliform macular dystrophy, Butterfly
dystrophy, fundus flavimaculatus & generalized drusen.
Here, ERG -N, EOG -abnormal.
• Measure of the
response to a visual
It is recorded with scalp
electrodes placed over
occipital lobe region, a
cortical area with
primarily a macular
• Diffuse light stimulus
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
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
• A small flickering test light (0.5-2*) is
superimposed on a constant
• 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
• Perimetry can also test the
• N useful for defects of
peripheral visual fields
careful STATIC of central
2-4* - early maculopathy.
• FLICKER PERIMETRY.
• Scanning Laser
• Macular disease is
sometimes part of a
process & in such cases