MACULAR

FUNCTION
TEST
DR. PUSHPANJALI

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 illa ry re a ctio n s
• 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 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.

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 5

CHART 3

CHART 6

CHART 4

CHART 7

Central Scotoma

Macropsia

Arcuate Scotoma

Micropsia

Positive/Absolute Paracentral Scotoma

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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