Diagnostic Procedures in Ophthalmology Full Colour1 140426073515 Phpapp02

Diagnostic Procedures in
OPHTHALMOLOGY
Diagnostic Procedures in
OPHTHALMOLOGY
SECOND EDITION
HV Nema
Former Professor and Head

Department of Ophthalmology
Institute of Medical Sciences
Banaras Hindu University
Varanasi, Uttar Pradesh, India
Nitin Nema
MS Dip NB
Assistant Professor
Sri Aurobindo Institute of Medical Sciences
Indore, Madhya Pradesh, India
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Diagnostic Procedures in Ophthalmology
2009, HV Nema, Nitin Nema
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
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This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure
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dispute, all legal matters to be settled under Delhi jurisdiction only.
First Edition:
2002
Second Edition: 2009
ISBN 978-81-8448-595-0
Typeset at JPBMP typesetting unit
Printed at Replika Press
Contributors
Jorge L Ali
MD, PhD
Director, Vissum
Institute of Ophthalmology of Alicante
Alicante, Spain
Sonal Ambatkar
DNB
Glaucoma Service
Aravind Eye Hospital
Tirunelveli, Tamil Nadu, India
Francisco Arnalich
Sreedharan Athmanathan
MD, DNB
Virologist
LV Prasad Eye Institute
Hyderabad, Andhra Pradesh, India
MD
Professor
Dr RP Centre for Ophthalmic Sciences
AIIMS, New Delhi, India
Tinku Bali
MS
Consultant
Sir Ganga Ram Hospital, New Delhi, India
Rituraj Baruah
MS
Senior Registrar
Lady Hardinge Medical College
New Delhi, India
Jyotirmay Biswas
MS
Ex-Fellow
Sankara Nethralaya
Chennai, Tamil Nadu, India
Taraprasad Das
MS
Director
Bhubaneswar, Orissa, India
MD
Vissum
Alicante, Spain
Mandeep S Bajaj
Surbhit Chaudhary
MS, FAMS
Munish Dhawan
MD

Lingam Gopal
MS, FRCS
Chairman
Medical Research Foundation
Sankara Nethralaya, Chennai
Tamil Nadu, India
AK Grover
MD, FRCS
Chairman
Sir Ganga Ram Hospital
New Delhi, India
Roshmi Gupta
MD
Consultant, Narayana Nethralaya

Bengaluru, Karnataka, India
Sanjiv Gupta
MD

Head, Ocular, Pathology and Uveitis

Tamil Nadu, India
Stephen C Hilton
Ambar Chakravarty
Santosh G Honavar
MS, FRCP
Honorary Professor and Head

Department of Neurology
Vivekananda Institute of Medical Sciences
Kolkata, West Bengal, India
OD
West Virginia University

Morgantown, USA
MD, FACS
Director
Department of Ophthalmic Plastic Surgery and
Ocular Oncology, LV Prasad Eye Institute
viii

Anjali Hussain
MS
Consultant
Subhadra Jalali
MS
Head
Smt Kanuri Santhamma Retina-Vitreous Centre
Sadao Kanagami
FOPS
Professor
Kitasato University School of Medicine
Teikyo, Japan
Sangmitra Kanungo
MD, FRCS
Consultant
Shahnawaz Kazi
MS
Fellow
Sankara Nethralaya
R Kim
DO
Head
Retina-Vitreous Service
Aravind Eye Hospital and
Postgraduate Institute of Ophthalmology
Madurai, Tamil Nadu, India
Parmod Kumar
OD
Glaucoma Imaging Centre

New Delhi, India
S Manoj
MS
Consultant
Retina-Vitreous Service
Aravind Eye Hospital and Postgraduate Institute
of Ophthalmology, Madurai, Tamil Nadu, India
S Meenakshi
MS
Amit Nagpal
MS
Consultant
Pediatric Ophthalmology Sankara Nethralaya
Consultant
Tamil Nadu, India
A Narayanaswamy
Consultant
Sankara Nethralaya
Rajiv Nath
MS
Professor
KG Medical University
Lucknow, Uttar Pradesh, India
Tomohiro Otani
MD
Professor
Gunma University School of Medicine
Maebashi, Japan
Nikhil Pal
MD
Senior Resident
Rajul Parikh
MS
Consultant, Sankara Nethralaya

David Piero
OD
Vissum
Alicante, Spain
K Kalyani Prasad
MS
Consultant
Krishna Institute of Medical Sciences
Leela V Raju
MD
Monongalia Eye Clinic

Morgantown, USA
VK Raju
MD, FRCS, FACS
Clinical Professor
West Virginia University
Morgantown, USA
LS Mohan Ram
D Opt, BS

Contributors
R Ramakrishnan
MS
Professor and CMO

Aravind Eye Hospital
Tirunelveli, Tamil Nadu, India
Manotosh Ray MD, FRCS
Associate Consultant
National University Hospital
Singapore
Pukhraj Rishi
MD
Consultant
Sankara Nethralaya
Monica Saha
MBBS
KG Medical University
Lucknow, Uttar Pradesh, India
Chandra Sekhar
MD
Director
Harinder Singh Sethi MD, DNB, FRCS
Senior Research Associate

Pradeep Sharma
Yog Raj Sharma
MD
Professor
Deependra Vikram Singh
Devindra Sood
MD
Consultant, Glaucoma Imaging Centre

New Delhi, India
MS Sridhar
MD
Consultant
S Sudharshan
MS
Fellow
Sankara Nethralaya
Kallakuri Sumasri
B Optm
Retina-Vitreous Centre
T Surendran
MS, M Phil
Professor
Dr RP Centre for Medical Sciences
Vice Chairman and Director

Pediatric Ophthalmology
Sankara Nethralaya
Rajani Sharma MD (Ped)
Garima Tyagi B Opt
Savitri Sharma
Vasumathy Vedantham
Senior Resident
Department of Pediatrics
MD
Head
Jhaveri Microbiological Centre
Tarun Sharma MD, FRCS
Director
Retina Service, Sankara Nethralaya
MD
Senior Resident
Dr RP Centre for Ophthalmic Sciences, AIIMS
New Delhi, India
Retina-Vitreous Centre
MS, DNB, FRCS
Consultant, Retina-Vitreous Service

Aravind Eye Hospital and Postgraduate
Institute of Ophthalmology
Madurai, Tamil Nadu, India
L Vijaya
MS
Head
Glaucoma, Sankara Nethralaya
ix
Preface to the Second Edition

The goal of this second edition of Diagnostic Procedures in Ophthalmology remains the same as that of
the firstto provide the practicing ophthalmologists with a concise and comprehensive text on
common diagnostic procedures which help in the correct and speedy diagnosis of eye diseases.
Like other disciplines of medicine, the knowledge of ophthalmology continues to expand and
a number of newer and sophisticated investigative procedures have been introduced recently. Extensive
and detailed information on recent diagnostic approaches is available in resource textbooks or
online to ophthalmologists. To search these is time consuming, tiring and at times not practical
in a busy clinical practice set-up. Therefore, this ready reckoner has been conceptualized.
The book covers most of the basic and well-established diagnostic procedures in ophthalmology.
It starts with visual acuity and describes color vision and color blindness, slit-lamp examination,
tonometry, gonioscopy, evaluation of optic nerve head in glaucoma, perimetry, ophthalmoscopy
and ophthalmic photography. Most of these procedures are considered basic and carried out routinely
but to obtain an evidence-based diagnosis, a correct procedure for the examination must be followed.
Corneal topography is very useful in detection of corneal pathologies such as early keratoconus,
pellucid marginal corneal degeneration, corneal dystrophies, etc. It guides the ophthalmic surgeon
to plan appropriate refractive surgery. Recent development in the application of wavefront technology
can reduce different types of optical aberrations and may provide supervision and improve results
of the LASIK surgery.
A new chapter on Confocal Microscopy is included. Confocal microscopy, a noninvasive procedure,
allows in vivo observation of normal and pathogenic corneal microstructure at a cellular level.
It can identify subclinical corneal abnormalities.
Procedures like Fundus Fluorescein Angiography and Indocyanine Green Angiography are
invaluable diagnostic tools. They are not only useful in the diagnosis, documentation and followup but also in monitoring the management of the posterior segment eye diseases. With the development
of high quality fundus camera and digital imaging, utility of both techniques has significantly
increased.
Ultrasonography, as a diagnostic procedure, has immense importance in the modern
ophthalmology. Both A-scan and B-scan ultrasonography are dynamic procedures wherein diagnosis
is made during examination in correlation with clinical features. Three-dimensional ultrasound
tomography allows improved visualization and detection of small ophthalmic lesions. Ultrasound
biomicroscopy is a method of high frequency ultrasound imaging used for evaluating the structural
abnormality and pathology of the anterior segment of the eye both qualitatively and quantitatively.
It is very helpful in understanding the pathomechanism of various types of glaucoma.
xii

Optical Coherence Tomography is a noninvasive, cross-sectional imaging technique which provides
objective and quantitative measurements that are reproducible and show very good correlation
with clinical picture of retinal pathology especially macula. Presently, OCT is often used in assessment
of optic nerve head damage in glaucoma.
One must remember that imaging technique alone may not contribute to a correct diagnosis.
It is complementary to clinical examination. Therefore, results of imaging should always be interpreted
in conjunction with clinical findings and results of other relevant tests.
Electrophysiological tests are often ordered to assess the functional integrity of the visual pathway
and in evaluating the cause of visual impairment in children. Multifocal ERG and multifocal VEP
are newer techniques still under evaluation. It is claimed that multifocal ERG can distinguish
between the lesions of the outer retina and the ganglion cells or optic nerve. Results of
electrophysiological tests should never be analyzed in isolation but always be correlated with
clinical findings to establish a definitive diagnosis.
Etiological diagnosis of infectious keratitis and uveitis has been more vexing and often fraught
with pitfalls. Collection of samples from eye, their microbiological work-up and interpretation of
laboratory results have been described in chapters on keratitis and uveitis. Role of optical coherence
tomography in the diagnosis and management of complications of uveitis is also discussed.
A number of new chapters such as: Retinopathy of Prematurity, Localization of Intraocular Foreign
Body, Comitant Strabismus, Incomitant Strabismus, Dry Eye, Epiphora, Proptosis and Neurological Disorders
of Pupil have been added in the second edition of the book.
Retinopathy of prematurity is one of the important causes of childhood blindness. Risk factors,
documentation, staging, classification, screening procedure and management of the disease are
briefly described.
Precise localization of intraocular foreign body is a tedious procedure but is critically important
for its removal and management. Computerized tomography and magnetic resonance imaging
have replaced old cumbersome radiological methods for localization of intraocular foreign bodies,
metallic and wooden.
Strabismus often has an adverse effect on psychological functioning, personality trait and
working capabilities of an individual. Patients with strabismus suffer from low self-esteem and
have problem in social interaction. Therefore, early correction of strabismus is necessary for improving
the quality of the life of the patient. The chapter on comitant strabismus presents various methods
for examination and measurement of deviations. Incomitant strabismus, though less common, is
more troublesome. It usually results from cranial nerves (III,IV,VI) paralysis. Restrictive strabismus
may be associated with interesting clinical ocular syndromes.
Dry eye is one of the most common external ocular diseases seen by ophthalmologists. Prevalence
of dry eye is on rise mainly due to an environmental pollution, change in lifestyle and increase
in aging population. Should dry eye be considered a disorder of tear film and excessive tear evaporation
or a localized immune-mediated inflammatory response of ocular surface? Besides the controversy,
what is more important is an early diagnosis of dry eye and its proper management.
Preface to the Second Edition

Epiphora is an annoying symptom. It may occur either in infants or adults. An understanding
of anatomy and physiology of the lacrimal apparatus is necessary for the evaluation of epiphora.
A number of invasive and noninvasive tests are available to investigate patients with epiphora
and localize site of obstruction in the lacrimal passage.
Proptosis has a varied etiology. It may occur due to ocular, orbital and systemic causes. Generally,
proptosis requires interdisciplinary cooperation amongst ophthalmologists, neurologists, oncologists,
ENT surgeons, internists and radiologists. Investigation of patients with proptosis should begin
with simple standard noninvasive techniques and, if necessary, progress to more elaborate and
invasive procedures. Ultrasonography, CT and MRI are of immense value in the diagnosis.
Examination of pupil (size, shape and pupillary reactions) is essential in neurological disorders.
Typical pupillary signs can help in localizing lesions in the nervous system. Characteristics of
Adie tonic pupil and Argyll-Robertson pupil and a detailed evaluation of the third cranial nerve
palsy are described in the last chapter.
Most of the contributors who have vast experience in their respective fields have written chapters
for this book. To make the reader familiar, they have not only described diagnostic procedures
but also given characteristic findings of eye disorders with the help of illustrations. The book
has expanded greatly as many new chapters with numerous illustrations are added.
We hope the book should be of great help to the practicing ophthalmologists and clinical residents
providing a practical resource to investigative procedures in ophthalmology.
HV Nema
Nitin Nema
xiii
Preface to the First Edition

The word diagnosis comes from a Greek word meaning to distinguish or discern. Besides history
and clinical examination of the patient, diagnostic tests are required to aid in making correct diagnosis
of eye diseases. The role of diagnostic technology is not inferior to that of a clinicians acumen.
A correct diagnostic report helps in differentiating functional from organic and idiopathic from
non-idiopathic diseases. The number of diagnostic tests available to an ophthalmologist has increased
significantly in the last two decades. Both selective and non-selective tests are presently used for
the clinical and research purposes. Non-selective approach to testing is costly and does not provide
useful information. In order to be useful, diagnostic tests have to be properly performed, accurately
read, and correctly interpreted. The ordering oculist should always compare the results of test
with the clinical features of the eye disease.
The main aim of the bookDiagnostic Procedures in Ophthalmology is to provide useful information
on diagnostic tests, which an ophthalmologist intends to perform or order during his clinical practice.
Some of the procedures described in the book, assessment of visual acuity, slit lamp examination, tonometry,
gonioscopy, perimetry and ophthalmoscopy, are routine examinations. However, the technique of proper
examination and interpretation of findings to arrive at a correct diagnosis must be known to the
practising ophthalmologist or optometrist.
Procedures like ophthalmic photography, evaluation of optic nerve head, fundus fluorescein angiography
and indocyanine green angiography are invaluable because they not only help in the diagnosis and
documentation but also help in monitoring the management of eye disease. Corneal topography
gives useful data about corneal surface and curvature and contributes to the success of Lasik
surgery to a great extent. The role of A-scan ultrasonography in the measurement of axial length
of the eye and biometry cannot be over emphasised. B-scan ultrasonography is needed to explore
the posterior segment of the eye when media are opaque or an orbital mass is suspected. Ultrasound
biomicroscopy (UBM) and Optical coherence tomography (OCT) are relatively new non-invasive tools
to screen the eye at the microscopic level. UBM helps in understanding the pathogenesis of various
forms of glaucoma and their management. OCT obtains a tomograph of the retina showing its
microstructure incredibly similar to a histological section. It helps in the diagnosis and management
of the macular and retinal diseases. Electrophysiological tests allow objective evaluation of visual
system. They are used in determination of visual acuity in infants and in the diagnosis of the
macular and optic nerve disorders. What diagnostic tests should be ordered in the evaluation
of the patients with infective keratitis or uveitis? Chapters on Diagnostic Procedures in Infective
Keratitis and Diagnostic Procedures in Uveitis provide an answer.
The experts who have credibility in their fields have contributed chapters to the book. Not
only the procedures of diagnostic tests are described but to make the reader conversant, characteristic
findings in the normal and the diseased eye are also highlighted with the help of illustrations.
The book should be of great help to the practising ophthalmologists, resident ophthalmologists,
optometrists and technicians as it provides instant access to the diagnostic procedures in ophthalmology.
We are indebted to all contributors for their excellent contributions in short time in spite of
their busy schedule. Mr JP Vij deserves our sincere thanks for nice publication of the book.
HV Nema
Nitin Nema
Acknowledgements
The publication of the second edition of Diagnostic Procedures in Ophthalmology is possible with
the help and cooperation of many colleagues and friends. We wish to express our gratitude to
all the contributing authors for their time and painstaking efforts not only for writing the comprehensive
and well illustrative chapters but also updating and revising them to conform the format of the
book.
We are indebted to Prof JL Ali, Dr Vasumathy Vadantham and Dr Tarun Sharma for contributing
chapters on a short notice because the initial contributors failed to submit their chapters. Our
grateful thanks go to Dr Mahipal Sachdev for persuading Dr Manotosh Ray to write a chapter
on Confocal Microscopy.
Mrs Pratibha Nema deserves our deep appreciation; without her patience, tolerance and
understanding, this book would not have become reality.
Finally, Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (DirectorPublishing) and supporting staff of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi
especially deserve our sincere thanks for their cooperation and keen interest in the publication
of this book.
HV Nema
Nitin Nema
Contents
1. Visual Acuity ..................................................................................................................... 1
Stephen C Hilton, Leela V Raju, VK Raju
2. Color Vision and Color Blindness ........................................................................... 12

Harinder Singh Sethi
3. Slit-lamp Examination ................................................................................................... 33

Harinder Singh Sethi, Munish Dhawan
4. Corneal Topography ....................................................................................................... 46

Francisco Arnalich, David Piero, Jorge L Ali
5. Confocal Microscopy ...................................................................................................... 84

Manotosh Ray
6. Tonometry .......................................................................................................................... 95
R Ramakrishnan, Sonal Ambatkar
7. Gonioscopy ...................................................................................................................... 106

A Narayanaswamy, L Vijaya
8. Optic Disk Assessment in Glaucoma ................................................................... 115

Rajul Parikh, Chandra Sekhar
9. Basic Perimetry .............................................................................................................. 128

Devindra Sood, Parmod Kumar
10. Ophthalmoscopy ............................................................................................................. 151

Pukhraj Rishi, Tarun Sharma
11. Ophthalmic Photography ............................................................................................ 165

Sadao Kanagami
12. Fluorescein Angiography ............................................................................................ 181

R Kim, S Manoj
13. Indocyanine Green Angiography ............................................................................ 200

Vasumathy Vedantham
14. A-scan Ultrasonography .............................................................................................. 216

Rajiv Nath, Tinku Bali, Monica Saha
15. B-scan Ultrasonography .............................................................................................. 239

Taraprasad Das, Vasumathy Vedantham, Anjali Hussain
Sangmitra Kanungo, LS Mohan Ram
xviii

16. Ultrasound Biomicroscopy in Ophthalmology .................................................... 259
Roshmi Gupta, K Kalyani Prasad, LS Mohan Ram, Santosh G Honavar
17. Optical Coherence Tomography .............................................................................. 269

Tomohiro Otani
18. Electrophysiological Tests for Visual Function Assessment ........................ 279

Subhadra Jalali, LS Mohan Ram, Garima Tyagi, Kallakuri Sumasri
19. Diagnostic Procedures in Infectious Keratitis ................................................... 316

Savitri Sharma, Sreedharan Athmanathan
20. Diagnostic Procedures in Uveitis ........................................................................... 333

Jyotirmay Biswas, Surbhit Chaudhary, S Sudharshan, Shahnawaz Kazi
21. Retinopathy of Prematurity: Diagnostic Procedures and Management .... 353

Yog Raj Sharma, Deependra Vikram Singh, Nikhil Pal, Rajani Sharma
22. Localization of Intraocular Foreign Body ............................................................ 362

Amit Nagpal, Lingam Gopal
23. Comitant Strabismus: Diagnostic Methods ......................................................... 369

Harinder Singh Sethi, Pradeep Sharma
24. Incomitant Strabismus ................................................................................................. 395

S Meenakshi, T Surendran
25. Diagnostic Procedures in Dry Eyes Syndrome .................................................. 405

MS Sridhar
26. Evaluation of Epiphora ............................................................................................... 412

AK Grover, Rituraj Baruah
27. Diagnostic Techniques in Proptosis ...................................................................... 426

Mandeep S Bajaj, Sanjiv Gupta
28. Neurological Disorders of Pupil ............................................................................. 441

Ambar Chakravarty
Index .................................................................................................................................................. 461
Visual Acuity
STEPHEN C HILTON, LEELA V RAJU, VK RAJU
Visual Acuity
Vision is the most important of all senses.

Approximately 80% of the information from the
outside world is incorporated through the visual
pathway. Loss of vision has a profound effect
on the quality of life.
The process of vision includes:
1. Central resolution (visual acuity)
2. Minimal light sensitivity
3. Contrast sensitivity
4. Detection of motion
5. Color perception
6. Color contrast
7. Peripheral vision (spatial, temporal and
motion detection).
In the normal clinical settings, we measure
only one of these functions central resolution
at high contrast (visual acuity).1
Definition and Terminology of

Visual Acuity
The most basic form of visual perception is
detection of light. Visual acuity is more than just
detecting light. It is the measurement of the ability
to discriminate two stimuli separated in space
at high contrast compared with the background.
The minimal angle of resolution that allows a
human optic system to identify two points as

different stimuli is defined as the threshold of
resolution. Visual acuity is the reciprocal of the
threshold of resolution.2 Clinically, discriminating letters in a chart determine this, but this
task also requires recognition of the form and
shape of the letters, which are processes that
also involve higher centers of visual perception.
Discrimination at a retinal level may, therefore, be determined by less complex stimuli, such
as contrast sensitivity gratings. Theoretically, the
maximum resolving power of the human retina
could be derived from an estimate of the angle
of approximately 20 seconds of arc because this
represents the smallest unit distance between
two individually stimulated cones. Thus the
resolving power of the eye could be much
greater than what is measured by visual acuity
charts.3
Cones have the highest discriminatory
capacity, but rods can also achieve some
resolution. The greater the distance from the fovea
the level of visual acuity falls off rapidly. At a
5 distance from the foveal center, visual acuity
is only one quarter of foveal acuity.4 Luminance
of test object, optical aberrations of the eye and
the degree of adaptation of the observer also
influence the visual acuity.5

Visual thresholds can be broadly classified
into three groups:
1. Light discrimination (minimum visible,
minimum perceptible)
2. Spatial discrimination (minimum separable,
minimum discriminable)
3. Temporal discrimination (perception of
transient visual phenomena such as
flickering stimuli).
Many clinical tests can assess many visual
functions simultaneously. In a healthy observer
in best focus, the resolution limit, or as it is
usually called, the minimum angle of resolution
(MAR), is between 30 seconds of arc and one
minute of arc. Clinically, we use Landolt C and
Snellen E to assess visual acuity. The minimum
discriminable hyper-acuity or vernier-acuity is
another example of spatial discrimination. The
eye is capable of subtle discrimination in spatial
localization, and can detect misalignment of two
line segments in a frontal plane if these segments
are separated by as little as three to five seconds
of arc, considerably less than the diameter of
a single foveal cone. The mechanism subserving
hyper-acuity is still being investigated.
Charts and Scales to Record

Visual Acuity
The function of the eye may be evaluated by a
number of tests. The cone function of the fovea
centralis is assessed mainly by measurement of
the form sense, the ability to distinguish the shape
of objects. This is designated as central visual
acuity. It is measured for both near and far,
with and without the best possible correction
of any refractive error present. Because only
cones are effective in color vision and because
they are concentrated in the fovea, the
measurement of the ability to recognize colors
is also a measurement of foveal function.
The function of the peripheral retina which
contains mainly rods, may be assessed by

peripheral visual field.1
Visual acuity is the first test performed after
obtaining a careful history. Measurement of the
central visual acuity is essentially an assessment
of the function of the fovea centralis. An object
must be presented so that each portion of it is
separated by a definite interval. Customarily, this
interval has become one minute of an arc, and
the test object is one that subtends an angle of
five minutes of an arc. A variety of test objects
has been constructed on this principle, so that
an angle of five minutes is at distances varying
from a few inches to many feet5 (Figs 1.1 and
1.2). The most familiar examination chart is
Snellen chart (Fig. 1.3). Conventionally, reading
vision is examined at 40 cm (16 inches). The
testing distance of a preferred near distance chart
Fig. 1.1: Snellen letters subtend one minute of arc in

each section, the entire letter subtends five minutes of
arc
Fig. 1.2: Each component of Snellen letters subtend one

minute of visual angle the entire letter subtends five minutes
of visual angle at stated distance
Visual Acuity
Fig. 1.4: ETDRS chart
Fig. 1.3: Snellen chart
should be observed accurately. The Snellen

notation is simply an equivalent reduction for
near, maintaining the same visual angle. Most
of the Snellen-based distance acuity charts are
also commercially available as pocket charts
to check the near acuity at a preferred distance
for every patient or at a defined distance for
clinical trial purposes including ETDRS (Fig. 1.4)
and Snellen letter E.
The Jaeger notation is a historic enigma and
Jaeger never committed himself to the distance
at which the print should be used. The numbers
on the Jaeger chart simply refer to the numbers
on the boxes in the print shop from which Jaeger
selected his type sizes in 1854. They have no

biologic or optical foundation. Clinically, Jaegers
charts (Fig. 1.5) are widely used.
Central visual acuity is designated by two
numbers. The numerator indicates the distance
between the test object and the patient; the
denominator indicates the distance at which the
test object subtends an angle of five minutes.
In the United States these numbers are given
in inches or feet, whereas in the Europe the
designation is in meters.
The test chart commonly used in the United
States has its largest test object one that subtends
an angle of five minutes at a distance of 200
feet (6 m). Then there are test objects of 100, 80,
70, 60, 50, 40, 30, 20 and 15 feet. If the individual
is unable to recognize the largest test object, then
he or she should be brought closer to it, and
the distance at which he or she recognizes it
should be recorded. Thus, if the individual
recognizes the test object that subtends a five
minute angle at 200 feet when he or she is at
12 feet, the visual acuity is recorded as 12/200.
This is not a fraction but indicates two physical
Fig. 1.5A: Jaeger's type near vision chart
Visual Acuity
Fig. 1.5B
Fig. 1.5B: Near vision chart: Music type and numericals
Fig. 1.6: Broken C, letter E and pictures of familiar objects

for testing visual acuity in illiterates and children
measurements, the test distance and the size of

the test object.
The most familiar test objects are letters or
numbers. Such tests have the disadvantage of
requiring some literacy on the part of the patient.
Additionally, there is a variation in their ability
to be recognized. L is considered the easiest
letter in the alphabet to read and B is considered
the most difficult. To obviate this difficulty, broken
rings (Fig. 1.6) have been devised in which the
break in the ring subtends one minute angle,
and the ring subtends a five minute angle.
Similarly, the letter E may be arranged so that
it faces in different directions (Fig. 1.6). These
test objects are easier to see than letters, eliminate
some of the difficulties inherent in reading, and
can be used in the testing of illiterates and

persons not familiar with the English alphabet.
A variety of pictures (Fig. 1.6) have also been
designed for testing the visual acuity of children.
When a person is unable to read even a top
letter, he or she is asked to move toward the chart
or a chart can be brought closer. The maximum
distance from which he or she recognizes the top
letter is noted as the nominator. When visual acuity
is less than 1/60, the patient is asked to count
fingers from close at hand (CF at 20 cm). When a
patient cannot even count fingers, the patient is
asked if he or she can see examiners hand
movements (HM positive). When hand movements are not seen we have to record whether the
perception of light (LP) is present or absent by
asking the patient if he or she sees the light.
Standard illumination should be used for the
acuity chart (10 to 20 foot candles for wall charts).
When a patient is examined with the Snellen
chart in a dark room, the subject sees a high
contrast and glare-free target. But in real
circumstances, contrast and glare reduce visual
acuity, and even more so in a pathological
conditions. The contrast sensitivity function of
a subject may be affected even when Snellen
acuity is normal. The contrast sensitivity tests
are more accurate in quantifying the loss of vision
in cases of cataracts, corneal edema, neuroophthalmic diseases, and retinal disorders. A
patient with a low contrast threshold has a high
degree of sensitivity; therefore, a healthy young
subject may have a threshold of 1%, and a contrast
sensitivity of 100% (inversely proportional). It
is important to have adequate lighting when
testing visual acuity so that it does not become
a test of contrast sensitivity.
Factors Affecting Visual Acuity

Factors affecting visual acuity may be classified
as physical, physiological and psychological.
Visual Acuity
Uncorrected refractive error is a common cause
of poor acuity.
Physical factors include illumination and
contrast. Increased illumination increases visual
acuity from threshold to a point at which no
further improvement can be elicited. In the
clinical situation this is 5-20 foot candles. When
contrast is reduced more illumination is required
to resolve an object. Beyond a certain point,
illumination can create glare. Therefore, visual
acuity is recorded under photopic condition and
one wants to evaluate best visual acuity at the
fovea.
Physiological conditions include pupil size,
accommodation, light-dark adaptation and age.2
Pupil Size
The pupil size has great influence on visual acuity.
Visual acuity decreases if pupils are smaller than
2 mm due to diffraction. Pupil diameters larger
than 3.5 mm increase aberration. Variation in
pupil size changes acuity by altering illumination,
increasing depth of focus, and modifying the
diameter of the blur circle on the retina.
Accommodation
An accommodation creates miosis, which could
account for small hyperopic prescriptions being
rejected for distance viewing in younger
individuals.
It is worth while to discuss the role of a pinhole
in obtaining the best visual acuity in the clinical
setting. The optimum pinhole is 2.5 mm in
diameter. A pinhole in an occluder (Fig. 1.7) may
be introduced in a trial frame with the opposite
eye occluded. Single pinhole device is not
adequate. The patient must be able to find a hole,
therefore, multiple pinholes are preferred. If the
patient is older or infirm, or has tremors, he is
asked to read only a single letter from each line
as we proceed down the chart to record the vision.
B
Figs 1.7A and B: Occluder with multiple holes
Many patients have been referred for neuro-ophthalmologic consultation because of

painless loss of vision in one eye only. The best
visual acuity may be 20/60 in the affected eye
but when properly tested with the pinhole, the
acuity may improve to 20/20. This indicates that
the macula and optic nerve are functioning
normally. When the patients vision is improved
with pinhole one knows the problem is a refractive
one and simply need the change in glasses. If
the patients vision is less when looking through
the pinhole; it indicates that the patient has either
an organic lesion at macula, or a central scotoma,
or functional amblyopia. A patient with 20/400
vision that improves with pinhole to 20/70
indicates that the improvement is refractive, but
some pathology may also be present.
Visual Acuity Testing in Young

Children
Early determination of vision loss and refractive
error is an essential component of assessing the
infants ultimate visual development potential.
The visual acuity of a newborn as measured by
preferential looking is in the range of 30 minutes
of arc (20/600); acuity rapidly improves to six
minutes of arc (20/120) by three months. A steady
but modest improvement to approximately three
minutes of arc (20/60) occurs by 12 months of
age. One minute of arc (20/20) is usually obtained
at the age of three to five years.6
The examination is generally performed on
the parents lap. The room should never be totally
darkened because this may provoke anxiety.
Objective retinoscopy remains the best method
of determining a childs refraction.
Other clinical methods involve estimation of
fixation and following behavior. A test target
should incorporate high contrast edges. For
infants younger than six months the best target
represents the examiners face. For the child of
six months and older, an interesting toy can be
used. After assessment of the binocular fixation
pattern, the examiner should direct attention to
differences between the two eyes when tested
monocularly. Objection to occlusion of one eye
may suggest abnormality with the less preferred
eye.7
Three common methods are used for
determining resolution acuity:
1. Behavioral technique (preferential looking
Fig. 1.8)
2. Detecting optokinetic nystagmus (OKN Fig.
1.9)
3. Recording visual evoked potentials (VEP
Fig. 1.10).
It is desirable to measure the visual acuity
of children sometime during their third year to
detect strabismic or sensory amblyopia and to
recognize the presence of severe refractive errors.
Fig. 1.8: Preferential looking test chart
Fig. 1.9: OKN drum
In this group of preschool children, visual acuity

testing is easier to perform with the use of the
following charts:
1. Allen and Osterberg charts (Fig. 1.11)
2. Illiterate E chart
3. Landolt broken ring.
Visual Acuity
Fig. 1.10: VEP testing
Contrast is defined as the ratio of the difference

in the luminance of these two adjacent areas
to the lower or higher of these luminance values.
The amount of contrast a person needs to see
a target is called contrast threshold.
The contrast sensitivity is assessed by using
the contrast sensitivity chart. It has 5-8 different
sizes of letters in six or more shades of gray.
Some contrast sensitivity charts contain a series
of alternating black and white bars; 100 line pairs
per mm is equivalent to space of one minute
between two black lines. The alternating bar
pattern is described as spatial frequency. The
contrast sensitivity is measured in units of cycles
per degrees (CPD). A cycle is a black bar and
white spaces. To convert Snellen units to units
of cycles per degree, divide 180 by Snellen
denominator. Contrast sensitivity measurements
differ from acuity measurements; acuity is a
measure of the spatial resolving ability of the
visual system under conditions of very high
contrast, whereas contrast sensitivity is a
measure of the threshold contrast for seeing a
target.8
Visual Acuity in Low Vision

Patients
Fig. 1.11: Allen and Osterberg chart
Contrast Sensitivity
A general definition of spatial contrast is that
it is a physical dimension referring to the lightdark transition at a border or an edge of an image
that delineates the existence of a pattern or object.
Individual near acuity needs are different among

different population groups. For low vision
patients these differences are magnified. Two
persons with the same severe visual impairment
may exhibit marked differences in their ability
to cope with the demands of daily living. Visual
acuity loss, therefore, is the aspect that must be
addressed in individual rehabilitation plans.
Colenbrander9 subdivides several components
of visual loss into impairment aspects (how the
eye functions), visual ability (how the person
functions in daily living), and social/economic
aspects (how the person functions in society
(Table 1.1).
20/12.5
20/16
20/20
20/25
20/32
20/40
20/50
20/63
20/80
20/100
20/125
20/160
20/200
20/250
20/320
20/400
20/500 1.6in
20/630 1.2in
20/800 1in
20/1000
20/1250 1cm
20/1600 1cm
20/2000 1cm
NLP
Normal vision
Mild vision loss
Moderate vision loss
Severe vision Loss
Profound vision loss
Near-blindness
Total Blindness
No visual reading
must rely on talking
books or other
Marginal with aids

Uses magnifiers for spot
reading, but may prefer
talking books for leisure
Slower than normal with

reading aids
High-power magnifiers
(restricted field)
Near-normal with
appropriate reading aids
Low-power magnifiers
and large-print books
Normal reading speed

Reduced reading distance
No reserve for small
Normal reading speed

Normal reading distance
Reserve capacity for
small print
Vision
substitution
aids
Vision
enhancements
aids
None
Visual aids
10
5
0
30
25
20
15
50
45
40
35
70
65
60
55
90
85
80
75
110
105
100
95
VAS
In this range, residual vision

tends to become unreliable,
though it nonvisual sources may
still be used as an adjunct to
vision substitution skills.
In the EU, many benefits

start at this level. The
WHO includes this range
in its blindness category.
In the United States,

persons in this range
are considered legally
blind and qualify for
tax-break disability benefits.
In the United States,

children in this range qualify for
special educational assistance
Many functional criteria

(whether for a drivers
license or for cataract
surgery) fall within the range
Note that normal adult

vision is better than 20/20
Comments
Social and economic aspects

(how the person functions in society)
(From Colenbrander A. Preservation of vision or prevention of blindness [editorial]? Am J Ophthalmol 2002;133:2. p.264.)
4in
3in
2.5in
2in
10in
8in
6in
5in
25in
20in
16in
12.5in
63in
50in
40in
32in
Newsprint
(1 M)
Visual
acuity
Ranges
(ICD-9-CM)
Statistical estimate
of reading ability
Visual ability aspects/functional vision

(how the person functions-daily living skills)
Impairment aspects
(how the eye function)
TABLE 1.1: RANGES AND ASPECTS OF VISION LOSS
10
Visual Acuity
Summary
Both distance and near visual acuities are
recorded for each eye with and without spectacles.
Distance visual acuity is recorded at a distance
of 20 feet or in a room of at least 10 feet using
mirrors and projected charts. Near visual acuity
can be recorded using reduced Snellen or
equivalent cards at 40 cm. Acuity performance,
like any other human performance, is subject
to impairment depending on ocular and general
health, emotional stress, boredom, and a variety
of drugs acting both peripherally and centrally.
The examiner must provide encouragement and
must have patience.
For clinical studies the ETDRS charts are
recommended because near vision is often more
important in the daily life of older or infirm
patients. Reading charts or other near vision
testing charts should be used as part of the routine
assessment of the visual acuity. Visual acuity
measurement is often taken for granted. Many
pitfalls make this most important assessment
subject to variability.10Ambient illumination,
aging bulbs, dirty charts or slides, small pupils,
and poorly standardized charts are just
some of the factors that can lead to erroneous

results. A little care in ensuring the proper
environment for testing can significantly improve
accuracy.
References
1. Newell FW. Ophthalmology Principles and
Concepts. St Louis, Mosby, 1969.
2. Moses RA (Ed). Adlers Physiology of the Eye.
St Louis, Mosby, 1970.
3. Scheie H. Textbook of Ophthalmology.
Philadelphia, WB Saunders, 1977.
4. Duane TD. Clinical Ophthalmology. New York,
Harper and Row, 1981.
5. Michaels DD. Visual Optics and Refraction. St
Louis, Mosby, 1985.
6. Vander J. Ophthalmology Secrets. Hanley and
Belfus.
7. Borish I. Clinical Refraction. Professional
Publisher, 1970.
8. Owsley C. Contrast Sensitivity. Ophthalmic
Clinics of North America 2003;16:173.
9. Colebrander A. Preservation of Vision or
Prevention of Blindness? Am J Ophthalmol 2003;
133:263.
10. Kniestedt, Stamper RL. Visual Acuity and its
Measurements. Ophthalmic Clinics of North
America 2003; 16:155.
11
12
HARINDER SINGH SETHI
Color Vision and

Color Blindness
Color vision examination is an essential part

of screening before a person is taken up for a
job. A person who is color vision defective may
go through life quite unconscious of his color
deficiency and without making any incriminating mistakes, differentiating objects by their
size, shape and luminosity, using all the time
a complete color vocabulary based on his
experience which teaches him that color terms
are applied with great consistency to certain
objects and to certain achromatic shades, until
circumstances are arranged to eliminate these
accessory aids and then he realizes that his
sensations differ in some way from the normal.
Various tests have been developed to enable
screening of anomalous subjects with color
deficiency from a much larger group of normal
subjects.
main characteristics of color namely hue,

saturation, and brightness. Hue is a function
of wavelength. It depends on what the eye and
brain perceive to be the predominant wavelength
of the incoming light. An objects hue is its
color. Saturation refers to the richness of a
hue as compared to a gray of the same brightness.
Saturation is also known as chroma. Brightness
correlates to the ease with which a color is seen,
other factors being equal. Brightness is a
subjective term referring to the sensation
produced by a given illuminance on the retina.
The spectral wavelengths of different colors
are as follows: violet 430 nm; blue 460 nm; green
520 nm; yellow 575 nm; orange 600 nm and red
650 nm. The concept of white light is vague,
most agreeable definition is, white surface is one
which has spectral reflection factors independent
of wavelength (in the visible spectrum) and
greater than 70%.
Color Vision
Color is a sensation and not a physical attribute
of an object. Color is what we see and is result
of stimulation of retina by radiant energy in a
small band of wavelengths of the electromagnetic
spectrum usually considered to span about one
octave, from 380 nm to 760 nm. There are three
Factors Affecting Color Vision

Crystalline Lens
The lens absorbs shorter wavelengths; in young,
wavelengths of less than 400 nm and in old
people up to 550 or 600 nm are absorbed by
Color Vision and Color Blindness

the lens resulting in defective color vision on
shorter wavelength side.
Retinal Distribution of Color Vision

The center of the fovea (1/8 degree) is blue blind.
Trichromatic vision extends 20-30 from the point
of fixation. Peripheral to this red-green become
indistinguishable up to 70-80 and in far
peripheral retina all color sense is lost although
cones are still found in this region. In the central
5, macula contains carotenoid pigment,
xanthophyll. The molecules of the pigment are
arranged in such a way that they absorb blue
light polarized in the radial direction. If one looks
at a white card through linear polarizer, one
will see two blue sectors separated by two yellow
sectors the figure is called Haidingers brushes.
Macular pigment may also be seen as in
homogeneity in the field of blue or white light
called Maxwells spot.
Wavelength Discrimination
The normal observer is able to detect a difference
between two spectral lights that differ by as little
as 1 nm in wavelength in the regions of
490 nm and 585 nm. In the region of violet and
red a difference of greater than 4 nm is necessary.
Hue, Saturation and Lightness

Hue is the extent to which the object is red, green,
blue or yellow. Saturation is the extent to which
a color is strong or weak. Lightness is self
explanatory attribute, for example, yellow by color
is light.
Illumination
Illumination affects color vision of low
illuminances, the errors increase due to poorer
discrimination for most of the hue range while
testing color vision. An illuminance of 400 lux

( 100 lux) would be practical value for most
clinical applications.
Bezold-Burcke Effect
von Bezold (1873) and Burcke (1878) discovered
independently the phenomenon named after
them, that variation of the luminance levels
modifies hues.
Color Constancy; Aperture Colors and

Surface Colors
Color constancy is a phenomenon in which color
of the objects can be recognized unchanged in
spite of possible differences in the illumination.
Aperture colors are colors that alter due to change
in illumination. Surface colors do not vary with
illumination. Extrafoveal vision favors the
appearance of aperture colors and foveal vision
that of surface colors.
Complementary Wavelengths
Complementary wavelengths are those which,
when mixed in appropriate proportions, give
white.
Simultaneous Color Contrast

Color contrast is visually demonstrated by
observing the color of a spot in a surround. The
general rule is that the color of the spot tends
toward the complementary of the color of the
surround.
Successive Color Contrast

Successive color contrast is more commonly
described as colored after images, when one
stares at a red spot for several seconds and then
looks at a gray card one sees a green spot on
13
14

the card. The after image tends toward the
complementary of the primary image (StilesCrawford effect). The light entering near the edge
of the pupil is less effective than light entering
at the center of the pupil because of the shape
of the receptors and the fact that they are
embedded in a medium of different refractive
index. This effect is wavelength-dependent.
Color Triangle
Color triangle can be drawn to describe the
trichromacy of color mixtures and is useful for
deciding which bands of wavelength are
indistinguishable from each other. Three reference
wavelengths are chosen, i.e. 450 nm, 520 nm
and 650 nm and are placed at vertices of X, Y
and Z of a triangle, the position of other
wavelengths is determined. A color triangle does
not describe the color of a band of wavelengths
unless other circumstances are defined.
Theories of Color Vision

This is a complex topic as no theory explains
the phenomenon of color vision fully. Few
important theories are given below:
Young-Helmholtz Theory (Trichromatic

Theory)
Youngs concept is that there are three types of
retinal receptors with different spectral
sensitivities. Youngs principal colors are red,
green and violet. Youngs hypothesis was not
followed up until it was revived by Helmholtz
in 1852. The Youngs theory may be summarized
as follows:
a. At some stage of visual receptor mechanism
there are three different types of sensory
apparatus G1, G2, G3. These receptors must
be same for everyone but they may not be
same at the fovea as at the periphery.
b. Each of these receptors is characterized from

the spectral point of view by particular
function of wavelengths which may be
denoted by G and the response G1 of a
receptor for radiation with a spectral energy
distribution E may be supposed to have
the form.
G1 = Sgi E d.
c. Sensation of color is a function of the relative
values of the three responses G1.
d. Sensation of light is a function of a linear
combination of the three responses.
Fundamental sensations
By determining approximately the coordinate of
the confusion points of dichromats Arthur Konig
in1893 established a system of fundamental
sensations and identified red, green and violet
as fundamental colors. Blue was also identified
as fundamental color in addition to red and green
by Gothelin.
Granits Theory of Color Vision

Granit divides retina into receptor units, each
unit comprising groups of cones and rods which
are connected with a single ganglion cell or
several ganglion cells which synchronize their
discharges. These units are classified as
dominators or modulators. The dominators
which are numerous have a spectral sensitivity
curve which indicates that they are responsible
for the sensations of luminosity. Modulators
show a selective sensitivity which makes them
responsible for color discrimination. Granits
theory does not explain the fact of trichromatism.
Herings Theory of Color Vision

(Opponent Color Theory)
Hering assumed six distinct sensations arranged
in three opposing pairs: white-black; yellow-blue
and red-green; he explains three pairs as being

due to opposing actions of light on three
substance of the retina, a catabolism producing
warm sensation (white, yellow, red) and an
anabolism the cold ones. This theory is clearly
a psychological concept and aims at explaining
complex percepts than the intermediate effect of
the stimuli.
Anatomy of Color Vision

The understanding of visual pathway is complex
and not evident fully. There are two types of
photoreceptors in the retina: rods and cones.
Approximately 120 million rods are responsible
for night and peripheral vision. Rods contain
a photopigment called rhodopsin, a chemical
variant of vitamin A and a protein called opsin
that serves at very low levels of illumination.
Rods have their maximum density about 5
degrees from the fovea and cannot distinguish
one color from another. The fovea itself is
essentially rod-free containing only cones.
Approximately 7 million cones are responsible
for central and color vision. Cones have their
maximum density within 2 degrees of the center
of the fovea. Both types of receptors diminish
in number toward the retinal periphery.
Cones
In the retina three types of cones responsible
for the red, green and blue sensations have been
isolated. Three types of cone pigments in the
human retina absorb photons with wavelengths
between 400 nm and 700 nm. Color vision is
mediated by these three cone photoreceptors
referred to as long, middle, and short wavelengthsensitive (LWS, MWS, SWS) cones. The long
wavelength-sensitive (LWS) cones (sometimes
called red or red-catching) contain a pigment
called erythrolabe, which is best stimulated by
a wavelength near 566 nm. Medium wavelengthsensitive (MWS) cones (green or green-
catching) contain the pigment chlorolabe, which

has a maximal sensitivity to a wavelength near
543 nm. Short wavelength-sensitive (SWS) cones
(blue or blue-catching) contain cyanolabe,
which have maximal sensitivity at 445 nm. The
blue cones are absent in the center of the macula.
Trichromatic vision perception occurs in central
30 field. It is not uncommon to hear the cones
referred to as blue, green, and red cones, but
such nomenclature is misleading because the
L-cones are more sensitive to blue lights than
they are to red lights. The spectral sensitivities
of the three cone pigments overlap somewhat.
For example, light of 540 nm and 590 nm
stimulate both green (MWS) and red (LWS)
receptors yet we can easily distinguish between
these two wavelengths as green and yellow.
If the human retina contains all three cone
pigments in normal concentrations, and has
normal retinal function, the subject is a
trichromat. Any color the trichromat sees can
be matched with a suitable mixture of red, green,
and blue light.
Color Coded Cells

Two types of color coded cells are found at
peripheral levels (ganglion cells and lateral
geniculate body) of the visual system and they
have been named opponent color cells and double
opponent color cells. More complex types are
found at more central levels (striate cortex).
Opponent color cells: An opponent color cell is
one that gives only polarity of response for some
wavelengths and opposite polarity of response
for other wavelengths. Opponent color cells are
concerned with successive color contrast.
Double opponent color cells: These are cells
opponent for both color and space. The response
may be onto red light, off to green light in the
center of the receptive field and off to red light,
onto green light in the periphery of the receptive
15
16

field. Double opponent cells are concerned with
simultaneous color contrast.
Congenital vs Acquired Color

Deficiencies
Simple, complex and hypercomplex cells: In rhesus

monkey striate cortex there are a variety of cells
that are specific for both color and orientation.
They have been categorized as color sensitive
simple, complex and hypercomplex cells. Simple
cells have a bar-flank double opponent arrangement to their receptive fields. Complex color coded
cells respond to color boundaries of the appropriate orientation and the response is independent of the part of the receptive field being stimulated. The edge of hypercomplex cells must
be short.
Opponent color cells are found among
ganglion cells of the retina and lateral geniculate
body. Double opponent cells with centersurround or flank receptive fields are present
in the input layer IV of the striate cortex. Complex
and hypercomplex color coded cells are also
found in the striate cortex in layers II, III, V and
VI. Vaetichin in 1953 recorded a negative slow
potential from fish retinae called S-potential
of two types: L-type (luminosity type) and Ctype (chromaticity type). Mitarai in 1961 regarded
horizontal cells as responsible for S-potentials
of L-type and Mullers fibers for those of C-type.
The properties of S-potentials support the Herings
opponent color theory more than the trichromatic
theory of Young.
Congenital color vision deficiencies can be

distinguished functionally from acquired
deficiencies in a number of ways. Congenital
deficiencies typically involve red-green confusions, whereas acquired deficiencies, more often
than not, are a blue-yellow (Kllners rule). Also,
because some of the most common congenital
defects are linked to the X-chromosome, they are
more prevalent in males than females. Acquired
defects, in contrast, are not related to gender
except by gender differences to trauma or toxic
exposure. Acquired color deficiencies are more
likely to be asymmetric between the two eyes
than are hereditary defects; they are also less
likely to be stable with time. Congenital defects
are usually easier to detect with standard clinical
color vision tests, but some acquired ones can
be more subtle and thus are difficult to diagnose.
Finally, those with acquired color deficiencies
are also more likely to display color-naming
errors because, unlike those with congenital
deficiencies, they lack the life-long experience
with defective color perception.
Anomalies of Color Vision

Deficiency of color vision first was described by
Dalton in1794, the founder of the atomic theory,
who himself was color blind; hence the term
daltonism was coined. The color deficiency is of
two types: (1) congenital and (2) acquired. In
clinical evaluation of color vision it is important
to distinguish between acquired and congenital
defects.
Congenital Color Vision Deficiency

The color vision anomalies commonly being
X-linked are relatively common (8%) in men and
rare in women (Fig. 2.1). Nearly all congenital
color defects are due to absence or alteration of
one of the pigments in photoreceptors. Congenital
color deficits may be divided into classes
according to whether the patients are red deficient
(protans), green deficient (deuterans) or blue
deficient (tritans). The term anopia is used for
absolute deficiency and anomaly for relative
deficiency (Tables 2.1 and 2.2).
Anomalous trichromats are people who
generally require three wavelengths to match

TABLE 2.1: CLASSIFICATION OF COLOR BLINDNESS
Congenital: Males (8%), Females (0.4%)
classically X-linked recessive inheritance
pattern, always bilateral
(a) Achromatopsia
Cone monochromats
Rod monochromats
(b) Dyschromatopsia
Dichromats
- Deuteranopia
- Protanopia
- Tritanopia
Anomalous trichromats
- Protanomaly
- Deuteranomaly
- Tritanomaly
Acquired
Unilateral
Bilateral
Disease
Glaucoma
Hypertensive retinopathy
Diabetic retinopathy
AMD
Lesions of visual pathway
Alcohol-nicotine
Red-green defect
Blue-Yellow defect
Red-green defect
Blue-Yellow defect
Acquired defect
Blue-Yellow
Blue-Yellow
Blue-Yellow
Blue-Yellow
Red-Green
Red-Green
TABLE 2.2: VARIOUS TYPES OF COLOR DEFICIENCY
Anomalous trichromats
Dichromats
Monochromats
Red deficient
Green deficient
Blue deficient
Protanomaly
Protanopia
Rod monochromat
Deuteranomaly
Deuteranopia
Tritanomaly
Tritanopia
Blue monochromat
Fig. 2.1: Inheritance pattern of congenital color

vision defects
another wavelength but do not accept the color

matches made by normal people, Lord Rayleigh
in 1881 discovered trichromacy. Anomalous
trichromats have three classes of cones but one
is abnormal. Protanomalous people lack the red
receptors and instead they have two pigments
both peaking in the range of the normal green.
Similarly the deuteranomalous people lack green
receptors.
Dichromats require only two wavelengths to
match another wavelength and will accept the
color matches made by normal people. The
dichromats have two classes of cone receptors
with normal spectral sensitivity, the third class
being absent. Measurements of their pigments
can be made by reflection densitomer and cone
processes isolated by colored backgrounds
confirm the findings. Protanopes have normal
green and blue cones, red cones being absent.
Deuteranopes have normal red and blue cones
and tritanopes normal red and green cones.
17
18

Protans color deficient subjects are easier to
test and classify than deuterans and tritans;
because the red cone pigment is quite sensitive
to green wavelengths and both red and green
cone pigments are quite sensitive to blue
wavelength covering the green and blue range,
in deuterans and tritans, as the sensitivity of
visual pigment does not fall off sharply on the
short wavelength side of the peak.
Monochromatics can be blue cone monochromatics and rod monochromatics. Blue cone
monochromatics have normal blue cone pigment
but no red or green cone pigment. In rod
monochromatism only 500 nm pigment is present
in the retina and all three cones pigments are
absent.
Genetics of congenital color deficiencies
The protans and deuterons are commonly sexlinked recessive. About 1% males are protanopes,
1% protanomalous, 1% deutaranopes and 5%
deuternomalous. The incidence of color vision
deficiency (red-green) in females is 0.4%. The
gene for tritans is autosomal incompletely
dominant. Rod monochromatism is very rare;
occurs 1 in 30,000, autosomal recessive and thus
an increased incidence is seen in consanguineous
offsprings.
Acquired Deficiency of
Color Vision
Koellner formulated that lesions in the outer
layers of the retina give rise to a blue-yellow
defect, while lesions in the inner layers of
the retina and the optic nerve gives rise to red
green defect. However, the correlation is not
always true. Some patients with lesions in the
cerebral cortex may have color deficits. These
may involve naming of the colors or perception
of colors.
Factors Responsible for Deficiency of

Color Vision
Ocular Diseases
a. Squint amblyopia: Francois by means of clinical tests stated that color vision deficiencies
in squint amblyopia do not correspond to
the classical type of acquired deficiencies
but rather approximate the normal color
sense of eccentric retinal positions.
b. Glaucoma: Primary glaucoma and ocular
hypertension cause tritan-type of defect.
c. Diabetic retinopathy: Diabetic retinopathy
may cause color deficiency which may vary
from a mild loss of hue discrimination to
moderate blue-yellow color vision deficiency. In severe cases of diabetic retinopathy
the defect may resemble tritanopia.
d. Retinal disorders: Blue-yellow deficits are
found in senile macular degeneration,
myopia, retinitis pigmentosa, siderosis bulbi
and chorioretinitis.
e. Optic nerve disorders: In one study about 57%
of patients with resolved optic neuritis
were found to have color vision defects.
Red-green defects have been found in cases
of multiple sclerosis and optic atrophy.
Tobacco amblyopia causes red-green
defect.
f. Color vision after laser photocoagulation: After
argon-laser photocoagulation there may be
overall loss of hue discrimination and color
deficiency, mostly of blue-yellow.
Drugs
Many drugs are known to cause deficiency of
color vision. They can cause more than one type
of color deficiency (Table 2.3).

TABLE.2.3: DRUGS CAUSING COLOR
DEFICIENCY
Drugs
Type of color
deficiency
Chloroquine, Indomethacin,
oral contraceptives, antihistaminics,
estrogens, digitalis and butazolidin.
Blue-yellow
Ethyl alcohol, Ethambutol
Red-green
Tri- and bicyclic antidepressants
Mixed type
Systemic Disorders
Besides diabetes, a few systemic disorders are
known to be associated with defective color
vision. Following diseases may cause color
deficiency:
a. Cardiovascular disease: Patients with heart
diseases have been found to have blueyellow deficiency.
b. Turners syndrome: Red-green color deficiency
is usually encountered in the syndrome.
Color Vision Testing

The main objective for testing the color blindness
is to determine the exact nature of the defect and
whether the color deficiency is likely to be a source
of danger to the community and/or to the
individual, if given a particular job.
Types of Color Vision Tests

Color Confusion Tests
Pseudo-isochromatic (PIC) plates are example
of color confusion tests (Figs 2.2 and 2.3). PIC
Tests are designed on the basis of the color
confusions made by persons with color defects.
In these a symbol or figure in one color is placed
on a background of another color so that the
figure and background are isochromatic for the
color-defective person. PIC tests are used
primarily as screening tests to identify those with
an inherited color defect, although, some of the
C
Figs 2.2A to C: A Ishihara pseudo-isochromatic plates,
B Transformation plate seen as 3 by patients with
anomalous red-green color defect, C Vanishing or
disappearing digit type
19
20
Fig. 2.3: City University test
tests permit a diagnosis of type and severity.

Because the inventory of PIC tests is extensive,
only the more commonly used tests are described
here.
The most widely used test, Ishihara pseudoisochromatic plates, is a screening test used to
determine the presence of X-linked congenital
(red/green) color deficiency. Most screening tests
are designed to give a quick, accurate assessment
of red/green deficiencies. The Ishihara test is
not designed to detect tritan disorders or acquired
color defects unless the optic neuropathy is severe.
Arrangement Tests
The arrangement tests require the observer to
place colored samples in sequential order on the
basis of hue, saturation, or lightness or to sort
samples on the basis of similarity. One of the
earliest tests of this nature that is still available
but is rarely used today is the Holmgren Wool
test. In this matching test, 46 numerically coded
comparison schemes of yarn are selected to match
three test colors: yellow-green, pink, and dark
red. The comparison schemes differ from the test
schemes in being lighter or darker. The test is
not accurate for screening or classification and

is not recommended for clinical use. It is of
historical significance as an early occupational
test. The clinical arrangement tests that are in
use today are colored papers mounted in black
plastic caps. The caps are placed in order
according to specific instructions, and the order
is recorded as the sequence of numbers printed
on the underside of the caps. Results are plotted
on score forms for analysis and interpretation
and quantitative scores computed. The tests are
standardized for CIE standard illuminant C.
The Farnsworth-Munsell Dichotomous-15
(D-15) and the FM-100 test are examples of hue
discrimination based on arrangement tests
utilizing color chips mounted in a circular cap
that subtend exactly 1.5 degrees at a test distance
of 50 cm. This ensures that the observations of
the subject are made with the central rod free
retina. The D-15 contains 15 colored chips and
the FM-100 contains 85 chips. The chips have
identical brightness and saturation and differ
from one another. Farnsworth-Munsell tests
reveal the type of defect, but not the severity.
Color Matching Tests

The spectral anomaloscope and PickfordNicolson anomaloscope are used for color
matching examinations. They can provide the
examiner with information on the severity of a
particular color vision defect. The Nagel anomaloscope is the most widely used. It consists of
a spectroscope in which two halves of a circular
field are illuminated respectively by monochromatic yellow (589 nm) and a mixture of
monochromatic red and green (670 nm and 546
nm, respectively). The observer is asked to match
the two halves of the circle with the three primary
colors available.
The most widely used color vision tests are
the pseudo-isochromatic plates and the D-15

panel due to their ease of use and relative low
cost. The Nagel anomaloscope and FM-100 tests
are usually only found in academic or research
settings.
All color vision tests have specific requirements for lighting, viewing distance, and viewing
time. It is important for the examiner to be familiar
with the test requirements and score sheets before
conducting a color vision test, otherwise the
results may be inaccurate.
Lantern Tests
Lantern tests are used only for occupational
purpose. Different types of lantern tests are in
use in different countries. The FALANT is used
in the United States by marine and aviation
authorities; the Holmes Wright Type A is used
in the United Kingdom by aviation authorities;
and the Holmes Wright Type B is used in
Australia, the United Kingdom and other
Commonwealth countries by marine authorities.
The Edridge-Green Lantern is included in the
United States Coast Guard requirements, but it
is surpassed by the FALANT. Electroretinography (ERG) and microspectrophotometry may
be used in special circumstances.
Test Conditions
Lantern testing is performed after dark adaptation
but all other tests require artificial daylight conditions. Light adaptation is critical for anomaloscopy and especially for FM-100 hue testing, but
a color neutral glare-free background and correct
illumination are more important. Reliable results
can be obtained with an artificial daylight source
(such as a Macbeth Sol source) or fluorescent
lighting with a color temperature between 5850
and 6850 degrees Kelvin and good color
rendering index (Ra over 90). If appropriate
artificial light is not available then skylight is
a good source. The illumination should be
between 250 and 350 lux (approximately 1.5

meters below twin fluorescent globe). A failed
Ishihara test under incandescent globe is a failure
of the examiner to observe basic principles, not
a failure of the subject. A pass on the other hand
is still a pass and is statistically the more likely
outcome.
The viewing geometry should be with the
light 45 degrees to the surface and the subject
viewing the pages at 90 degrees to the surface.
Newly printed books sometimes have differential
reflectance between pigments so when tilted back
and forth in the light by an anomalous observer
they may provide luminance clues. Appropriate
optical correction for the 65 cm viewing distance
must be available if required. Experienced testers
know that some people read the small identifying
numbers on the bottom of each page and give
a memorized response. Cheating can be prevented
by covering these identifying numbers with a
secret label.
Clinical Significance of the Various

Tests
Lantern testing is entirely vocational since around
5% of males fail and these include all those with
a severe anomaly but a relatively unpredictable
group from those with the milder anomalies.
Anomaloscopy is the gold standard for clinical
testing, while the D-15 and FM-100 tests have
both clinical and vocational applications
(diamond sorters and croupiers).
A common vocational test battery should
consist of:
Ishihara plates 2 - 17 from the 38 plate series
D-15 color sorting test (3 or more cross over
errors is a failure)
Lantern testing.
Pseudo-isochromatic Color Plates

The most common use of plate tests is to identify
21
22

persons with congenital color defects. Pseudoisochromatic plates (for example, AO-HRR,
Ishihara, Dvorine,Tokyo Medical College, SPP1) provide efficient screening of congenital redgreen defects (efficiency 90-95%). Other tests have
been designed to detect achromatopsia (Sloan
Achromatopsia test), to differentiate incomplete
achromatopsia from complete achromatopsia
(Berson blue cone monochromatism plates), to
detect acquired defects (SPP-2), or to detect color
confusion (City University test). Plate tests have
the advantages of being relatively inexpensive,
easily available, simple to use, and appropriate
with children and persons who are illiterate. They
are only suitable for screening purpose, however,
they neither provide a quantitative evaluation
of color vision nor distinguish the type and severity
of the color vision defect. Plate tests are designed
to distinguish congenital color-defective from
color-normal observers, but they do not evaluate
the wide range of abilities and aptitudes of
observers with normal color vision to distinguish
colors. Given individual differences in
prereceptoral filters and normal photo pigment
polymorphisms, no plate test can be 100% effective
in screening. When used improperly
(nonstandard illuminant, binocular viewing,
colored lenses not removed from observer), their
efficiency can diminish dramatically.
The viewing distance required for pseudoisochromatic plates is 75 cm or approximately
30 inches. Proper refractive correction should
be provided to the patient in order for them to
see the plates clearly. Viewing time for each plate
should be no more than 4 seconds. Undue
hesitation can be a sign of a slight color deficiency.
color in red-green color defectives (Fig. 2.2B).

There are three editions - a 16 plate series, 24
plate series and a 38 plate series. The 10th
edition of Ishihara has 38 plates. It is best to use
the larger series because there are relatively few
reliable plates in the smaller series. Both 24 set
and 38 plate series set consist of two groups of
plates a group for those who are literate /
numerate which starts from plate 1 at the front
of the book, and a group for illiterates /
innumerate in which the colored pattern is a
meandering path of connected dots between two
X symbols. The second group is arranged so as
to commence with the last page of the book and
proceed in reverse order. The group of plates for
innumerate are seldom used because they are
not as easy or reliable to score, but they are based
on the same colorimetric principles as the set for
numerates. It is not necessary to use both types
in the one subject. From a colorimetric perspective there are four different types of test plate
employed in both the 38 and 24 plate series
preceded by a demonstration plate that is not for
scoring. In the large series plates 1 and 38 are
both for demonstration only, while in the smaller
series plates 1 and 24 are for demonstration. If
the subject fails viewing the demonstration plate
do not proceed with the test. The following
description applies to the numerate plates in the
38 plate series. The different types of plates in
the test are:
Ishihara Pseudo-Isochromatic
Plates (Confusion Charts)
Transformation plates (Fig. 2.2B): Anomalous color

observers give different responses to color normal
observers. In these plates, one number is seen
by a normal trichromat and another (different)
number is seen by a color deficient person. Those
with true total color blindness cannot read any
numeral. These are the plates numbered 2 to 9
inclusive.
The Ishihara color vision charts are developed

by Shinobu Ishihara in 1917. This test is based
on the principle of confusion of the pigment
Disappearing digit (Vanishing) plates (Fig. 2.2C):

The normal observer is meant to recognize the
colored pattern. On these plates, a number can

be seen by a normal trichromat but nothing can
be seen by the color deficient person. These are
plates 10 to 17 inclusive in the 38 plate series.
Hidden digit plates: The anomalous observer
should see the pattern. The number on a hidden
digit design cannot be seen by a normal trichromat
but can be seen by most people with red/green
deficiencies. Those people with total color
blindness cannot see any numeral. These are
plates 18 to 21 inclusive.
Qualitative plates: These are intended to classify
protan from deutan and mild from severe
anomalous color perception. The plates are
numbered 22 to 25.
Procedure of Testing
The plates are designed to be appreciated correctly
in a room which is lit adequately by daylight.
Introduction of direct sunlight or the use of electric
light may produce some discrepancy in the results
because of an alteration in the color values of the
charts. It is suggested that when it is convenient
only to use electric light, it should be adjusted as
far as possible to resemble the effect of natural
daylight. The plates are held 75 cm from the subject
and tilted at right angles to the line of vision. A
missed/ misread plate must be reread (may be in
a random order). The findings should be recorded
on the Ishihara color vision test and interpretation
marking chart (Table 2.4).
A correct response to the Ishihara introductory plate is expected and demonstrates suitable
visual acuity to perform the test and rules out
malingering.
Plates 1-25 have numerals and each answer
should be given without more than 3 seconds
of delay.
Plates 26-38 are tracings for use in illiterates,
and windings lines between the two Xs are
traced with a dry soft brush. Each tracing
should take less than 10 seconds.
Each eye should be tested separately (as

should be done for all color vision tests).
The recommendations of the test state that
of the first 21 plates if 17 or more plates are
read correctly by an individual his color sense
should be regarded as normal. If 13 or less plates
are correctly read then the person has a redgreen color defect. It is rare to have persons who
read 14-16 plates correctly.
Hardy, Rand, Rittler (H-R-R) Plates

Hardy, Rand, Rittler (H-R-R) plates are another
type of pseudo-isochromatic (PIC) plate test. This
test is similar to the Ishihara test except that
the H-R-R plates classify and quantify the type
of color defect whether protan, deutran, or tritan
(blue/yellow). H-R-R plates have colored
symbols/shapes rather than numbers. This
makes H-R-R plates a good choice for children
and illiterates. Since it is capable of detecting
tritan disorders, this test is especially useful when
an acquired color vision defect is suspected.
Lighting, viewing distance, and viewing time
are the same as that of testing with Ishihara
plates. The first four (non-numbered) plates of
the H-R-R series are for demonstration only
(similar to the Ishihara 12). The first six
(numbered) plates are screening plates. Color
vision is deemed normal and no further testing
needs to be done if the subject gives correct
responses to the screening plates. If there is an
incorrect response to one or more of the screening
plates, the examiner must follow the directions
on the scoring sheet and show additional plates
to the subject in order to specifically classify the
color vision defect.
City University Color Vision Test

The City University test (Fig. 2.3) was developed
by Fletcher. It consists of 10 black charts each
of which has 5 color dots. One of the dots is
23
24
TABLE 2.4: INTERPRETATION AND MARKING OF THE ISHIHARA COLOR VISION TEST
Number
of plate
Normal
person
Person with red-green deficiency
12
12
12
29
70
57
35
15
17
74
21
10
11
12
97
13
45
14
15
16
16
17
73
18
19
20
45
21
73
Protan
Strong
Mild
Strong
Person with
total color
blindness and
weakness
Deutan
Mild
22
26
(2)6
2(6)
23
42
(4)2
4(2)
24
35
(3)5
3(5)
25
96
(9)6
9(6)
The mark x shows that the plate cannot be read. Blank space denotes that the reading is indefinite. The numerals
in parenthesis show that they can be read but they are comparatively unclear

located in the center being encircled with 4 other
dots so that a subject has to match the central
color dot with one of the 4 other dots.
American Optical Company Plates

The American Optical Company (AOC) plates,
a screening test for protan and deutan defects,
appears to be a composite of other tests. In
addition to a demonstration plate, there are 14
test plates that include 6 transformation and 8
vanishing plates. The figures are single- and
double-digit Arabic numerals. There are at least
two different fonts used on different plates. Five
or more errors on the 14 test plates constitute
failure of the test. Plates with double-digit
numbers are failed if the response to either digit
is incorrect.
Dvorine
The Dvorine is another widely used screening
test for protan and deutan defects. The test booklet
contains both PIC plates and a Nomenclature
test, which is a unique and valuable feature of
this test. The plates are presented in two sections:
15 plates with Arabic numerals and 8 plates
with wandering trails, with 1 demonstration
plate in each section. Any symbol missed is an
error. Three or more errors in the first section
constitute a failure. The Dvorine Nomenclature
test is used to assess color naming ability. There
are eight discs (2.54 cm in diameter) of saturated
color and eight discs of unsaturated or pastel
colors, which include red, brown, orange, yellow,
green, blue, purple, and gray. A rotatable wheel
allows the presentation of one disc at a time.
Color-naming aptitude adds another dimension
to a color vision assessment, and the results are
appreciated by patients and employers curious
to know the impact of a color defect on the ability
to name colors.
Tritan Plate (F-2)

The Tritan plate, or F-2, is a single plate that
Farnsworth designed to screen for tritan color
defects. It is a good test and it can also be used
for screening for red-green (protan-deutan)
defects. The test is performed by a vanishing
plate consisting of outlines of two interlocking
squares with different chromaticities on a purple
background. One square is purple-blue and
vanishes for patients with the red-green defects;
the other square is green-yellow and vanishes,
or is seen less distinctly compared with the
purple-blue square, for the tritan. Persons with
normal color vision see both squares, but the
green-yellow one is more distinct.
Arrangement Tests
Farnsworth-Munsell 100-Hue Test
(Pigment Matching Test)
Farnsworth-Munsell test (Fig. 2.4A) is a psychotechnical test, which quantifies a persons ability
to discriminate hues of pigment color. This simple
and useful test consists of 85 colored chips that
are designed to approximate the minimum
difference between the hues that a normal
observer can distinguish (1-4 nm). Color deficient
Fig. 2.4A: Farnsworth-Munsell 100-hue test
25
26
Fig. 2.4B: Farnsworth-Munsell 100-hue test results from four subjects:

A Normal; B Protan defects; C Deutan defects; D Tritan defects
persons make characteristic errors in arranging

the chips. The results are recorded on a circular
graph. The greater the error arranging the chips,
the farther the score is plotted from the center
of the circle (Fig. 2.4B). Automated score for FM
100-hue test is also available.
The currently available standard version
consists of 85 knobs with pigment-colored paper
on top arranged in 4 horizontal panels. Each

panel has 2 knobs fixed at its 2 ends. The subject
is required to arrange the knobs in each panel
in such a manner that the colors of the knobs
appear to be changing gradually from one end
of the panel to another.
Generally recommended time for arranging
each panel is 2 minutes. The time spent on

arranging the each panel is recorded. Scores of
a knob/cap is the sum of the differences between
the number of that cap and the number of the
caps adjacent to it on either side. Sum of the
scores of the entire set of knob / caps goes to
make the total error score (TES). Then, the scores
of each knob are plotted on a circular graph.
By plotting the scores in a graph, it is seen that
characteristic patterns are obtained in specific
defects (Fig. 2. 4 B). The test is capable of detecting
all types of color deficiencies. The test results
show that:
1. Average discrimination lies between 20 to
100 total error score,
2. Superior discrimination is below 20 total
error score, and
3. Low discrimination is more than 100 total
error score.
Farnsworth D-15 Test

The Farnsworth D-15 test (Fig. 2.5) consists of
single box of 15 colored chips. The test can be
carried out more rapidly than the 100-hue test.
Viewing distance required is 50 cm or approxi-
mately 20 inches. Unlimited testing time is

usually allowed but the subject may be told he/
she has two minutes to complete the test in order
to prevent dawdling. The object of the test is
to arrange the caps in order using the fixed
reference cap as a starting point. The subject is
instructed to take the cap which most closely
resembles the fixed reference cap, and place it
next to it; then find the cap that most closely
resembles the cap he just placed, and place it
next to it. Once the subject has arranged all the
caps, the lid is closed and the box flipped over.
The examiner then scores the test based on the
order in which the subject placed them (the caps
are numbered on the bottom). The examiner then
connects the numbers on the score sheet in the
order in which the patient placed the caps. The
score is either passing or failing. A circular
pattern on the score sheet indicates passing, a
criss-crossing or lacing pattern indicates failing.
The D-15 panel uses only saturated colors,
therefore, subtle defects such as those seen with
an anomalous trichromat may be missed. The
D-15 is useful for detecting dichromacy, in
particular, tritan defects which are often
associated with eye diseases and drug toxicity.
The disadvantage with this test is that minor
defects are not detected. Dichromatic subjects
will generally form a series of parallel or crisscrossing lines with at least two lines crossing
the chart in the same direction. The type of
deficiency is indicated by the index line most
nearly parallel to the crossover lines.
Lanthony Desaturated D-15 Test
Fig. 2.5: Farnsworth D-15 color test kit
The Lanthony desaturated D-15 test (Fig. 2.6)

is similar to the Farnsworth D-15 except that
the color on chips is much less saturated. This
makes the hue circle smaller and the arrangement
task more difficult. It is especially useful for
detecting subtle acquired color deficiencies.
27
28

are much more difficult to administer than
pseudo-isochromatic plates and arrangement
tests. The first anomaloscope was designed by
Nagel and is based on the color match known
as the Rayleigh equation, that is, R + G =Y. Because
of their relatively high price, anomaloscopes are
rarely used in private practice.
Nagel Anomaloscope (Spectral

Matching Test)
Fig. 2.6: Lanthony desaturated D-15
The Sloan Achromatopsia Test

The Sloan Achromatopsia test is a matching test
designed for rod monochromats described by
Sloan in 1954. The test consists of seven plates,
each with a different color: gray, red, yellowred, yellow, green, purple-blue, and red-purple.
Each plate includes 17 rectangular strips forming
a gray scale from dark to light in 0.5 steps of
the Munsell value. In the center of each rectangle
is a colored disc that has the same Munsell value
from one end of the gray scale to the other. The
patients task is to identify the rectangle that
matches the lightness of the colored disc. This
is a difficult task for persons with normal color
vision because of the color difference, but it is
readily and precisely accomplished by complete
achromats, who see the colors as grays of different
lightness. There are normative data for both
persons with normal color vision and achromats.
Nagel (1970) constructed anomaloscope for

studying the color vision defects. It is based on
the color match known as the Rayleigh equation,
that is Red (R) + Green (G) = Yellow (Y). The
Nagel anomaloscope (Fig. 2.7) assesses the
observers ability to make a specific color match.
In anomaloscope, the observer is asked to match
a mixture of red and green wavelengths to a
yellow. This instrument consists of a source of
white light, which is split into spectral colors
by a prism. These colors are viewed through a
telescope. The field of vision consists of a circle
divided into two halves. The lower half projects
a spectral Yellow (Sodium line) and this has
to be matched by a mixture of Red (Lithium line)
and Green (Thallium line) in the other half. The
ratio of the two component lights can be
controlled by press buttons on the base of the
telescope on a scale of 0 73, where 0 is pure
green, and 73 is pure red. The readings are
interpreted as follows: the red/green mix
Anomaloscopes
Anomaloscopes are instruments that assess the
ability to make metametric matches. The results
are used for definitive diagnosis and quantitative
assessment of color vision status. Anomaloscopes
Fig. 2.7: Nagel anomaloscope

proportions can be expressed in the form of an
Anomaly Quotient (AQ). Normal observers have
AQ between 0.7 and 1.4; higher AQs indicate
deuteranomaly (AQ usually >1.7), whereas lower
AQs indicate protanomaly. A major advantage
of the Nagel anomaloscope is that it can
distinguish between dichromatic and anomalous
trichromatic vision by measuring the balance of
red and green wavelengths in the mixture field.
Pickford-Nicolson Anomaloscope
The Pickford-Nicolson anomaloscope can be
used for three different matches or colorimetric
equations:
The Rayleigh equation [R + G = Y],
The Engelking equation [B + G = CY] and
The Pickford - Lakowski equation [B + Y =
W].
The matching field is presented on a screen
for free viewing at a variety of distances, and
there are no intervening optics between the
patient and the matching field. The size of the
field is changed by selecting different apertures:
the largest is 2.54 cm (1 inch) in diameter and
the smallest, 0.48 cm (3/16 inch). Different colors
are obtained by inserting broadband filters. The
Pickford-Lakowski equation is used to assess
the consequence of senescent changes in the
spectral transmission of the ocular media
(yellowing of the lens), it also has value in
examining acquired color defects. The Engelking
equation is used for diagnosis of the blue - yellow
or tritan color defects. Individual variability in
density of the macular pigment and lens pigmentation affects both the Engelking and PickfordLakowski equations and, accordingly, confounds the interpretation of an individual result.
navigational aids are extensively used. Lantern

tests are performance-based, and they do not
diagnose, classify, or grade the level of color
vision defect. Rather, they attempt to determine
whether the person is capable of performing the
color signal recognition tasks with adequate
proficiency to maintain safety standards. There
are two types of lantern tests, those that use actual
signal light filters and those that use simulations
of signal lights.
Farnsworth Lantern Test (Falant)

In the United States, the Farnsworth Lantern
(Falant) is the standard lantern test (Fig. 2.8).
It simulates marine signal lights under a variety
of atmospheric conditions. Two lights are
presented in a vertical display in any of the nine
possible combinations of three colorsred, green,
and whitein the two positions. A subject must
average eight out of nine correct responses to
Lantern Tests
In marine, rail, and airline transportation, and
in the armed forces, colored signals and
Fig. 2.8: Holmes-Wright Lantern
29
30

pass the test. White lights are particularly
problematic, especially for milder color defects.
It is reported that the test is not representative
of actual field conditions.
Edridge-Green Lantern Test

The Edridge-Green Lantern (Fig. 2.9) is an
instrument used for testing the ability of a person
to recognize color of transmitted light. It was
built to simulate the light of railway traffic signals,
as they are visible from a distance. The apertures
represent the equivalents of five and half-inch
railway signals at 600, 800 and 1000 yards,
respectively when viewed from 20 feet distance.
Usually two apertures 1.3 and 13 mm are used,
set of filters showing signal red, yellow, green
and blue colors are shown, each color being
shown twice for each aperture size.
Other Tests
Electroretinography
Use of electroretinography (ERG) in the modem
era is more useful for detection of color vision
deficiencies for two reasons: (i) new methods
allow to separate and observe accurately the
photopic and scotopic components of ERG with
the possibility of better study of cone activity
and (ii) with the use of computer averaging,
picking up of oscillatory potentials is more easy.
Microspectrophotometry
In spectrophotometry, an individual cone of a
dissected retina is aligned under a small spot
of light and its absorption is measured at various
wavelengths. The most direct evidence of Youngs
trichromatic theory (3 classes of cones) comes
from spectrophotometry. The results of microspectrophotometry confirm three groupings with
peak sensitivities at 437-458 nm, 520-542 nm
and 562-583 nm.
Color Vision Deficiencies and

Everyday Life
Fig. 2.9: Edridge-Green Lantern
The recommendations of the test state that

a candidate should be rejected if he calls
1. Red as Green
2. Green as Red
3. White light as Green or Red or vice versa
4. Red-Green or White light as Black.
Any candidate who makes any other errors
should be tested with other test.
Many tasks depend on our ability to discriminate

color. Selecting products at the grocery store,
matching paint colors or items of clothing, or
connecting color-coded wiring all depend on
efficient color vision. Color vision deficiencies
can seriously affect an individuals ability to
learn, to work at a chosen occupation and move
effectively in the world.
Young children are expected to learn color
names early in their educational experience and
color is frequently used to categorize educational
materials. Good color vision is also important
for students of art, chemistry, biology, geology
and geography. A child with deficient color
vision will have disadvantage on such tasks as

color naming, coding, and matching. Color vision
testing should be done for all children as early
as possible, and certainly prior to starting school.
If a color deficiency is present, the childs school,
teacher, and parents should be informed so that
methods of instruction can be modified to meet their
visual needs. Teachers and parents can help the
child in a number of different ways. First, images
and utensils such as crayons, pencil and pens can
be labeled with words or symbols. Second,
discrimination between items of different color can
be facilitated by the use of high luminance contrast.
For example, it would be better to use white chalk
on a black or green chalkboard or a dark marker
on a white board than combinations that provide
less luminance contrast. The level of luminance
contrast in colored materials can be determined
quite easily by making a black and white photocopy
of them or by converting them to black and white
on your computer. Third, children should be taught
common objects by their usual color (e.g. bananas
are normally yellow and the sky is blue).
Occupations vary in their requirement of color
identification. For some, good color judgment is
desirable but not necessary. For others, knowledge
of ones color vision is critical. Examples where
good color judgment can be critical for careers
include a painter, safety officer, dermatologist,
pharmacist, cartographer, coroner, chemist, buyer
of textiles, food inspector, electrician, and marine
navigator. Color perception failures in such jobs
could be costly, even disastrous.
Enhancing Performance with Filters

The color performance of the patients with color
deficiency can be sometimes enhanced using
colored filters. By absorbing wavelengths
selectively, these filters help the observer to
differentiate stimuli based on their relative
brightness. For example, a red object viewed
through a green filter or a green object viewed
through a red filter will appear much darker.
For example the X-chrom lens is a red contact

lens worn on one eye that absorbs shorter
wavelengths and passes longer ones. By
comparing the relative brightness in eye with
the X-chrom lens to that in the eye without it,
a dichromats ability to distinguish red from green
can be enhanced. While such monocular comparisons may be useful in specific applications,
the user remains a dichromat and is unlikely
to find the approach practical for everyday use.
Summary
Ophthalmic personnel are frequently asked to
perform color vision testing. Knowing whether a
congenital or acquired defect is suspected can
help determine which color vision test should be
administered. All color vision tests have specific
requirements for lighting, viewing distance,
viewing time, and scoring. It is important to be
familiar with the various testing and scoring
guidelines in order to provide the requesting
doctor with accurate and useful information.
Bibliography
1. Alprey M, Mocller J. Red and green cone visual
pigments of deuternornalous trichromacy.
J Physiol 1977;266:647.
2. Brown PK, Wald G. Visual pigments in single
rods and cones of the human retina. Science
1964;144:45.
3. Dada VK. Practical problems of colour vision
defectives. Indian Practitioner 1977; 30: 251-55.
4. Dalton J. Extraordinary Facts relating to the
Vision of Colours. Mem Manchester Lit & Phil
Soc 1798, 5(1): 28. Edin J Sci 1798, 9: 97 cited
by Duke-Elder ref 6.
5. De valois RL, Abramov I, Jacobs GH. Analysis
of response patterns of LGN cells. J Ophthalmol
Soc Amer 1966;56:966.
6. Duke-Elder S. Diagnostic Methods: The colour
sense. In System of Ophthalmology. Henry
Kimpton, London 1962; Vol VII: 380-84.
31
32

7. Duke-Elder S. Congenital colour defects. In
System of Ophthalmology. Henry Kimpton,
London 1964; Vol III (Part 2): 661-68.
8. Duke-Elder S. Colour vision. In System of
Ophthalmology. Henry Kimpton, London 1968;
4: 617-51.
9. Edridge-Green. Physiology of Vision, London
1920.
10. Farnsworth D. Protan, deutan and tritan. J Opt Soc
Amer 1943;33:568.
11. Farnsworth D, Reed. Small-field Tritanopia. USN
Submar Med Res Lab Rep No 19, 1944.
12. Farnsworth D. Manual of the FarnsworthMunsell 100-hue test for the Examination of Color
Discrimination. 1949; revised 1957, pp 1-7.
13. Francois J, Verriest G. Acquired diseases
producing colour vision defects. Vision Res
1961;1:201.
14. Francois J. La discrimination chromatique dans
amblyopie strabique. Documents Ophthal
1967;23:318.
15. Geddes. Prevalence of colour vision deficients.
Br J Psychol 1946;37:30.
16. Georgia Antonakon Chrousos. Ocular findings
in Turners syndrome: A perspective study.
Ophthalmology 1984;91:926.
17. Gouras P. Identification of cone mechanism in
monkey ganglion cells. J Physiol 1968;199:533.
18. Hardy LH, Rand G, Rittler MC. Comparison of
HRR with other tests. Arch Ophthalmol 1954;
51:216.
19. Hart WM Jr. Acquired dyschromatopsias. Surv
Ophthalmol 1987;32:10.
20. Hart WM Jr. Colour vision. In Adlers Physiology
of the Eye. Mosby, St Louis 1992;708-27.
21. Hering. Zur Lehre vom Lichtsinne Wien, 1878
cited by Duke-Elder ref 6.
22. Holmgren. Holmgrens wool test. Ann Rep
Smithsonian Inst 1877; 131.
23. Ishihara S. Test for Colour Blindness Manual of
Ishihara Plates, 1917, 5th ed. Tokyo 1925. and 14th
ed. 1959, Kanehara Shuppan Co Ltd, Tokyo
Kyoto, Japan.
24. John A, Fleishman, Roy W Beck. Defects in visual
function after resolution of optic neuritis.
Ophthalmology 1987;94:1029.
25. Kinnear PK, Sahraie A. New Farnsworth-Munsell
100-hue test norms of normal observers for each
year of age 5-22 and for age decades 30-70. Br J
Ophthalmol 2002;86:1408-11.
26. Ladd-Franklin. Tetrachromatic Theory. Z Psychol
Physiol Sinnes 1893;4:211.
27. Maxwell C. Fundamental response curve of the

cone pigment. Trans Roy Soc Edin 1885; 21(2):
275.
28. Michael CR. Colour vision mechanisms in
monkey striate cortex: Simple cells with dual
opponent colour receptive fields. J Neurophysiol
1978;41:1233.
29. Michael CR. Colour sensitive complex cells in
monkey striate cortex. J Neurophysiol 1978;4:
1250.
30. Michael CR. Colour sensitive hypercouplex cells
in monkey striate cortex. J Neurophysiol 1979;
42:726.
31. Miller SJH. Colour blindness or achromatopsia.
In Parsons Diseases of the Eye. 18th ed.
Edinburgh, Churchill Livingstone, 1900, 269-70.
32. Mitarai G. Glia-neuron interactions and
Adaptional mechanisms of the retina. ln Jung
R, Kormaluber H (Eds). The Visual System:
Neuroplysiology and Psychophysics 1961.
33. Nakamura K. New color vision test to evaluate
faulty color recognition. Jpn J Ophthalmol 2002;
46: 601-06.
34. Neitz J, Jacobs GH. Polymorphism in normal
color vision. Vision Res 1990;30:62.
35. Newton I. Composition of white light. Phil Trans
1672;6:3075.
36. Nigel W Daw: Colour vision: Adlers Physiology
of the Eye, Robert Moses (Ed). St Louis, Mosby,
1981.
37. Pearlman AL, Birch J, Meadows JC: Cerebral
colour blindness:An aquired defect in hue
discrimination. Amer Neurol 1979;5:253.
38. Rushton WAH. A cone pigment in the
protanope. J Physiol 1963;168:345.
39. Swanson WH, Cohen JM. Color vision.
Ophthalmol Clin N Am 2003;16:179-203.
40. Taylor WOG. Effects on employment of colour
vision defectives. Br J Ophthalmol 1971;155:
753-760.
41. Vola JL, Leprince G. 100-Hue at mesopic level.
Mod Probl Ophthal 1978;19:67-70.
42. Wald G. Defective colour vision and its inheritence. Proc Nat Acad Sci USA 1966;55:1347.
43. Wiesel TN, Hubel DH: Spatial and chromatic
interactions in the lateral geniculate body of
the rhesus monkey. J Neurophysiol 1966;29:1115.
44. Young T. A course of lectures on natural
physiology. Phil Trans 91, 43, 92, 12, 387, 1801-07.
45. Yves le Grand. Light Colour and Vision. London:
Chapman and Hall, 1957.
Slit-lamp Examination
HARINDER SINGH SETHI, MUNISH DHAWAN
Slit-lamp
Examination
The slit-lamp is one of the important examining

tools of ophthalmologists. Clinical ophthalmologists all over the world routinely use a slit-lamp
to examine their patients. A raw slit-lamp was
introduced in the early 1900s, but presently, it is
a sophisticated instrument (Fig. 3.1). One of the
most important advantages of slit-lamp
examination is that one can examine the eye

structure in three dimensions (3D). There are
three basic requirements for appreciation of
depth with a slit-lamp. The first depends upon the
clinician possessing a third grade of binocular
vision called steriopsis. The second involves the
direction of the incoming light source, and is
dependent upon the fact that the light beam can
be moved so it comes in from one side or the other.
The third involves the shape of the slit and is
dependent upon the fact that the light source can
be moved separately from the oculars.
History
Fig. 3.1: Slit-lamp
One of the first individuals to apply microscopy

to the living eye was Purkinje, who studied the
iris with an adjustable microscope by illuminating the field of view. The uniocular slit-lamp
was born years later when Louis de Wecker
combined an eyepiece objective and adjustable
condensing lens within a tube. It was improved
by Siegfried Czapski, who added binocularity
to the microscope. However, none of the units
had sufficient and adjustable illumination.
Allvar Gullstrand, an ophthalmologist and 1911
Nobel laureate developed a true slit-lamp to
33
34

Illumination System
Fig. 3.2: Allvar Gullstrand
illuminate the eye (Fig. 3.2). Then Henker and

Vogt improved upon Gullstrands device in 1910s
by creating an adjustable slit-lamp and
combining Czapskis microscope with
Gullstrands slit-lamp illumination. The modern
slit-lamp is a tool capable of stereoscopically
examining optical sections of the anterior
segment of the eye in great detail. Vogt used the
slit-lamp biomicroscope to study a vast array of
eye diseases and documented his findings in a
publication, Lehrbuch und Atlas der
Spaltlampenmikroskopie des Leibenden Auges
in 1930s. Besides examination of the anterior
segment of the eye, the slit-lamp, in conjunction
with certain contact lenses, is often used to
examine the anterior chamber angle and
posterior segment of the eye.
Optics of Slit-lamp
The slit-lamp is a compound microscope with
an objective lens and an eyepiece. The two main
components of the modern slit-lamp are the
illumination system and observation system
(Fig. 3.3).
The illumination system of most slit-lamps

consists of two different designs. The first
design, the Haag-Streit type illumination, allows
de-coupling in the vertical meridian. Such
vertical de-coupling is particularly useful when
performing gonioscopy to minimize reflections
and for indirect funduscopy to gain increased
peripheral views. The second design, the Zeiss
type illumination system, does not allow decoupling in the vertical meridian. The Zeiss
illumination is light and compact and makes
the slit-lamp easy to use. In either case, the
illumination systems are capable of producing
a homogenous and aberration-free beam of
white light. Most slit-lamps have halogen bulbs
to yield shorter wavelengths of light, which
allows better visualization of smaller structures
compared with longer wavelengths of light (i.e.
tungsten bulbs). A condensing lens first focuses
the light onto slit aperture. This light is again
focused by another lens onto the eye after being
reflected by tilted mirror. Blue and green (redfree) filters are available in slit-lamp to study
fluorescein staining pattern and microaneurysm
and nerve fiber layer.
Observation System
The second main component of slit-lamps is the
observation system. Modern slit-lamp microscopes can magnify images between X5 and X25,
with some microscopes allowing magnification
to X40 and even X100. Magnification is generally
achieved by three methods:
Flip-type
Galilean rotating barrel, and
Continuous zoom system.
However, magnification of the slit-lamp is
less important than its resolution. The resolution
of a slit-lamp is dependent on the wavelength
of light used, the refractive index between the
Figs 3.3A to F: A The binocular eyepieces provide stereoscopic vision and can be adjusted to accommodate the
examiners interpupillary distance. The focusing ring can be twisted to suit the examiners refractive error. B The
illumination arm can be swung 180 degrees side to side on its pivoting bases allowing the examiner to direct the
light beam anywhere between the nasal and temporal aspect of the eye. The dimension of the light beam can be
varied in height and width with the levers. C The patient positioning frame consists of two upright metal rods to
which are attached a forehead strap and a chin rest. D The joystick allows for focusing by shifting forward, backward,
laterally or diagonally. The joystick can also be rotated to lower or elevate the light beam. The locking screw located
at the base secures the slit-lamp from movement when it is not in use. E Knurled knob is slit-beam height adjuster,
Flip lever controls filters, from left to right: bright, dim, red-free. F ON/OFF power switch provides high or low options
in light intensity
eye and objective, the working distance, and

the diameter of the objective lens. In practice,
the first three of these factors are not easily
modifiable, but the objective lens diameter can
be modified to increase resolution. However,
a very large diameter lens can introduce optical
aberrations. The observation system is also
influenced by the proximity of the patients eye
to the examiners eyes. This necessitates a
convergence system for binocular viewing, and
most modern slit-lamp biomicroscopes are
designed with 10 to 15 degrees of convergence
to minimize eye strain to the examiner.
Clinical Procedure
Before using the slit-lamp, it is important to
ensure that the instrument is correctly set up.
The following points should be checked:
The eyepieces should be focused for the
observer for his/her own refractive error.
Often a little more minus correction is
required than the observers actual refractive
error due to proximal accommodation and
convergence.
The pupillary distance (pd) is adjusted for
the observer (perhaps the pd should be
35
36
slightly less than that usually measured to

account for proximal convergence).
Check that the slit-lamp is parallel on the
runners of the table.
Check that the observation and illumination
systems are coupled, and the slit-beam is
of even illumination and has sharply
demarcated edge (otherwise irregularity of
the beam may be falsely interpreted as
irregularity of tissues).
The locations of the controls are known.
The observer and patient are comfortable
in the mid-travel of the slit-lamp. Mid-travel
is the location of the slit-lamp when it is
half-way up or down.
The slit-lamp examination is conducted in

a semi dark room. Patient is seated in front
of slit-lamp on an adjustable stool and his head
is steadied by placing chin on chin-rest and
his forehead rests on the bar of head-rest. As
with any technique, a general routine should
be followed, in most cases when examining
the eye and adnexa, a large field of view is
used initially and then focus in on detail when
required with higher magnification. The
examination should be commenced using the
X10 eyepieces and the lower powered objective.
Use the lowest voltage setting on the transformer. Select the longest slit-length by means
of the appropriate lever. Adjust the chin-rest
so that the patients eyes are approximately
level with the black marker on the side of the
head rest. Adjust the height of the slit-lamp
until the slit-beam is centered vertically on the
patients eye. Focus the slit-beam on the eye
by moving the joystick either towards or away
from the patient. Coarse positioning can be
effected without using the microscope but
critical focusing should be carried out whilst
viewing through the microscope. The angulation
between the observation arm and the
illumination arm is adjusted. In addition,
accessories like a fixation light, Hruby lens, an

applanation tonometer, camera or CCTV can
be attached. Laser system can also be attached
to a slit-lamp utilizing its optics for laser
delivery.
Examination Techniques
The various techniques of slit-lamp examination
are:
1. Diffuse illumination
2. Direct focal illumination
a. Narrow beam (optic section)
b. Broad beam (parallelepiped)
c. Conical beam
3. Indirect illumination
4. Retroillumination
a. Direct
b. Indirect
5. Specular reflection
6. Sclerotic scatter
7. Oscillatory illumination
8. Tangential illumination.
Diffuse Illumination
Diffuse illumination (Fig. 3.4) is a good method
for observing the eye and adnexa in general.
Fig. 3.4: Diffuse illumination
The beam width is kept at maximum and
magnification is kept low and light is thrown
at an obtuse angle. It gives an overview of lids,
conjunctiva, cornea and lens. Detail examination
is not possible with diffuse illumination. Its main
purpose is to illuminate as much of the eye
at once for general observation. A broad beam
of light is directed at the cornea from an angle
of approximately 45 degrees. Position the
microscope directly in front of the patients eye
and focus on the anterior surface of the cornea.
Low to medium magnification (X7-X16) should
be used which allows the observer to view as
many of the structures as possible. When
viewing the eye with achromatic light one
should note on gross inspection, any corneal
scar, tear debris, irregularities of Descemets
membrane or pigmentary changes in the
epithelium. These findings are investigated
more thoroughly with other types of illumination.The diffuse illumination mode is also used
with cobalt blue filter after fluorescein staining.
Fluorescein staining is also used to evaluate
positioning of contact lenses, tear breakup time
(TBUT), and staining of the cornea for corneal
ulcer.
Diffuse, wide-beam, illumination together
with the red free (green) filter is helpful when
viewing the bulbar conjunctiva, and episcleral
blood vessels. With the aid of the red free filter
small hemorrhages, aneurysms and engorged
vessels stand out well.
Direct Focal Illumination

Direct focal illumination is the most commonly
used method of viewing tissues of the anterior
segment of the eye. The focused slit is viewed
directly by the observer through the microscope
(Fig. 3.5A). The magnification can be increased
(X10 to X40) to view any areas of interest in
greater detail.
Fig. 3.5A: Direct illumination: the light source is positioned

off to one side, and a bright slit-beam is shone directly
onto the object to be studied. The light is scattered in
all directions by the object, and some of this scattered
light finds its way back to the oculars, where it can be
observed by the examiner
Direct/focal illumination can be used with

different types of beams:
a. Narrow beam (optic section)
b. Conical beam
c. Broad beam (parallelepiped).
Narrow Beam
Narrow beam optical section is used primarily
to determining the depth or elevation of a defect
of the cornea, conjunctiva or locating the depth
of an opacity within the lens of the eye (Fig.
3.5B). With the optic section, it is possible to
detect corneal thickness, site of foreign body,
scars and opacities, the depth of anterior
chamber and location of cataracts. The
biomicroscope should be directly in front of
the patients eye, the illumination source at
about 45 degrees and the illumination mirror
in click position. The slit-width is almost
closed (0.5-1.0 mm wide by 7-9 mm high). Set
the magnification on low to medium (X7-X10)
and focused on the patients closed lid. The
37
38
Fig. 3.5B: Direct illumination: Narrow beam (optic section)
thickness of the eyelid (about 1 mm) means

focusing on the cornea is accomplished with
only slight movement of the joystick. With eyes
open, give the patient a point of fixation such
as the fixation light, or the top of the examiners
opposite ear. Once the cornea is in sharp focus,
scan the cornea from temporal limbus to nasal
limbus. To maintain a clear, distortion-free view,
the illumination source is always moved to the
opposite side when crossing the mid-line of
the cornea. With a clearly focused optic section
slightly temporal to the center of the cornea,
magnification is increased to X16, then to X20,
and brightness is also increased. Try to note
the following:
1. The front surface bright zone is the surface
of the tears,
2. The next dark line is the epithelium,
3. The next brighter thin line is Bowmans
membrane,
4. The gray wider granular area is the stromal
zone, and
5. The last bright inner zone is the endothelium
To attain an optic section of the crystalline
lens, the angular separation of the illumination
source is reduced until the light beam just grazes
the edge of the pupil and the vertical height
is reduced to approximate the pupil size. This
alignment can easily be accomplished from
outside the biomicroscope. When the beam cuts

just across the edge of the pupil, the crystalline
lens will appear sectioned. By focusing the
biomicroscope with joystick with one hand and
controlling the direction or angle of the light
source with the other hand, the different layers
of the lens can be brought into focus. The
anatomical location of lens opacities can be
visualized. Furthermore, the degree of nuclear
opalescence and color can be evaluated and
graded. Medium or high magnification gives
the best details of lens.
Van Hericks technique for grading the
anterior chamber angle uses an optic section
placed near the limbus with the light source
always at 60 degrees (Figs 3.6A and B). The
biomicroscope is placed directly before the
patients eye. This technique only allows an
estimate of the temporal and nasal angles. The
classification of the angle grades and risk of
angle closure are summarized in Table 3.1.
Split limbal technique: It can be used for an
estimation of the superior and inferior angles
(Fig. 3.7). The slit-lamp and illumination system
Fig. 3.6A: Van Herick angle estimation method
Fig. 3.6B: Split limbal technique for assessing

anterior chamber angle depth
TABLE 3.1: CLASSIFICATION OF ANTERIOR CHAMBER ANGLE BASED ON
VAN HERICK ANGLE OF THE ANTERIOR CHAMBER ESTIMATION METHOD
Angle grade
Risk of angle closure
Cornea to angle ratio
Wide open angle incapable of closure.

Iris to cornea angular separation equals
to 35-45
Anterior chamber depth (shadow) is equal to or

greater than corneal thickness
Moderately open angle incapable of closure.

Iris to corneal angular separation equals to
20-35
Anterior chamber depth (shadow) is between

1/4 and 1/2 of the corneal thickness
Moderately narrow angle closure possible.

Iris to corneal angular separation equals
to 20
Anterior chamber depth (shadow) is equal

to 1/4 of the corneal thickness
Extremely narrow angle, closure chance

high. Iris to corneal angular separation
equals to 10
Anterior chamber depth (shadow) is equal to less

than 1/4 of the corneal thickness
Basically closed angle. Iris to corneal

angular separation is 0
Anterior chamber depth (shadow) is nil or only

a very narrow slit
are in click position aligned directly in front

of the patient. The beam width is that of an
optic section which is focused on the limbalcornea junction thus splitting the cornea and
limbus. Then view the arc of light through the
cornea and that falling on the iris without the
aid of the slit-lamp. The angular separation seen
at the limbus-corneal junction is an estimation
of the anterior chamber angle depth in degrees.
Conical beam
Examination of the anterior chamber for cells
or flare must be performed before either dilation
or applanation tonometry. High magnification
(X16-X20) and high illumination may be needed.
High illumination is used to detect floating
aqueous cells and flare by the Tyndall effect
(particles of dust floating in a sun light beam).
The traditional method of locating and grading
cells and flare is to reduce the beam to a small
circular pattern with the light source 45 to 60
degrees temporally and directed into the pupil.
The biomicroscope is positioned directly in front
of the patients eye with high magnification
and with as bright illumination as the patient
will permit. The examiner always allows a
period of time to dark adapt. The conical beam

is focused on a dark zone lying between the
cornea and the anterior lens surface. This zone
is normally optically empty and appears totally
black. Flare (protein escaping from dilated
vessels) makes the normally optically empty
zone appear gray or milky when compared to
the normal eye. Cells will reflect the light and
can be seen as white dots. The techniques used
may be either to oscillate the light source with
the joystick from left to right while focused
in the anterior chamber or to focus from the
posterior cornea to the anterior lens while
oscillating the light source.
Broad beam (parallelepiped)

A parallelepiped is one of most common types
of illumination used (Fig. 3.7). It is used in
combination with a number of different types
of illuminations. The biomicroscope should be
placed directly in front of the patients eye,
the illumination source at about 45 degrees and
the illumination mirror in click, position. A
parallelepiped is essentially an optic section with
2.0-4.0 mm slit-width and variable height. The
parallelepiped presents a three dimensional
39
40
Fig. 3.7: Broad beam (parallelepiped)
view of the cornea or the crystalline lens. The

three dimensional view permits observation of
distinguishable details within the crystalline lens
zones of discontinuity. As with the optic
section, the angle between the illumination
source and biomicroscope may be varied to
expose more corneal epithelium, stroma and
endothelium. The whole cornea should be
scanned using a parallelepiped. When scanning
the cornea, a clear undistorted view must be
maintained by positioning the light source to
the opposite side when crossing the mid-line
of the cornea. Both normal and abnormal
findings can be seen when scanning the cornea
with varied levels of magnifications and
brightness. Look for the following findings:
1. Tear debris is usually related to allergies
or occasionally with infections.
2. Corneal nerves are white thread-like
structures that bifurcate and trifurcate and
are located anywhere within the cornea.
3. Blood filled vessels extend from the limbus
onto or into the cornea, and may be
diagnostic of chronic or acute insult or
inflammation.
4. Ghost vessels extend from the limbus into
the cornea. They are empty of blood and
diagnostic of past deep corneal inflammation.
5. Corneal scars are white in color and

diagnostic of some past corneal damage,
ulcer, abrasion or foreign body.
6. Corneal striae are white usually vertical
thread-like twisting lines found in the
Descemets membrane and posterior
stroma. They are diagnostic of poor fitting
soft contact lens and diabetes.
7. Endothelial pigmentation, when heavy and
located vertically on the endothelium, is
known as Krukenbergs spindle, it may be
diagnostic of iris atrophy and pigmentary
glaucoma. Transillumination of the iris may
reveal transillumination iris defects (TIDs).
Scanty and very fine pigment deposits are
commonly seen and are not pathological.
Indirect Illumination
Indirect illumination means looking at tissue
outside the area which is directly illuminated
and can be used in conjunction with most of
the above techniques. Corneal opacities, corneal
nerves and limbal vessels are easily seen under
indirect illumination as glare is reduced.
Examine always directly as well as indirectly
illuminated areas of the structure. To use this
type of illumination place the biomicroscope
directly in front of the patients eye and the
illumination light source at about 45 degrees.
Make sure the illumination mirror is in click
position. Use a parallelepiped beam sharply
focused on a given structure like the cornea.
The light passes through the cornea and falls
out of focus on the iris. The dark area just lateral
or proximal to the parallelepiped is the indirect
or proximal zone of illumination. This is the
area of the cornea which one surveys through
the biomicroscope. This type of illumination
is helpful in detection of microcystic edema,
faint corneal infiltrates and irregularities of the
corneal epithelium and tears. Because it utilizes
direct, indirect and retroillumination simultaneously, one should consider it to be as
important as any other type of illumination.
Retroillumination
Retroillumination is another form of indirect
viewing. The light is reflected off the deeper
structures, such as the iris or retina, while the
microscope is focused to study the more anterior
structures in the reflected light (Figs 3.8A to
D). It is used to study the cornea in light reflected
from the iris, and the lens in light reflected
from the retina. Structures that are opaque to
light appear dark against a light background

(e.g. corneal scars, pigment, and lens opacity).
Portions that scatter light appear lighter than
the background (e.g. edema of the epithelium,
corneal precipitates). This method is useful for
examining the size and density of opacities,
but not their location.
Retroillumination uses a parallelepiped that
bounces unfocused light off one structure while
observing the back of another. The alignment
and angular separation of the biomicroscope
to the illumination source will vary. The light
source beam is reflected off another structure
like the iris, crystalline lens or retina while the
Figs 3.8A and B: Retroillumination: This technique allows the observer to view a clear structure with light that has
been transmitted through, rather than just bounced off it. A Light from the slit-lamp is shone through the pupil, reflected
off the fundus, and transmitted through the lens and cornea. B Light is reflected off the iris and transmitted through
the cornea
Figs 3.8C and D: Retroillumination
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42

biomicroscope is focused on a more anterior
structure. For retroillumination or transillumination of the iris or crystalline lens a low to
medium magnification (X7-X10) is used. A slitwidth 1-2 mm wide and 4-5 mm high is used
with the biomicroscope and light source placed
in direct alignment with each other. They are
both positioned directly in front of the eye to
be examined. Focus the slit just off the edge
of the iris and on the front of the lens. If there
are defects or atrophy of the iris they will be
seen as a retinal orange glow coming back
through each defect or hole. Patients who have
numerous endothelial pigment deposits must
have their iris transilluminated. The cornea is
probably the most common structure viewed
on retroillumination. Keratic precipitates will
appear white in direct illumination but dark
by retroillumination. This technique is valuable
for observation of deposits on the corneal
endothelium and invading blood vessels.
Sclerotic Scatter
Sclerotic scatter examination uses the principle
of total internal reflection (Fig. 3.9). Slit-lamp
is set to a low X6-X10 magnification and a
narrow vertical-slit (1-1.5 mm in width) is
directed in line with the temporal or nasal
limbus. A halo of light will be observed around
the limbus as light is internally reflected within
the cornea, but scattered by the sclera. Presence
of corneal opacities, edema or foreign bodies
will be made visible by the scattering light,
appearing as bright patches against the dark
background of the iris and pupil. Even minute
nebular opacities can be picked up.
Specular Reflection
Specular reflection is achieved by positioning
the beam of light and microscope in such a
position so that the angle of incidence is equal
Fig. 3.9: Sclerotic scatter: A bright, wide-slit is shone directly

at the limbus; most of the light is trapped within the cornea
through total internal reflection, and, therefore, the cornea
appears dark. When the light hits the opposite limbus
or anything abnormal located within the corneal substance,
it will scatter; some of the scattered light is directed back
to the oculars, the abnormality is visible to the observer
to the angle of reflection. The light can be

reflected from either the anterior or posterior
corneal surface. Note that the reflected light
should pass through only one eyepiece, and,
therefore, this method is monocular. Any
roughness or irregularity as induced by the
presence of corneal guttata is visible due to
irregular reflection of light. A parallelepiped
is used to view the endothelial cells of the
cornea. The cells are seen only by one eye and
they appear in the opposite direction of the
illumination light source. A parallelepiped is
used for specular reflection. The angle between
the illumination source and the biomicroscope
should be approximately 60 degrees and a high
magnification and high illumination must be
used.
Place the biomicroscope directly in front of
the patients eye and the illumination light
source at 45-60 degrees. Just off the limbus,
obtain a sharply focused parallelepiped of the
cornea. Slowly advance the parallelepiped
across the cornea until a dazzling reflection of
the filament is seen within the biomicroscope.
This reflection is only seen by one eye. Keeping
the reflected light within the field of view of
biomicroscope, the focus is moved back toward
the endothelial cells. There will be a point where
two images of the filament are seen, one bright,
and the other ghost-like or copper-yellow in
color. When the biomicroscope is focused on
the ghost-like filament a mosaic of hexagonal
cells are seen. It should be noted that even with
X40 magnification the endothelial cells do not
look as large as most texts show. They resemble
the appearance of the dimpled surface of an
orange peel or basketball. When the slit-lamp
illumination system and the biomicroscope are
at equal angles of incidence and reflection, the
endothelium of cornea is viewable. Both front
and back surfaces of the crystalline lens can
also be viewed by using the specular reflection.
Oscillatory Illumination
In oscillatory illumination, a beam of light is
rocked back and forth by moving the
illuminating arm or rotating the prism or mirror.
This method may be used to determine
occasional aqueous floaters and the extent of
opacities in the crystalline lens.
Tangential Illumination
In tangential illumination iris is examined under
very oblique illumination while the microscope
is aligned directly in front of the eye. It is useful
for examining tumors of the iris.
Clinical Application
Slit-lamp biomicroscopy is very useful in the
diagnosis of eye diseases. It should routinely
be performed in almost all diseases of the eye.
1. Eyelids and lashes: A low magnification,

with a long and fairly narrow beam should
be used to scan the eyelashes and lid
margins. The examination can reveal the
presence of crusted material, lash loss, erythema and flaking suggestive of blepharitis.
2. Conjunctiva: For examination of conjunctiva, pull the lower lid away from the globe
with hand and look at the palpebral and
bulbar conjunctiva. One may find foreign
body, purulent material, injection, conjunctival follicles, pinguecula or pterygium.
Try to see the entire cul-de-sac while the
patient looking up. The upper lid must
be everted to examine the upper palpebral
conjunctiva.
3. Cornea: A narrow beam should be directed
approximately 45 degrees at the cornea. Scan
the entire corneal surface, moving lids and
beam appropriately while trying to evaluate
the epithelium, stromal thickness and
endothelium. Note any defects, opacities or
pigment dusting on the endothelium. If
defects are seen or suspected, instill a topical
anesthetic and fluorescein stain. Make the
beam as large as possible and flip the cobalt
blue filter on. Examine the epithelium for
areas of bright yellow-green staining. The
staining represents an epithelial defect.
4. Anterior chamber: The depth of the anterior
chamber can be determined by comparing
the corneal thickness to the space between
the posterior surface of the cornea and the
iris surface. The beam should be directed at
approximately 45 degrees and just inside the
temporal limbus. An anterior chamber
depth of less than 1/4 of the corneal
thickness is considered a narrow-angle. A
search for flare should also be made.
5. Iris: The iris is generally screened with
a narrow-beam with full height. It should
be fairly flat and free of masses. Small
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44

pigmented nevi are common, but should
be flat. The pupillary margin should be
round. A slight extension of the posterior
pigment around the margin is common
but the presence of vessels on the iris is
abnormal (rubeosis iridis).
6. Lens: The anterior capsule, cortex, nucleus,
and posterior capsule of the lens are
scanned with a narrow and full beam of
the slit-lamp. When opacity in the lens is
present, localize its depth within the lens.
Pupillary dilatation facilitates the
localization. If the pupils are dilated, widen
the beam slightly, lower the height and
direct the beam in a straight line toward
the retina between the microscope and the
eye near the pupillary border. It results
in retroillumination and focus on the lens
to find iris defects or lens opacities.
7. Anterior vitreous: Anterior vitreous is seen
with a narrow beam. Small proteinaceous
strands are normal, but cells, blood or
opacities in the vitreous are abnormal and
warrant investigations.
Fig. 3.10: Goldmann applanation tonometer
Slit-lamp Attachments
Besides routine examination of the eye, the slitlamp with the help of its attachments is used
for various investigative procedures. Important
slit-lamp attachments with their use are
mentioned below:
Goldmann tonometer (Fig. 3.10) is used for
applanation tonometry.
Pachymeter (Fig. 3.11) is used for measurement of corneal thickness.
Gonioscope (Figs 3.12A to C) is used for
visualization of the angle of the anterior
chamber.
Hruby lens is used for funduscopy.
Digital camera for fundus photography (Fig.
3.13).
Fig. 3.11: Corneal pachymeter mounted on slit-lamp
B
Fig. 3.13: Slit-lamp with digital camera
Bibliography
C
Figs 3.12A to C: Goldmann gonioscopes: A Singlemirror, B Double-mirror, C Three-mirror
1. Fingeret M, Casser L, Woodcombe HT. Atlas

of Primary Eye Care Procedures. Norwalk,
Appleton & Lange, 1990.
2. Waring GO, Laibson PR. A systematic method
of drawing corneal pathologic conditions. Arch
Ophthalmol 1977:95:1540-42.
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46
FRANCISCO ARNALICH, DAVID PIERO, JORGE L ALI
Corneal
Topography
The cornea is the most important refractive

element of the human eye, providing approximately two-thirds of optical power of the eye,
accounting for about 43-44 diopters at the corneal
apex. Because its surface is irregular and
aspherical, it is not radially symmetric, and simple
measurement techniques are inadequate.
The great upsurge in refractive surgery led
to a need for improved methods to analyze corneal
surface and shape since refraction and keratometric data alone were insufficient to predict
surgical outcomes. Understanding and quantifying corneal contour or shape has become essential in planning modern surgical intervention
for refractive surgery, as well as in corneal
transplantation. It is also very valuable for
assessing optical performance of the eye.
The different methods for evaluating the
anterior surface of the cornea, developed over
several centuries, have, in the present era, led
to the modern corneal topographers.
History of Corneal Measurement

In 1619 Scheiner analyzed corneal curvature by
matching the image of a window frame reflected
onto a subjects cornea with the image produced
by one of his calibrated spheres.
Fig. 4.1: Helmholtz ophthalmometer
Keratometer
In 1854 Helmholtz described the first true
keratometer, which he called an ophthalmometer
(Fig. 4.1). With some minor improvements, it is
still being used clinically for calculating
refraction, intraocular lens power and contact
lens fitting.
This apparatus is based on the tendency of
the anterior corneal surface to behave like a
convex mirror and reflect light. The projection
of four points, or mires, onto the cornea, creates
a reflected image that can be converted into a
Corneal Topography
corneal radius, r, using a mathematical
equation that considers distance from the mire
to cornea (75 mm in the keratometer), image size
and mire size (64 mm in keratometer). The corneal
radius can be transformed into dioptric power
using the formula:
DP= (index of refraction of the lens - 1)/ r
The standard keratometric index represents
the combined refractive index of the anterior and
posterior surfaces of the cornea, considers the
cornea as a single refractive surface, and is
1.3375. Thus, the equation can be simplified to:
DP= 337.5/ r
Although keratometers are still common in
ophthalmology clinics, they do have specific
limitations that need to be considered in order
to avoid misleading conclusions.
1. Most traditional keratometers measure the
central 3 mm of the cornea, which only
accounts for 6% of the entire surface.
2. It assumes that the cornea is a perfectly
sphero-cylindrical surface, which it is not.
The cornea is aspheric in shape, flattening
between the center and the periphery.
Usually the central corneal curvature is fairly
uniform, and this is the reason why it can
be used to calculate corneal power in normal
patients. However, this is not true in some
pathogenic conditions like ectatic disorders
or after refractive surgery.
3. The keratometer provides no information
as to the shape of the cornea either inside
or outside the contour of the mire. Several
corneal shapes can all give the same
keratometric value so this apparatus is of
little use should it become necessary to
reconstruct the whole corneal morphology.
reflections of a series of illuminated concentric

rings (known as Placidos rings) first time in
1880 (Fig. 4.2). In 1896 Gullstrand developed
a quantitative assessment of photokeratoscopy.
The keratoscope, like a keratometer, projects
an illuminated series of mires onto the anterior
corneal surface, usually consisting of concentric
rings. The distance between the concentric rings
or mires gives the observer an idea of the corneal
shape. A steep cornea will crowd the mires, while
a flat cornea will spread them out. Surface
irregularity is seen as mire distortion.
When a photographic camera is attached to
the keratoscope, it becomes a photokeratoscope,
which gives semi-quantitative and qualitative
information about the paracentral, midperipheral
and peripheral cornea.
Based on the mathematical equation, it is
possible to calculate corneal power from object
size. Still, photokeratoscopy gives limited
information on the central area, which is not
covered by the mires.
Fig. 4.2: Placidos rings
Keratoscopy and Photokeratoscopy
Videokeratoscopy
Goode presented the first keratoscope in 1847.

Placido is credited to photograph the corneal
Modern corneal topographers are based on

videokeratoscopy. A video camera is attached
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48

to the keratoscope, and the information is
analyzed by a computer that displays a colorcoded map of power distribution or corneal
curvature of the anterior corneal surface (Fig.
4.3). It overcomes some of the limitations of other
methods, since it measures larger areas of the
cornea, with larger number of points thus
increasing resolution. Computer technology
makes it possible to create permanent records
and conducts multiple data analyses.
Q is asphericity, a parameter that is used to specify

the type of conicoid.
For a perfect sphere this parameter takes the
value of zero (Q=0), for an ellipsoid with the major
axis in the X-Y plane (oblate surface) the asphericity is positive (Q>0), for an ellipsoid with
the major axis in the Z axis (prolate surface) asphericity is negative (-1<Q<0), while for a paraboloid
with its axis along the Z axis the value is -1, and
it is less than -1 for a hyperboloid (Fig. 4.4).
Other parameters have been defined to
classify the conicoid form of the cornea: P,
the shape factor (P=Q+1), or the eccentricity
value, e, defined as e = Q
Fig. 4.3: Videokeratography system
Shape of the Normal Cornea

The anterior corneal surface is a refractive surface
characterized by an almost spherical shape. The
human cornea is not a perfect sphere and is
usually assumed to have a conic section. This
model could be represented in a simple way by
means of following equation:
X2 + Y2 + (1 + Q)Z2 2RZ = 0
The Z axis is the axis of revolution of the
conic, R is the radius at the corneal apex, and
Fig. 4.4: Different types of conic section
Several studies have shown that the anterior

corneal configuration tends to be prolate, i.e. the
cornea progressively flattens out towards
periphery by 2-4 diopters (Fig. 4.5).The
asphericity of the normal cornea, depending on
different studies, ranges from -0.26 to -0.11.
Corneal Topography
Fig. 4.5: Corneal profile in principal meridians
This tendency to flatten towards periphery

can be detected in the topographic map. Toward
the periphery, dioptric power appears to decline,
and the nasal area flattens more than the temporal
area (Fig. 4.6). This could be helpful in distinguishing right eye topography from the left eye
topography. The topographic patterns of the two
corneas of the same individual often show mirrorimage symmetry.
Corneal topographic patterns (Fig. 4.7) have

been studied in normal eyes and the following
shapes have been found: round (23%), oval
(21%), symmetric bow-tie typical for regular
astigmatism (18%), asymmetric bow-tie (32%),
and irregular astigmatism (7%). In the round
and oval shapes there is an area of uniform
dioptric power close to 43 diopters (D) in the
center of the cornea. The bow-tie configuration
Fig. 4.6: Corneal topography in a normal right eye. There is a flattening

towards the periphery, more pronounced at the nasal area
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50
B
Figs 4.7A and B: A Oval topographic pattern, B Bow-tie pattern
that shows an against-the-rule astigmatism
reflects the existence of corneal astigmatism.

Depending on the position of the axes, corneal
astigmatism is defined as against-the-rule (the
steepest axis is horizontal), with-the-rule (the

steepest axis is vertical), or oblique (the steepest
axis is near the meridian angles of 45 or 135).
Corneal Topography
D
Figs 4.7C and D: Normal corneal topographic patterns:
C With-the-rule astigmatism, D Oblique astigmatism
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52
Fundamentals and Technological

Approaches to Corneal Topography
Specular Reflection Techniques
Placido Disk System
A Placido disk system consists of a series of
concentric illuminated rings or mires that are
reflected off of the cornea and recorded by videocomputerized systems. Currently, several companies manufacture instruments called videokeratoscopes that picture corneal shape based on the
Placido disk method, and, in fact, this approach
has been the most clinically and commercially
successful. Two types of Placido targets have
been used:
1. Large diameter target (disk-shaped), this is
less sensitive to misalignment due to a long
working distance, but there can be a loss
of data due to interference by the patients
brow and nose.
2. Small diameter target (cone-shaped), this is
designed for a short working distance and
can be influenced by automatic alignment
and focusing or compensation of
misalignment for accuracy. It does not
present data loss due to shadows.
Limitations of placido disk system: Placido-based
apparatus creates a three-dimensional system
by making geometric assumptions about the
cornea since the apparatus does not measure
corneal surface directly. These assumptions are
not accurate for irregular and aspheric corneas.
The reflection technique depends on the integrity
and normality of the tear layer.
Interferometric Method-based Systems

In essence, a reference surface (or its hologram)
is compared to the tested surface, the corneal
surface, and interference fringes are produced
as a result of differences between the two shapes,
which can be interpreted as a contour map of

surface elevations. Interference techniques are
used in the optical industry to detect lens and
mirror aberrations of subwavelength dimensions.
High accuracy is theoretically possible, but
clinical use has not been very wide-spread as
yet.
Moire Deflectometry-based Systems

The deflections of the rays reflected off the corneal
surface are analyzed to build up a surface
elevation map.
Diffuse Reflection Techniques

The following three methods, Moire fringes,
Rasterography, and the Fourier transform
profilometry method, modify the natural specular
condition of the anterior surface of the cornea
transforming it into a diffusing surface instilling
fluorescein in the eye. A structured light pattern
(grid or raster) is projected onto the cornea. Due
to the topography of the cornea, if the fringes
are observed from a point that is different from
that of the projecting point, a distorted fringe
pattern is observed. These stereo-triangulation
methods locate the cornea in space (x, y and
z coordinates) and can reconstruct corneal shape.
The only difference between the three methods
is the way in which data is processed and
analyzed.
Techniques using Scattered Light-slitbased Systems

When the slit image is on the cornea, it splits
into a specular reflection and a refracted beam
that penetrates the corneal surface and is scattered
by the tissue of the cornea. An image of this
scattered light within the corneal tissue is
captured by an imaging system, which uses
triangulation to measure the elevation of the
Corneal Topography
anterior and posterior corneal surfaces with
respect to a reference plane.
ORBSCAN II TM (Fig. 4.8) uses placido disk
and slit-based systems to obtain 40 slit-images
of the cornea. These images are captured over
one second and recorded.
Fig. 4.9: Photokeratoscope raw image
Fig. 4.8: Orbscan II system
How to Interpret a Corneal

Topography Map?
Accurate interpretation of corneal shape using
color-coded topographic maps is difficult and
confusing for many clinicians, even experienced
cornea specialists. In order to obtain the best
performance in the analysis of corneal maps,
several important points must be taken into
consideration. It is critical to check the raw image
first. Then it is necessary to focus on the scale
and step intervals with which the color-coded
topographic map is built up. It is also important
to review different topographic displays,
especially when evaluating irregular or postsurgery corneas.
Raw Photokeratoscope Image

The photokeratoscope image displays the
placidos rings projected onto the cornea (Fig.
4.9). When considering a color-coded map, the

clinician must check that the unprocessed data
upon which it is based, are reliable. If the videokeratoscope image is irregular, data cannot be
processed by the instrument in a meaningful way.
Thus, for Placido disk-based computerized
videokeratoscopes, the videokeratoscope image
should not be ignored. In fact, it is recommended
to check this map before referring to any of the
other topographic displays, and to go back to
it when there are any doubts regarding the
accuracy of the displayed data. This image
provides important information for assessing tear
film quality, mire centering on the cornea, lid
opening, or the causes of local irregularities, and
other artefacts. If the device used displays
computer tracking of the placido mires it is
important to rule out tracking errors.
Devices that rely only on scanning slittechnology to analyze the anterior corneal surface
lack valuable information provided by the raw
videokeratoscope image. Whether the resulting
map is based on reliable primary data or not
is impossible to verify without the raw image.
Some instruments identify regions of
uncertainty, showing mire distortions that cannot
be reliable, by leaving blank areas on the colorcoded map. Other instruments merely extrapolate
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54

onto the uncertain regions information gathered
from adjacent regions with reliable data.
Color-Coded Scales
The shape of a cornea can be measured and
represented by color-coded maps in which a
given color indicates a different curvature or
elevation. The usual color spectrum for corneal

powers shows near-normal power as green, lower
than-normal power as cool colors (blues) and
higher than normal powers as warm colors (reds).
Most topographers offer absolute as well as
normalized scales to allow the clinician to
customize the information for maximal clinical
value (Fig. 4.10):
B
Figs 4.10A and B: Corneal topography map represented using a
normalized scale A, an absolute scale B
Corneal Topography
i. Normalized scale (variable scale) uses a given
color for different curvatures or elevations
on each cornea analyzed, depending on the
range for that particular cornea, determined
by its flattest and steepest values. These
maps are difficult to interpret and can lead
to an incorrect diagnosis since they may
magnify subtle changes in corneal surface
if the scale is too narrow, or minimize large
distortions if the scale is too wide. In
addition, color recognition, one of the
primary clues used to interpret on corneal
topography, is lost with a variable scale,
since it uses different colors for different
eyes.
ii. Absolute scale (fixed scale) uses the same color
for the same curvature or elevation no matter
which eye is examined. However, there are
many different absolute scales since the
examiner can choose different variables
such as range or step size (intervals in color
changes). For the specified scale, however,
each display will use the same colors, steps
and range. In order to facilitate comparisons
over time and between patients, it is

recommended to stick with a given fixed
scale for routine examinations and to change
the scale in the particular cases in which
this becomes necessary. As an example the
popular Klyce/Wilson scale ranges from 28
D to 65 D in equal 1.5 D intervals. Currently,
there is no consensus as to the best absolute
scale, but in general, dioptric scales with
intervals smaller than 0.5 D are not clinically
useful and provide details that are not
relevant and may complicate map interpretation. For corneas with large dioptric ranges,
for instance in advanced keratoconus
intervals greater than 0.5 D are recommended. Regarding scales for elevation maps,
elevation steps of approximately 5 microns
appear to be clinically useful.
As mentioned previously, color pattern
recognition makes it possible to identify common
topographic patterns such as the corneal cylinder,
keratoconus (local area of inferonasal steepening)
or pellucid marginal degeneration (butterflypattern or inferior arcuate steepening), as well
Fig. 4.11: Corneal topography after myopic LASIK
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56

as features associated with refractive surgery (Fig.
4.11), such as optical zone size, centration, and
central islands.
Topographic Displays: Corneal Maps

Different types of maps are used for displaying
curvatures, elevations and irregularities of the
cornea.
Axial Map (Sagital Map)
Refractive Map
The refractive map displays the refractive power
of the cornea, which is calculated based on Snells
law of refraction, assuming optical infinity (Fig.
4.12C). This map correlates corneal shape to
vision, and is useful in understanding the effects
of surgery.
Elevation Map
Although this is the original and most commonly

used map, its values only provide a good
approximation for the paracentral cornea (Fig.
4.12A). The axial map measures the radius of
curvature for a comparable sphere (with the same
tangent as the point in question) with a center of
rotation on the axis of the videokeratoscope.
Localized changes in curvature and peripheral
data are poorly represented, because of the
spherical bias of the reference optical axis.
However, newer algorithms in some devices (e.g.
arc-step method) have improved the accuracy of
curvature measurements in the peripheral region.
The elevation map displays corneal height or

elevation relative to a reference plane (Fig. 4.12D),
with a presumed assumption of the shape, which
may be the best-fit sphere, best-fit asphere,
average corneal shape, or even based on
preoperative data. Points above the reference
surface are positive (hot colors) and points below
the reference surface are negative (cool colors).
This map shows the three-dimensional (3D)
shape of the cornea and is useful in measuring
the amount of tissue to be removed by a refractive
surgical procedure, assessing postoperative
visual problems, or planning and/or monitoring
surgical procedures.
Local Tangential Curvature Map

(Instantaneous Map)
Difference Map
The tangential map displays the tangential/

instantaneous/local radius of curvature or
tangential power, which is calculated by referring
to the neighboring points and not to the axis
of the videokeratoscope (Fig. 4.12B). Tangential
maps reflect local changes and peripheral data
better than axial maps. They are very useful in
detecting local irregularities, corneal ectactic
diseases, or surgically induced changes. For
example, in keratoconus corneas with a
displaced apex, tangential maps are less
influenced by peripheral distortion, and can
determine the position and extent of the cone
more precisely than axial maps.
The difference map displays the changes in

certain values between two maps (Fig. 4.13). It
is used to monitor any type of change, such as
recovery from contact lens-induced warpage or
surgery-induced changes.
Relative Map
The relative map displays some values by
comparing them to an arbitrary standard (e.g.
sphere, asphere, or normal cornea) and a specific
mathematical model. This map enhances or
magnifies unique features of the cornea being
examined.
Corneal Topography
Fig. 4.12A: Axial map
Fig. 4.12B: Instantaneous map
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Fig. 4.12C: Refractive map
Fig. 4.12D: Elevation map

Figs 4.12A to D: Different kind of topography maps for the same cornea
Corneal Topography
Fig. 4.13: Difference map
Irregularity Map (Surface Quality Maps)

The irregularity map uses the same technique
as the elevation map, but takes as a reference
surface the best-fit spherocylindrical toric surface.
The difference between the actual surface and
the theoretical surface represents that part of the
cornea that cannot be optically corrected. Like
refractive power maps, the irregularity map only
has clinical meaning when considering the
values over the pupillary area.
Numerous other displays, including three
dimensional maps (Fig. 4.14) and astigmatic
vector analysis are available but less commonly
used.
Fig. 4.14: Three-dimensional elevation map
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Fig. 4.15: Bad image for topography analysis due to

lack of focus
A Good Topography Examination

Corneal topography is a non-invasive imaging
technique for mapping the surface curvature of
the cornea. The specific method varies depending
on the device used, but some aspects are common.
The patient is seated facing a bowl containing
an illuminated pattern which is focused on the
anterior surface of his cornea. The reflected
pattern is analyzed by a computer that calculates
the shape of the cornea by means of different
graphic formulae. Although computer programs
are created to be very accurate, they can not
recognize, and account for, every problem. Critical
points for precise measurement are accurate
alignment, centering and focusing (Fig. 4.15). They
depend on the ability of the examiner to take
a good measurement. Another potential source
of error is tear film irregularities, for example
focal flattening over a dry patch. These may be
most easily identified on the raw image.
Tear film breakup causes mistracking of the
mires and artefacts in the topography pattern
and apparently look like significant irregularities (Fig. 4.16). These corneal irregularities
could suggest a corneal pathology, such as
keratoconus, and result in wrong diagnosis (Fig.
4.17). To avoid disturbing the tear film, corneal
topography should be performed before adminis-
Fig. 4.16: Distortion of the placido rings because of

tear film breakup
tering dilating drops and taking intraocular

pressures.
In addition, one must avoid artefacts induced
by the nose or the eyelids which can lead to
a loss of information in certain areas (Fig. 4.18).
These errors are transformed into black areas
or areas without data on the topographic map.
Correct positioning of the head, eyes and eyelid
opening should be ensured to avoid these
problems.
Quantitative Descriptors of Corneal

Topography: Corneal Indexes
Color-coded maps provide a rapid visual method
for clinical diagnosis, but do not supply
numerical values that can be used for clinical
management. Several corneal indexes describe
different features of corneal topography quantitatively and are of great aid in contact lens fitting,
for improved assessment of the optical quality
of the corneal surface, and can be used in artificial
intelligence systems to aid in the diagnosis of
corneal shape anomalies. Some of the most useful
corneal indexes are described below:
Corneal Topography
Fig. 4.17: Topographic irregularities and patches on the map

because of a tear film instability
B
Figs 4.18A and B: Loss of information of certain areas of the cornea due to
eyelids not opened enough A, and due to nose B
Basic Topographic Indexes

Simulated Keratometry Reading
(SimK values)
This is a simple descriptor of corneal topography
that provides the power and axes of the steepest
and flattest corneal curvatures just as K1 and

K2 are provided by the classic keratometer, to
which it correlates well. The cylinder is calculated
from the difference between SimK1 and SimK2.
Its common uses are:
a. Contact lenses fitting
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b. Refractive surgery calculations, and
c. Assessing an irregular corneal shape, since
it gives the quantity and axis of astigmatism.
Minimum Keratometry Reading (MinK)

This is the minimum meridional power from rings
7, 8 and 9. The average power and axis are
displayed.
Corneal Eccentricity Index (CEI)

This index estimates the eccentricity of the central
cornea, and is calculated by fitting an ellipse
to the corneal elevation data. A positive value
is for a prolate surface, negative value for an
oblate surface (for example flattened corneas after
myopic refractive surgery), and zero value for
a perfect sphere. Normal central corneas are
prolate, meaning they are steeper in the center
than in the periphery, and tend to be around
0.30. This value is used for fitting contact lenses.
Average Corneal Power

This is the area-corrected average of corneal power
in front of the pupil. It usually corresponds to
the spherical equivalent of the classic keratometer,
except after decentered refractive surgery. It may
be helpful in determining central corneal curvature when calculating the appropriate intraocular
lens power.
Surface Regularity Index and

Potential Visual Acuity
Surface regularity index (SRI) measures the
regularity of the corneal surface that correlates
with the best spectacle-corrected visual acuity
assuming the cornea to be the only limiting factor.
This index adds up the meridional mire-to-mire
power changes over the apparent pupil entrance.
The SRI value increases with increase in the
irregularity of the corneal surface, and its normal

value is less than 1.0. It measures optical quality.
Potential visual acuity (PVA) is a range of the
expected visual acuity that is achievable based
on the corneal topography and can be calculated
based on SRI.
Surface Asymmetry Index

Surface asymmetry index (SAI) is a descriptor
of the corneal surface that measures the difference
between points located 180 apart in a great
number of equally spaced meridians. Therefore,
as the cornea becomes less symmetric, the index
differs more from 0.
Other indexes, some of which will be
mentioned below, have been developed, and
might be exclusive to one particular topographer.
The clinician should evaluate the meaning, utility
and validity of each index since some indexes
have been tested in peer-reviewed literature while
others have not.
Screening Tools and Artificial

Intelligence Programs (Neural
Networks) for Classification and
Auto Diagnosis
As mentioned previously, even for an experienced
person, interpretation of topography can be
difficult, particularly when trying to differentiate
the early stages of a disease from a normal cornea
(suspected keratoconus), or when trying to
differentiate between two similar conditions
(contact lens warpage vs. early keratoconus).
Several mathematical algorithms have been
developed to help solve this problem, with high
sensitivity and specificity.
Rabinowitz and Mc Donnell developed the
first numerical method for detecting keratoconus
using only topographic data. They use the I-S
value, which measures the differences between
the superior and inferior paracentral corneal
Corneal Topography
regions, the central corneal power (Max K), and
the power difference between both eyes. Their
study presented that patients with keratoconus
(suspect) had central corneal power > 47.2 D
or I-S > 1.4 while those with clinical keratoconus
had central corneal power > 47.8 D or I-S > 1.9.
However, using only these simple
measurements for a diagnosis could create
specificity problems. To solve the specificity
problem, the new strategy must be able to detect
and consider the unique characteristics of
keratoconus maps, such as local abnormal
elevations. The Keratoconus Prediction Index,
developed by Maeda et al, is calculated from
the Differential Sector Index (DSI), the Opposite
Sector Index (OSI), the Center/Surround Index
(CSI), the SAI, the Irregular Astigmatism Index
(IAI), and the percent Analyzed Area (AA). This
method partially overcomes the specificity
limitation.
Maeda et al also developed the neural network
model, based on artificial intelligence. It is a much
more sophisticated method for classifying corneal
topography and detecting different corneal
topographic abnormalities; it employs indexes
that were empirically found to capture specific
characteristics of the different corneal pathologies, including keratoconus. Further modifications in neural network approach developed by
Smolek and Klyce supposedly produce 100%
accuracy, specificity and sensitivity in
diagnosing keratoconus.
Corneal Aberrometry: Fundamentals

and Clinical Applications
Whenever a point object does not form a point
image on the retina, as it should be in an ideal
optical system, one encounters an optical
aberration. Although one may feel that he is
measuring the total refractive error, when
refracting a patient, one is actually only
considering two components of a whole host

of refractive components in the optics of the eye.
However, these two components sphere and
cylinder do constitute the main optical
aberrations of an eye. Even in a normal eye with
no subjective need for refraction, optical
aberrations can be detected.
Since the cornea has the highest refractive
power, more than 70% of the eyes refraction,
it is the principal site of aberrations, although
the lens and the tear film may also contribute
to aberrations.
Fundamentals
Measuring Total Wavefront Aberration
It is possible to express ideal image formation
by means of waves. An ideal optical system will
provide a spherical converging wave centered
at the ideal point image. However, in practice,
the resulting wavefront, differs from this ideal
wavefront. The deviation from this ideal
wavefront is called wavefront aberration, and the
more it differs from zero, the more the real image
differs from the ideal image and the worse the
image quality. Ocular wavefront sensing devices
use four main technologies to determine the
resulting or output wave:
1. The Shack-Hartmann method is the most
widely used and is inspired by astronomy
technology. It consists of analyzing the wave
emerging from the eye after directing a small
low energy laser beam. This reflected wave
is divided by means of a series of small
lenses (lenslet array) which generates
focused spots. The position of spots is
recorded and compared to the ideal one
2. The Tscherning technique uses typically a grid
that is projected onto the retina. The
distortion of the pattern is analyzed and
used to calculate the wavefront aberration
of the eye.
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3. The ray tracing system is similar to the
Tscherning technique. However, instead of
a grid, a programmable laser serially projects
light beams that forms spots on the retina
at different locations.
4. The spatially resolved refractometer evaluates
the wavefront profile using the subjective
patient response. This technology is not
practical for clinical use.
Measuring Corneal Wavefront Aberration

It is known that 80% of all aberrations of the
human eye occur in the corneal area and only
20% of aberrations originate from the rest of the
ocular structures. The effect of corneal aberrations
is especially important after corneal surgery such
as keratorefractive procedures or penetrating

keratoplasty, since the anterior corneal surface
is the only one modified. The corneal wavefront
aberration, which is the component of the total
ocular wavefront aberration attributed to the
cornea, can be derived from the corneal topographic height data. Specifically, the calculation of
wavefront aberrations is performed by expanding
the anterior corneal height data into a set of
orthogonal Zernike polynomials (Fig. 4.19).
Zernike Polynomials
For a quantitative description of the wavefront
shape there is a need for a more sophisticated
analysis than conventional refraction, as the latter
only divides the wavefront in two basic terms:
Fig. 4.19: Corneal wavefront analysis derived from height topography data
Corneal Topography
Fig. 4.20: Zernike polynomial expansion
sphere and cylinder. One can obtain more

information by breaking down the wavefront into
terms which are clinically meaningful, besides
the sphere and the cylinder. For this purpose,
a standard equation has been universally
accepted by refractive surgeons and vision
scientists, known as Zernike polynomials.
Zernike polynomials are equations which are
used to fit the wavefront data in a three dimensional way. The wavefront function is decomposed into terms that describe specific optical
aberrations such as spherical aberration, coma,
etc. (Fig. 4.20). Each term in the polynomial has
two variables, (rho) and (theta), where is
the normalized distance of a specific point from
the center of the pupil, and is the angle formed
between the imaginary line joining the pupillary
center with the point of interest and the horizontal.
According to that, we can imagine that
aberrations are strongly influenced by pupil size,
and, therefore, aberrometric measurements
should be related to the diameter of the patients
pupil.
Zernike terms (Znm) are defined using a double
index notation: a radial order (n) and an angular
frequency (m). When talking about first, second,

third order aberrations we point to indicate the
radial order (n). Each radial order involves n
+ 1 term. There are an infinite number of Zernike
terms that can be used to fit an individual
wavefront. However, for clinical practice, terms
up to the 4th radial order are usually considered:
1. Zernike terms below third order can be
measured and corrected by conventional
optical means. The first order term, the prism,
is not relevant to the wavefront as it
represents tilt and is corrected using a prism.
The second order terms represent low order
aberrations that include defocus (spherical
component of the wavefront) and astigmatism (cylinder component). Wavefront
maps that measure only defocus and
astigmatism can be perfectly corrected using
spectacles and contact lenses.
2. After the second radial order comes high
order aberrations. These are not measured by
conventional refraction or auto refraction.
The aberrometer is the only method available
that can quantify these complex kinds of
distortions.
3. Third order terms describe coma and trefoil
defects.
4. Fourth order terms represent tetrafoil,
spherical aberration and secondary astigmatism components.
Because spherical and coma aberrations refer
to symmetrical systems and the eye is not
rotationally symmetrical, the terms spherical-like
and coma-like aberrations are normally used
(Fig. 4.21).
Wavefront Maps
Wavefront map describes the optical path difference between the measured wavefront and the
reference wavefront in microns at the pupil
entrance. The wavefront error is derived
mathematically from the reconstructed wavefront
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Fig. 4.21: Spherical-like and coma-like wavefront aberration maps
by one of the techniques described above. It is

plotted as a 2D or 3D map for qualitative analysis
in a similar fashion to corneal topography maps.
In wavefront error maps, each color represents
a specific degree of wavefront error in microns
(Fig. 4.22) and like corneal topography maps,
it is necessary to consider the range and the
interval of the scale.
Optical and Image Quality

In order to evaluate the impact of aberrations
on visual quality following quantitative parameters have been defined (Fig. 4.23):
Peak to valley error (PV error): This is a simple
measure of the distance from the lowest point
to the highest point on the wavefront and is not
Corneal Topography
Fig. 4.22: Corneal wavefront aberration maps that include

all kind of aberrations including low and high order
the best measurement of optical quality since

it does not represent the extent of the defect.
results and it is linked to the RMS by the Marchal

formula.
Root mean square error (RMS error): This measure

is by far the most widely used. In a simple way,
the RMS wavefront error is a statistical measure
of the deviation of the ocular or corneal wavefront
from the ideal (Table 4.1). In other words, it
describes the overall aberration and indicates
how bad individual aberrations are.
Point spread function (PSF): This is the spread

function observed on the retina when the object
is a point in infinity. PSF measures how well
one object point is imaged on the output plane
(retina) through the optical system. In the eye,
small pupils (approximately 1 mm) produce
diffraction-limited PSFs, because of the pupil
border. In larger pupils, aberrations tend to be
the dominant source of degradation.
Strehl ratio: This represents the ratio of the

maximum intensity of the actual image to the
maximum intensity of the fully diffracted limited
image, both being normalized to the same
integrated flux. This ratio measures optical
excellence in terms of theoretical performance
Modulation transfer function, Phase transfer function

and Optical transfer function: Sinusoidal gratings
greatly simplify the study of optical systems,
because irrespective of the amount of eye aberra-
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Fig. 4.23: Visual quality summary obtained with the CSO topographer. It is possible to visualize the wavefront
map (gray scale), Strehl ratio, PSF and MTF function
TABLE 4.1:
REFERENCE VALUES FOR CORNEAL ABERRATIONS IN THE NORMAL POPULATION
Pupil
(mm)
Total
RMS
Astigmatism
RMS
Spherical
aberration
Coma RMS
Sphericallike RMS
Comalike RMS
0.19 0.07
0.14 0.08
0.04 0.03
0.05 0.03
0.07 0.02
0.09 0.03
0.53 0.21
0.43 0.24
0.15 0.05
0.14 0.08
0.18 0.05
0.20 0.08
1.26 0.43
0.92 0.53
0.52 0.17
0.42 0.23
0.57 0.16
0.52 0.22
RMS: root mean square, Coma primary coma: terms Z31, Spherical aberration primary spherical aberration: term
Z40 Spherical-like: terms fourth and sixth order, Coma-like: terms third and fifth order
Reference: Vinciguerra P, Camesasca FI, Calossi A. Statistical analysis of physiological aberrations of the cornea.
J Refract Surg 2003; 19 (Suppl): S265-9.
Corneal Topography
tions, sinsusoidal grating objects always produce
sinusoidal grating images. Consequently, there
are only two ways that an optical system can
affect the image of a grating, by reducing contrast
or by shifting the image sideways (phase-shift).
The ability of an optical system to faithfully
transfer contrast and phase from the object to
the image at a specific resolution are called
respectively the modulation transfer function (MTF)
and the phase transfer function (PTF). The eyes
optical transfer function (OTF) is made up of the
MTF and the PTF. A high-quality OTF is,
therefore, represented by high MTF and low
PTF.
Clinical Applications
Aberrometers allow practitioners to gain a better
understanding of vision by measurement of high
order aberrations. These aberrations reflect a
refractive error that is beyond conventional
spheres and cylinders. There may be a large group
of patients whose best corrected visual acuity
(BCVA) may improve significantly on removal
of the optical aberrations and this new refractive
entity has been called aberropia. Reduced optical
quality of the eye produced by light scatter and
optical aberrations may actually be the root cause
of blurred vision associated with dry eye
syndrome and tear film disruption. Measurement
of these aberrations can also be helpful in
keratoconus, orthokeratology, post graft fitting,
irregular astigmatism or when refractive surgery
has reduced the patients optical quality.
Customized ablations are the future step in
laser technology that should address not only
spherical and cylindrical refractive errors (loworder aberrations), but also high-order aberrations such as trefoil and coma (Fig. 4.24). Thus,
vision can be optimized to the limits determined
by pupil size (diffraction) and retinal structure
and function.
Clinical Uses of Corneal Topography

Pathological Cornea
Corneal topography is a very important tool in
the detection of corneal pathologies, especially
ectatic disorders. Screening for these anomalies
or their potential development is a critical point
in preoperative evaluation for refractive surgery.
Keratorefractive procedures are contraindicated
in these abnormal corneas.
Keratoconus
Keratoconus is characterized by a localized
conical protrusion of the cornea associated with
an area of corneal stromal thinning, especially
at the apex of the cone. The typical associated
topographic pattern is the presence of an inferior
area of steepening (Fig. 4.25). In advanced cases,
the dioptric power at the apex is at or above
55 D. In a small group of patients, the topographic
alterations may be centered at the central cornea.
In these cases there may be an asymmetric bowtie configuration, and normally the inferior loop
is larger than the superior loop (Fig. 4.26).
Keratoconic corneas have three common characteristics that are not present in normal corneas:
1. An area of increased corneal power surrounded by concentric areas of decreasing power
2. An inferior-superior power asymmetry
3. A skewing of the steepest radial axes above
and below the horizontal meridian.
Keratoconus suspects are problematic. They
may signal impending development of a clinical
keratoconus, but they may also represent a
healthy cornea. The lack of ectasia in the fellow
cornea does not indicate that the keratoconus
suspect will not progress to true keratoconus.
In these cases the ideal management is close
follow-up of the signs of keratoconus in order
to check on their stability, and a thorough
analysis of the videokeratographic indexes.
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B
Figs 4.24A and B: Customized ablation designed according to corneal aberration for the correction
of aberrations induced by a decentered ablation. There is a large amount of coma: axial map
A and customized ablation designed B with the ORK-CAM software (Schwind)
Pellucid Marginal Degeneration

Pellucid marginal degeneration is characterized
by an inferior corneal thinning between 4 and
8 Oclock positions above a narrow band of clear
thinned corneal stroma. The ectasia is extremely
peripheral and it presents a crescent-shaped
morphology. This pattern has a classical
butterfly appearance that results in a flattening

of the vertical meridian and a marked againstthe-rule irregular astigmatism (Fig. 4.27).
Keratoglobus
Keratoglobus is a rare bilateral disorder in which
the entire cornea is thinned out most markedly
Corneal Topography
Fig. 4.25: Keratoconus topography pattern
near the corneal limbus, in contrast to the

localized central or paracentral thinning of
keratoconus. It is very difficult to obtain reliable
and reproducible measurements in these cases
due to the high level of irregularity and the poor
quality of the associated tear film. Reliable
topographic examinations show an arc of
peripheral increase in corneal power (steepening)

and a very asymmetrical bow- tie configuration.
Terriens Marginal Degeneration

In Terriens marginal degeneration there is a
flattening over the areas of peripheral thinning.
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Fig. 4.26: Keratoconus with an asymmetric bow-tie configuration
When thinning is restricted to the superior and/

or inferior areas of the peripheral cornea, there
is a relative steepening of the corneal surface
approximately 90 degrees away from the
midpoint of the thinned area. Therefore, high
against-the-rule or oblique astigmatism is a
common feature, as this disorder involves more

frequently the superior and/or inferior peripheral
cornea. If the area of thinning is small or if the
disorder extends around the entire circumference
of the cornea, central cornea may remain
relatively spared with a spherical configuration.
Corneal Topography
Fig. 4.27: Pellucid marginal degeneration topography pattern
Fig. 4.28: Corneal astigmatism induced by a pterygium
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Pterygium
Pterygium is a triangular encroachment of the
conjunctiva onto the cornea usually near the
medial canthus. When the lesion continues to
grow out onto the cornea, it could lead to a high
degree of astigmatism. When the growth of
pterygium is about 2 mm or more, a flattening
of the cornea at the axis of the lesion occurs
(Fig. 4.28). This produces a marked with-the-rule
astigmatism, even of more than 4 D. The evolution
of the pathology and the surgical outcome could
be monitored by changes in corneal topography.
Postoperative Cornea in
Refractive Surgery
Keratorefractive procedures attempt to alter the
curvature of the central and mid-peripheral
cornea, and usually have a minimal effect on
the corneal periphery. The area in which the
curvature is modified is called the optical zone.
This tends to be surrounded by a small zone
of altered curvature before normal cornea is
reached at the periphery. The corneal effect of

surgery could be determined by analyzing the
difference map between the preoperative and
postoperative measurements.
Postradial Keratotomy (RK)

Radial keratotomy (RK) corrects myopia by
placing a series of radial incisions (nearly full
corneal thickness) leaving a central clear zone
(optical zone). These incisions cause a flattening
of the central cornea due to retraction of the most
anterior collagen fibers and the outward pressure
of the intraocular force. This area of flattening
is surrounded at an approximately 7 mm zone
by a bulging ring of steepening called the
paracentral knee. This increases asphericity and
corneal irregularity.
A very typical finding in these corneas is
a topographic pattern with a polygonal shape.
Depending on the number of incisions made,
squares, hexagons or octagons can be seen. The
angles of the polygons correspond closely to the
central ends of the incisions (Fig. 4.29).
Fig. 4.29: Polygonal pattern in a postradial keratotomy cornea
Corneal Topography
Postastigmatic Keratotomy (AK)
Astigmatic keratotomy is a simple modification
of the radial keratotomy that is used to correct
astigmatism. Rather than placing incisions
radially on the cornea, incisions are strategically
placed on the steepest meridian. The incisions
induce a flattening in that meridian, but provoke
steepening in the perpendicular meridian, in a
process called coupling. Coupling results from
the presence of intact rings of collagen lamellae
that run circumferentially around the base of
the cornea. With the surgery, these rings become
oval in the operated meridian and transmit forces
to the untouched meridian. The stigmatic change
achieved is the sum of the flattening in one
meridian and the steepening in its perpendicular
meridian.
Postphotorefractive Keratotomy
Photorefractive keratotomy (PRK) is a procedure
which uses a kind of laser (excimer laser, a cool
pulsing beam of ultraviolet light) to reshape the

cornea. To correct myopia, the excimer laser
flattens the central cornea by removing tissue
in that area. However, the optical zone needs
to be steepened to correct hyperopia. This is
achieved by removing an annulus of tissue from
the mid-periphery of the cornea.
The topographic pattern in myopic corrections shows a flattening of the central cornea,
oblate profile (Fig. 4.30). The treatment zone is
usually easily delineated by the close proximity
of adjacent contours at its edge. Hyperopic
corrections have a pattern of central steepening
surrounded by a ring of relative flattening at
the edge of the treatment zone (more prolate
profile) (Fig. 4.31). In astigmatic treatment, the
treatment zone is oval.
Inadequate ablations during surgery can be
detected postoperatively by analyzing the
resulting corneal topography. Decentrations can
only be identified by a relatively asymmetric
localization of the treatment area (Fig. 4.32). Other
Fig. 4.30: Topographic pattern after a myopic ablation
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Fig. 4.31: Topographic pattern after a hyperopic ablation
Fig. 4.32: Pattern of decentered myopic ablation
Corneal Topography
Fig. 4.33: Central island after myopic photoablation
complicated patterns that may lead to severe

vision disturbances are the presence of focal
irregularities or central islands (Fig. 4.33)
produced by an inhomogeneous laser beam or
an irregular process of corneal healing.
Postlaser in situ Keratomileusis

Postlaser in situ keratomileusis (LASIK) is an
excimer laser procedure like PRK, but in this
case tissue is ablated under a superficial corneal
flap in order to minimize the influence of the
epithelium. The topographic patterns for myopic
and hyperopic corrections are the same as in
PRK (Figs 4.30 and 4.31). Although the ablation
is covered by a flap of corneal tissue, surface
irregularities and central islands may still occur.
Decentration may also occur in a LASIK ablation,
depending on the patients ability to maintain
eye fixation during surgery (Fig. 4.34). Epithelial
in-growth at the periphery of the flap-stromal
interface produces an area of steepening
surrounded by an area of marked flattening
making the corneal surface more irregular (Fig.

4.35).
Postlaser Thermal Keratoplasty

In laser thermal keratoplasty (LTK), a Holmium
laser is used to heat corneal stromal collagen
in a ring around the outside of the pupil. The
heat causes the tissue to shrink, producing a
zone of localized flattening centered on the spot,
and a surrounding zone of steepening. This
bulging effect of the central cornea makes it possible to correct hyperopia. The typical topographic
pattern shows the central corneal steepening and
a ring of flattening overlying the spots.
Postintrastromal Corneal Rings

Implantation
Intrastromal rings are small segments or rings,
made of a plastic-like substance, that are inserted
into the periphery of the cornea to correct small
degrees of myopia or hyperopia. They act as
spacers and by changing the orientation of the
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B
Figs 4.34A and B: Topographic patterns of LASIK decentered ablations after
myopic treatment A and after hyperopic treatment B
Corneal Topography
B
Figs 4.35A and B: Topographic analysis in a post-LASIK cornea with an epithelial
in-growth at the inferonasal area: placido rings image A, and axial map B
collagen lamellae, depending on their shape and

position, flatten or steepen the central cornea.
Intrastromal rings could also be used to reduce
the corneal steepening and astigmatism
associated with keratoconus (Fig. 4.36).
Postkeratoplasty
Keratoplasty topographies exhibit a wide variety
of patterns, depending on the type of keratoplasty
performed, the quality of the surgical procedure,

whether sutures are still in place in the cornea,
and the time elapsed after the procedure. Sutures
usually induce a central bulge in the corneal
graft and its removal results in a decrease of
the astigmatic component. The prolate configuration after keratoplasty is the most frequent
pattern with a high degree of irregularity (Fig.
4.37). There can be multiple regions of abnormally
high or low power, or both simultaneously in
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Fig. 4.36: Management of keratoconus by intrastromal rings
the map. Irregular astigmatism over the entrance

pupil may be detrimental to optimum visual
acuity in the keratoplasty patient.
Contact Lens-induced Corneal

Warpage or Molding
Corneal warpage is characterized by topographic
changes in the cornea following contact lens wear
(most frequently in wearers of hard or RGP lenses)
as a result of the mechanical pressure exerted
by the lens. There are at least 4 different forms
of noticeable topography change that usually
occur mixed with one another: (i) peripheral

steepening, (ii) central flattening, (iii) furrow
depression, and (iv) central molding or central
irregularity (Fig. 4.38).
Inferior corneal steepening (pseudokeratoconus)
is caused by a superiorly riding contact lens that
flattens above the visual axis with an apparent
steepening below. The topographic image could
appear similar to keratoconus, but both conditions
are easily differentiated. In corneal warpage, the
shape indexes do not indicate any keratoconic
condition, and the flat K is not as steep as in
keratoconus.
Corneal Topography
Other Uses of Corneal Topography
Fig. 4.37: Topographic pattern after

penetrating keratoplasty
Corneal topography is a diagnostic tool, but it

is also essential before all refractive procedures,
to enable the surgeon to understand the refractive
status of an individual eye, and plan the optimum
refractive treatment. The corneal topography is
also used for the following purposes:
1. To guide removal of tight sutures after
corneal surgery (keratoplasty, cataract
surgery, etc.) that are causing steepening
of the cornea (Fig. 4.39).
2. To help in the designing the astigmatic
keratotomy.
Fig. 4.38: Corneal warpage
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Fig. 4.39: Superior corneal steepening caused by a tight suture
3. To guide contact lens fitting: Selection of

the probe lens and design of the lens.
4. To calculate the keratometry values for the
calculation of the required power of an
intraocular lens for implantation. This is
an important issue in corneas that have
undergone refractive surgery, because it is
more difficult to estimate the real keratometric
values in order to avoid over or under
corrections.
5. To evaluate the effect of a keratorefractive
procedure.
Bibliography
1. Ambrosio R Jr, Klyce SD, Wilson SE. Corneal
topographic and pachymetric screening of
keratorefractive patients. J Refract Surg 2003;19:
24-29.
2. Bogan SJ, Waring GO, Ibrahim O, Drews C, Curtis

L. Classification of normal corneal topography
based on computer-assisted videokeratography.
Arch Ophthalmol 1990;108:945-9.
3. Boyd BF, Agarwal A, Alio JL, Krueger RR,
Wilson SE. (Eds). Wavefront analysis, aberrometers and corneal topography. Highlights of
Ophthalmology, 2003.
4. Cairns G, McGhee CNJ. Orbscan computerized
topography: Attributes, applications, and
limitations. J Cataract Refract Surg 2005;31:20520.
5. Corbett M, OBrart D, Rosen E, Stevenson R.
Corneal topography: principles and applications.
BMJ Publishing Group, 1999.
6. Corneal Topography. American Academy of
Ophthalmology. Ophthalmology 1999;106:162838.
7. Courville CB, Smolek MK, Klyce SD. Contribution of ocular surface to visual optics. Exp
Eye Res 2004;78:417-25.
8. Dabezies OH, Holladay JT. Measurement of
corneal curvature: keratometer (ophthalmo-
Corneal Topography
9.
10.
11.
12.
13.
14.
15.
16.
17.
meter). In Contact Lenses: the CLAO Guide

to Basic Science and Clinical Practice. Kendall/
Hunt Publishing Co, 1995;253-89.
Hamam H. A new measure for optical performance. Optom Vis Sci 2003; 80:174-84.
Joslin CE, Wu SM, McMahon TT, Shahidi M.
Higher-order wavefront aberrations in corneal
refractive therapy. Optom Vis Sci 2003;80:80511.
Karabatsas CH, Cook SD. Topographic analysis
in pellucid marginal corneal degeneration and
keratoglobus. Eye 1996;10:451-55.
Kaufman H, Barron B, McDonald M, Kaufman
S. Companion handbook to the cornea. London,
Butterworth Heinemann,1999.
Klyce SD. Corneal topography and the new
wave. Cornea 2000;19:723-29.
Krachmer JH, Mannis MJ, Holland EJ (Ed).
Cornea. Surgery of cornea and conjunctiva. St
Louis, Elsevier-Mosby, 2005.
Maeda N, Klyce SD, Smolek MK. Neural
network classification of corneal topography.
Preliminary demonstration. Invest Ophthalmol
Vis Sci 1995;36:1327-35.
Meja-Barbosa Y, Malacara-Hernndez D. A
review of methods for measuring corneal
topography. Optom Vis Sci 2001;78:240-53.
Miller D, Greiner JV. Corneal measurements
and tests. In Principles and Practice of Ophthalmology. Philadelphia,WB Saunders,1994.
18. Molebny VV, Panagopoulou SI, Molebny SV,

Wakil YS, Pallikaris IG. Principles of ray tracing
aberrometry. J Refract Surg 2000;16:S572-75.
19. Rabinowitz YS. Keratoconus. Surv Ophthalmol
1998;42:297-319.
20. Rabinowitz YS, Nesburn AB, McDonnell PJ.
Videokeratography of the fellow eye in
unilateral keratoconus. Ophthalmology 1993;100:
181-86.
21. Rao SK, Padmanabhan P. Understanding
corneal topography. Curr Opin Ophthalmol
2000;11:248-59.
22. Thibos LN, Applegate RA, Schwiergerling JT,
Webb R. Standards for reporting the optical aberrations of eyes. J Refract Surg 2002;18:S652-60.
23. Vincigerra P, Camesasca FI, Calossi A. Statistical
Anlysis of phisiological aberrations of the
cornea. J Refract Surg 2003;19(suppl):265-69.
24. Wang L, Koch DD. Corneal Topography and
its integration into refractive surgery. Comp
Ophthalmol Update 2005;6:73-81.
25. Wilson SE, Ambrosio R. Computerized corneal
topography and its importance to wavefront
technology. Cornea 2001;20:441-54.
26. Wilson SE, Klyce SD. Advances in the analysis
of corneal topography. Surv Ophthalmol 1991;35:
269-77.
27. Wilson SE, Lin DT, Klyce SD, Insler MS. Terriens
marginal degeneration: corneal topography.
Refract Corneal Surg 1990;6:15-20.
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MANOTOSH RAY
Confocal
Microscopy
Confocal microscopy, one of the most advanced

imaging technologies, offers several advantages
over conventional wide-field optical microscopy.
It has the ability to control the depth of field,
eliminate or reduce the background information
away from the focal plane and the capability
to collect serial optical sections from thick
specimens. The basic key to the confocal approach
is the use of spatial filtering techniques to
eliminate out-of-focus light or glare. There has
been a tremendous interest in confocal microscopy in recent years, due in part to the relative
ease with which extremely high quality images
can be obtained. Confocal microscopy has
enhanced the ability to image the cornea in vivo.
The application of this technology permits the
acquisition of images of high spatial resolution
and contrast as compare to conventional
microscopy.
Confocal microscope employs an oscillating
slit aperture in an ophthalmic microscope
configuration, especially suitable for the analysis
of cell layers of cornea. It can focus through the
entire range of a normal cornea from epithelium
to endothelium. A series of scan shows: (a)
epithelium, (b) corneal nerves, (c) keratocytes,
(d) endothelium and (e) a computer generated
slice of cornea. There are distinct advantages
of confocal microscope over the regular

microscope. When focused on a transparent
tissue like cornea with regular microscope, the
unfocused layers affect the visibility of the
focused layer. Confocal microscope, on the other
hand, can focus on different layers distinctly
without affecting the quality of the image.
Optics
A halogen light source passes through movable
slits (Nipkow disk). A condenser lens (front lens)
projects the light to the cornea. Only a small
area inside the cornea is illuminated to minimize
the light scattering. The reflected light passes
through the front lens again and is directed to
another slit of same size via beam-splitter. Finally
the image is projected onto a highly sensitive
camera and displayed on a computer monitor
(Fig. 5.1).
The confocal microscope utilizes a transparent viscous sterile gel that is interposed
between front lens and cornea to eliminate the
optical interface with two different refractive
indices. The front lens works on Distance
Immersion Principle. The working distance
(distance between front lens and the cornea) is
Confocal Microscopy
performed, a graphic shows the depth coordinate
on the Z axis and the level of reflectivity on
the Y axis. The graphic also displays the
distance between two images along the
anteroposterior line. This simultaneous graphic
recording is called Z scan graphic. The
reflectivity on Z scan is entirely dependent on
the tissue being scanned. A transparent tissue
displays low reflectivity whereas a higher
reflectivity is obtained from an opaque layer.
Therefore, different corneal layers would display
different reflectivity on Z scan. The corneal
endothelium displays the maximum reflectivity
while stroma is the lowest. An intermediate
reflectivity is obtained from epithelial layers. A
typical Z scan of entire normal cornea shows
high endothelial reflection curves followed by
low stromal reflection and then late intermediate
reflectivity from superficial corneal epithelium.
Thus confocal miscroscopy enables to perform
corneal pachymetry or even can measure the
distance between two corneal layers.
Fig. 5.1: Optics of confocal microscope
1.92 mm. The back and forth movement of the

front lens enables scanning of the entire cornea
starting from anterior chamber and corneal
endothelium to most superficial corneal
epithelium. Use of standard X40 immersion lens
gives magnified cellular detail and an image field
of 440 330 m. Other lenses (e.g. X20) delivers
wide field but less distinct cell morphology.
Newer model (Confoscan 2.0) captures 350
images per examination at a rate of 25 frames
per second. Thickness of the captured layers
varies from 3 to 5 microns depending on
scanning slit characteristics.
In addition, every recorded image is
characterized by its position on the Z axis of
the cornea. Every time a confocal scan is
Confocal Microscopy of Normal

Cornea
This is a noninvasive technique of imaging of
corneal layers that provides excellent resolution
with sufficient contrast. A well-executed scan
can visualize the corneal endothelium, stroma,
subepithelial nerve plexus and epithelial layers
distinctly. The limitations are non-visualization
of normal Bowmans layer and Descemets
membrane since these structures are transparent
to this microscope. However, it is possible to
view these structures when they are pathologically involved. Eyes with corneal opacity or
edema can also be successfully scanned. The
quality of image depends on: (a) centration of
the light beam, (b) stability of the eye, and (c)
optimum brightness of the illumination.
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Epithelium
Corneal epithelium has five to six layers. Three
different types of cellular component are
recognized in the epithelium.
Superficial (2-3 layers): flat cells
Intermediate (2-3 layers): polygonal cells
Basal cells (single layer): cylindrical cells.
The superficial epithelial cells appear as flat
polygonal cells with well-defined border, prominent nuclei and uniform density of cytoplasm.
The main identifying features of superficial
epithelial cells are nuclei, which are brighter than
surrounding cytoplasm and usually associated
with perinuclear hypodense ring (Fig. 5.2). The
intermediate epithelial cells are similar polygonal
cells as superficial layers but the nuclei are not
evident. Basal cell layers are smaller in size and
appear denser than other two layers (Fig. 5.3).
The nucleus is not evident in basal layers also.
Fig. 5.3: Basal epithelial cells. High cell density with

well demarcated cell borders
Now deep vertical fibers derive from deep corneal

plexus to run anteriorly to form subbasal and
subepithelial nerve plexus. Small nerve fibers
from subbasal plexus terminate at the superficial
epithelium.
This complex anatomy was not possible to
visualize in vivo until the advent of corneal
confocal microscope. Generally, the nerve fibers
appear bright and well contrasted against a dark
background (Fig. 5.4). Confocal microscopy can
visualize the orientation, tortuosity, width,
branching pattern and any abnormality of the
corneal nerves.
Fig. 5.2: Superficial epithelial cells with prominent nuclei
Subepithelial Nerve Plexus

Corneal nerves originate from long ciliary nerve,
a branch of ophthalmic division of trigeminal
nerve. Nerve fibers from long ciliary nerve form
a circular plexus at the limbus. Radial nerve
fibers originate from this circular plexus and run
deep into the stroma to form deep corneal plexus.
Fig. 5.4: Subepithelial nerve fibers
Confocal Microscopy
Stroma
Corneal stroma represents 90% of total corneal
thickness. It has three components:
a. Cellular stroma: Composed of keratocytes
and constitutes 5% of entire stroma.
b. Acellular stroma: Represents the major
component (90-95%) of stroma. The main
component has regular collagen tissue
(Type-I, III, IV) and interstitial substances.
c. Neurosensory stroma: Represented by
stromal nerve plexus and nerve fibers
originating from it.
The keratocyte concentration is much higher
in the anterior stroma and progressively
decreases towards the deep stroma. Generally,
the keratocyte count is approximately 1000 cells/
mm in anterior stroma while the average value
drops to 700 cells/mm in the posterior stroma.
Confocal image of stroma shows multiple
irregularly oval, round or bean-shaped bright
structures that represent keratocyte nuclei. These
nuclei are well contrasted against dark acellular
matrix (Fig. 5.5). Anterior stromal keratocyte
nuclei assume rounded bean-shaped morphology while the same in rear stroma are more often
irregularly oval. A bright highly reflective
keratocyte represents a metabolically activated
keratocyte of a healthy cornea. In a normal

healthy cornea collagen fibers and interstitial
substances appear transparent to confocal
microscope and impossible to visualize. It is
possible to identify stromal nerve fibers in anterior
and mid stroma. These nerve fibers belong to
deep corneal plexus and appear as linear bright
thick lines. The stromal nerve fiber thickness is
greater than epithelial nerves. Occasionally,
nerve bifurcations are also clearly visible.
Endothelium
Endothelium is a non-innervated single layer
of cells at the most posterior part of cornea.
Endothelial cell density is maximal at birth and
progressively declines with age. Normal
endothelial cell count varies from 1600 to 3000
cells/mm (average 2700 cells/mm) in a normal
healthy adult.2-4 However, cornea can still
maintain the integrity till the cell count declines
below 300-500 cells/mm.
Fig. 5.6: Hexagonal endothelial cells in a healthy cornea
Fig. 5.5: Stromal keratocytes with bright oval-shaped nuclei
Homogeneous hexagonal cells with uniform

size and shape represent healthy endothelial cells.
Increasing age and endothelial assault cause
pleomorphism and polymegathism. Confocal
microscopy easily identifies endothelial cells.
These cells appear as bright hexagonal and
polygonal cells with unrecognizable nucleus. The
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cell borders are represented by a thin, nonreflective dark line (Fig. 5.6). A X20 objective lens
provides wide field with less magnification. It
is possible to perform cell count and study the
minute details of cellular morphology.
Confocal Microscopy in Corneal

Pathologies
Keratoconus
Keratoconus is a non-inflammatory ectatic
disorder of the cornea characterized by a
localized conical protrusion associated with an
area of stromal thinning. The thinning is most
apparent at the apex of the cornea. The steep
conical protrusion of the corneal apex causes
high myopia with severe irregular astigmatism.
Other features of keratoconus include an iron
ring, known as Fleischers ring that partially or
completely encircles the cone.5 The cone appears
as oil drop reflex on distant direct ophthalmoscopy due to internal reflection of light. Deep
vertical folds oriented parallel to the steeper axis
of the cornea at the level of deep stroma and
Descemets membrane are known as Vogts striae.
An acute corneal hydrops appears when there
is a break in the Descemets membrane. The
corneal edema usually subsides after few months
leaving behind scar and flattening the cornea.
The corneal nerves become more readily visible
due to thinning of the cornea. High irregular
astigmatism precludes adequate spectacle
correction. In the early stages, use of contact lenses
may improve the visual acuity. However, contact
lens fitting can be extremely difficult and in
advanced cases it ceases to improve visual acuity
optimally forcing the patient to rely on only
options left, corneal transplantation.
The most effective way to identify early cases
of keratoconus is computerized corneal
topography that has become a gold standard
for diagnosis and follow-up of the disease in

recent years.6,7 Confocal microscopy is a relatively
newer investigative modality to assess the
keratoconic cornea. Morphological changes in
keratoconus are mostly confined to the corneal
apex and depend on the severity of the disease.
Rest of the cornea may appear normal. The typical
polygonal shape of superficial epithelial cells
is lost. They appear distorted and elongated in
an oblique direction with highly reflective nuclei
(Fig. 5.7). Cell borders are not distinguishable.
There may be areas of basal epithelial loss as
evident by a linear dark non-reflective patch in
confocal microscopy. The subepithelial nerve
plexus generally appears normal. However, the
subbasal nerve fibers are curved and take the
course of stretched overlying epithelium. Corneal
stroma is also affected by keratoconus. The
confocal images of stroma are highly specific.
The characteristic stromal changes are multiple
striae represented by thin hyporeflective lines
oriented vertically, horizontally or obliquely (Fig.
5.8). These are confocal representation of Vogts
striae.8 In advanced stages of keratoconus, the
keratocyte concentration is reduced in anterior
stroma. The shape of the keratocytes is also
altered. Occasionally, highly reflective bodies
Fig. 5.7: Obliquely elongated superficial epithelium in

keratoconus
Confocal Microscopy
but with progression of the disease they can
involve the posterior stroma as well.
Confocal microscopy reveals highly reflective,
bright, dense structures in the anterior and midstroma. Keratocytes are not involved. Depth of
stromal involvement may be ascertained by using
Z scan function. This is an added advantage
over other contemporary investigations that
enables surgeon to plan for surgical modalities.
Confocal microscopy is also useful in differential
diagnosis and follow-up of the disease.
Posterior Polymorphous Dystrophy

Fig. 5.8: Advanced keratoconus: vertical striae in the
stroma
with tapering ends are visible in anterior stroma

near the apex. The nature of these abnormal
bodies is not yet known but it may be due to
altered keratocytes. The corneal endothelial
changes vary from none to occasional pleomorphism and polymegathism.
Corneal Dystrophies
Corneal dystrophies are inherited abnormalities
that affect one or more layers of cornea. Usually
both eyes are affected but not necessarily
symmetrically. They may present at birth but
more frequently develop during adolescence and
progress gradually throughout life. Some forms
are mild, others severe.
Granular Dystrophy
This is an autosomal dominant bilateral noninflammatory condition that results from
deposition of eosinophilic hyaline deposits in
the corneal stroma.9 It specifically affects the
central cornea and eventually can cause
decreased vision and eye discomfort. Initially,
the lesions are confined to superficial stroma
Posterior polymorphous dystrophy (PPD) is a

rare inherited disorder of the posterior layer of
the cornea. It is a bilateral disorder with early
onset, although early stage diagnosis is rare since
most of the affected individuals remain
asymptomatic. The characteristic endothelial
changes are small vesicles or areas of geographic
lesions. In fact, endothelial cells lining of the
posterior surface of the cornea have epitheliallike features.10,11 These cells can also cover the
trabecular meshwork, leading to glaucoma in
some patients. Most severe cases may develop
corneal edema due to compromised pump
function of the endothelial cells.
Confocal microscopy shows multiple round
vesicles at the level of Descemets membrane and
endothelium.12 PPD usually distorts the normal
flat profile of the endothelial cells and present
large dark cystic impressions on confocal scan.
The endothelial cells surrounding the lesion
appear large and distorted.
Fuchs Endothelial Dystrophy

Fuchs endothelial dystrophy is a chronic bilateral
hereditary (variable autosomal dominant or
sporadic) disorder of corneal endothelium. It
typically presents after the age of 50 and more
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common in females. There is a loss of endothelial
cells that results in deposition of collagen
materials in Descemets membrane (guttata).
Corneal guttata is the hallmark of this disease.
The integrity of corneal endothelium is essential
to maintain the metabolic and osmotic function
of the entire cornea. Corneal edema in Fuchs
dystrophy initially involves the posterior and
mid-stroma. As the disease advances, the edema
progresses to involve the anterior cornea;
resulting in formation of bullous keratopathy.
Confocal microscopy is useful to visualize
the corneal guttata. This technique has a distinct
advantage over conventional specular microscopy that fails to visualize the endothelium when
there is significant corneal edema.13 The corneal
guttata appears dark with bright central reflex
(Fig. 5.9).14 In advanced stage the endothelial
morphology altered completely but it is still
possible to identify the distorted cell borders.14
In the early stages of bullous keratopathy, intraepithelial edema is seen as distorted cellular morphology with increased reflectivity. It can also
identify the bullae in the basal epithelial layer.
Fig. 5.9: Distorted endothelium in Fuchs endothelial

dystrophy
Laser in situ Keratomileusis

Laser in situ keratomileusis (LASIK) is one of
the latest techniques of excimer laser refractive
surgery that is currently being successfully used

by refractive surgeons for the correction of various
types of refractive errors. LASIK has become the
technique of choice to correct myopia and
hyperopia with or without astigmatism.15 LASEK
is a modification of photorefractive keratectomy
(PRK) where excimer laser is used to ablate
superficial corneal stroma after the epithelium
has been removed. LASIK involves the use of
microkeratome to prepare a hinged corneal flap
of uniform thickness. The excimer laser is
subsequently used to ablate the mid-corneal
stromal bed and thereafter the flap is reposited
to its original position without applying any
suture. After LASIK, the healing of corneal tissue
occurs quickly since there is minimal damage
to the corneal epithelium and the Bowmans
membrane.
Traditionally, the cornea is evaluated with
slit-lamp biomicroscopy and computerized
corneal topography both pre- and postoperatively. Confocal microscopy adds newer dimensions to the commonly employed investigations.
Functional outcome of LASIK depends on many
factors including the biomechanics, healing
process and the inflammatory response of the
flap interface that is created between the epithelial
flap and stromal bed. Confocal scan is useful
in evaluation of following parameters.
Corneal flap thickness
Interface study
a) Healing process
b) Inflammatory response
c) Abnormal deposits
Corneal nerve fiber regeneration, and
Residual stromal thickness.
A well-designed flap is the key to successful
outcome of LASIK. Thinner flaps are more at
risk from flap complications. A few studies with
confocal microscopy had suggested that actual
flap thickness after LASIK is consistently lower
than predicted thickness.16 The reasons are not
Confocal Microscopy
yet known. However, corneal edema that may
be caused by microkeratome cut and suction may
play an important role. Postoperative scarring
and tissue retraction could be other possible
factors. Using a Z scan, it is possible to identify
the interface that corresponds to a very low level
of reflectivity. The flap thickness is obtained by
measuring the distance between high reflective
spike from the front surface of the cornea and
the low reflective interface (Fig. 5.10).
white bodies (Fig. 5.11). Microstriae are present

at the Bowmans layer. Excessive interface
microstriae and bright particles may lead to
astigmatism and eventually poor outcome after
LASIK. These microstriae can be imaged with
confocal microscope even when the slit-lamp
examination is unremarkable.
Fig. 5.11: Bright highly reflective particles

at the flap-stroma interface
Fig. 5.10: Measurement of flap thickness in LASIK
The interface usually appears as a hyporeflective space in between relatively hyperreflective

cellular stroma. Interface can easily be imaged
by confocal microscope. Typically, the keratocyte
concentration is lower than normal in the
interface. Bright particles and microstriae are
consistently visible in the interface. These bright
particles most probably originate from microkeratome blade and represented by highly reflective
Diffuse lamellar keratitis (DLK) also known

as sands of Sahara syndrome, is a noninfectious
inflammation of the interface. The etiology is not
known but it is assumed to be toxic or allergic
in nature. In confocal scan DLK appears as diffuse
and multiple infiltrates in the interface with no
anterior or posterior extension.
Subepithelial nerve fibers are affected by
LASIK. No nerve is visible in immediate postoperative period. However, the regenerating
nerve fibers appear as thin irregularly branching
line when confocal scan is performed 5-7 days
after surgery. The residual stromal thickness can
also be measured using Z scan technique as
described while evaluating the epithelial flap.
Corneal Grafts
Confocal microscope is a useful tool to followup the corneal grafts and to diagnose the
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abnormal changes that may occur postoperatively. It provides images at the cellular level
to identify any pathological changes even before
it becomes clinically evident. It can also be used
to assess the donor cornea.
Corneal graft survival is entirely dependent
on optimum number of healthy endothelial cells.
Endothelial cell loss occurs rapidly after corneal
transplantation17. Majority of cell loss takes place
during the first two postoperative years.18 Several
studies had suggested that endothelial cell loss
is much higher after corneal grafting when the
primary indications are bullous keratopathy or
hereditary stromal dystrophy in compare to
keratoconus and corneal leukomas.19,20 Another
interesting fact is that endothelial cell loss is
greater when corneal transplantation is
performed on phakic eyes than on aphakics.21
Confocal microscopy scores over conventional specular microscopy while evaluating
endothelial cell characteristics especially in eyes
with stromal edema. Endothelial morphology in
confocal scan has been described earlier.
Immediate postoperative period, endothelium
looks normal and healthy. However, as time
progresses, endothelial cell density decreases as
evidenced by pleomorphism and polymegathism. Occasionally, a bright preendothelial
deposits appear, the significance of which is not
yet known (Fig. 5.12).
Reinnervation after grafting is another issue
well addressed by confocal microscopy. First sign
of innervation that starts few months after
keratoplasty is visible at the periphery of the
graft stroma. However, complete innervation may
take many years to develop. Regenerated nerve
fibers look similar to that found in a normal
cornea. Occasionally, they may take a tortuous
and convoluted course depending on age (e.g.
older patients) and primary indications of
keratoplasty (e.g. bullous keratopathy, corneal
dystrophies).
Fig. 5.12: Pleomorphism, polymegathism and

preendothelial deposits in a corneal graft
It is well known that allograft rejection is

one of the most common causes of graft failure.
Graft rejection can be classified as epithelial,
subepithelial and endothelial rejection, of which
the endothelial rejection is the worst. Confocal
Fig. 5.13: Co-existence of degenerated and normal

endothelial cells in early endothelial allograft rejection
Confocal Microscopy
features of epithelial rejection are distorted basal
epithelial cells with altered subepithelial
reflectivity. Subepithelial rejection is identified
by discrete opacities underneath the epithelial
layer.22 Endothelial rejection, on the other hand,
is characterized by coexistence of normal looking
and degenerated endothelial cells, focal endothelial cell lesions and bright highly reflective
microprecipitates (Fig. 5.13).23
Intracorneal Deposits
Sources of intracorneal deposits can be exogenous or endogenous. They can involve various
layers of cornea individually or in combination.
inclusion bodies located at the basal epithelial

layer.24 Confocal microscopy adds newer dimensions to the existing knowledge. It demonstrates
involvement of entire cornea, although vortex
keratopathy is primarily a corneal epithelial
pathology. The characteristic features are
presence of highly reflective, bright intracellular
deposits at the basal epithelial layer (Fig. 5.14).
Overlying epithelium is usually normal. In
advanced cases these microdeposits may extend
to the stroma and eventually to the endothelium.25
Stromal keratocyte density is often reduced.
Exogenous sources:
Long-term use of contact lenses
Refractive surgery
Vitreoretinal surgery using silicone oil
Drugs: Amiodarone, Chloroquine
Endogenous sources:
Wilsons disease
Hyperlipidemia
Fabrys disease
Hemosiderosis
The clinical diagnosis is based on slit-lamp
biomicroscopy and systemic features in selected
cases. The knowledge of confocal features in these
disorders is limited except in drug induced
keratopathies.
Fig. 5.14: Intracellular deposits at basal

epithelial layer in amiodarone toxicity
Vortex Keratopathy
Conclusion
Vortex keratopathy known as cornea verticillata

is characterized by whorl-like corneal epithelial
deposits. It can be induced by various drugs,
e.g. amiodarone (used for cardiac arrhythmias)
and anti-malarials (chloroquine, hydroxychloroquine). Clinically, vortex keratopathy is manifested as golden-brown opacities at the inferior
corneal epithelium. On electron microscopy, they
appear as intracytoplasmic lysosom-like lamellar
Ophthalmic investigations and instrumentations

have come long way over the past decades.
Confocal microscope is one of those wonderful
innovations in recent time. It is becoming more
popular everyday and its indications are
expanding. Confocal microscopy is truly an
exciting tool that can be useful for the clinical
diagnosis, follow-up and analysis of many
corneal lesions.
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Acknowledgement
I would like to thank Aria Mangunkusumo and
Vanathi Ganesh for their help.
References
1. Weigand W, Thaer AA, Kroll P, et al. Optical
sectioning of the cornea with a new confocal
in vivo slit-scanning videomicroscope.
Ophthalmology 1995;102(4):485-92.
2. Oliveira-Soto L, Efron N. Morphology of corneal
nerves using confocal microscopy. Cornea
2001;20(4):374-84.
3. Tuft SJ, Coster DJ. The corneal endothelium.
Eye 1990;4:389.
4. Nucci P, Brancato R, Mets MB, et al. Normal
endothelial cell density range in childhood. Arch
5. Gass JD. The iron lines of the superficial cornea:
Hudson-Stahle line, Stockers line, and
Fleischers ring. Arch Ophthalmol 1964;71:348.
6. Maguire LJ, Bourne WM. Corneal topography
in early keratoconus. Am J Ophthalmol 1989;
108:107.
7. Maguire LJ, Lowry J. Identifying progression
of subclinical keratoconus by serial topography
analysis. Am J Ophthalmol 1991;112:41.
8. Somodi S, Hahnel C, Slowik C, et al. Confocal
in vivo microscopy and confocal laser-scanning
fluorescence microscopy in keratoconus. Ger
J Ophthalmol 1996;5(6):518-25.
9. Werner LP, Werner L, Dighiero P. et al. Confocal
microscopy in Bowmans and stromal corneal
dystrophies. Ophthalmology 1999;106(9):16971704.
10. Hirst LW, Waring GO. Clinical specular microscopy of posterior polymorphous endothelial
dystrophy. Am J Ophthalmol 1983;95(2):143-55.
11. Mashima Y, Hida T, Akiya S, et al. Specular
microscopy of posterior polymorphous endothelial dystrophy. Ophthalmic Paediatr Genet 1986;
7(2):101-07.
12. Chiou AG, Kaufman SC, Beuerman RW, et al.
Confocal microscopy of posterior polymorphous endothelial dystrophy. Ophthalmologica
1999;213(4):211-13.
13. Chiou AG, Kaufman SC, Beuerman RW, et al.

Confocal microscopy in cornea guttata and
Fuchs endothelial dystrophy. Br J Ophthalmol
1999;83(2):185-89.
14. Rosenblum P, Stark WJ, Maumenee IH, et al.
Hereditary Fuchs dystrophy. Am J Ophthalmol
1980;90:455.
15. Reviglio VE, Bossana EL, Luna JD, et al. Laser
in situ keratomileusis for the correction of
hyperopia from +0.50 to +11.50 diopters with
Keracor 117C laser. J Refract Surg 2000;16(6):71623.
16. Durairaj VD, Balentine J, Kouyoumdjian G, et
al. The predictability of corneal flap thickness
and tissue laser ablation in laser in situ
keratomileusis. Ophthalmology 2000;107(12):
2140-43.
17. Harper CL, Boulton ML, Marcyniuk B, et al.
Endothelial viability of organ cultured corneas
following penetrating Keratoplasty. Eye
1998;12(5):834-38.
18. Vasara K, Setala K, Ruusuvaara P. Follow up
study of corneal endothelial cells, photographed
in vivo before eneucleation and 20 years later
in graft. Acta Ophthalmol Scand 1999;77(3):27376.
19. Obata H, Ishida K, Murao M, et al. Corneal endothelial cell damage in penetrating keratoplasty.
Jpn J Ophthalmol 1991;35(4):411-16.
20. Abott RL, Fine M, Guillet E. Long-term changes
in corneal endothelium following penetrating
keratoplasty. A specular microscopic study.
Ophthalmology 1983;90(6):676-85.
21. Ing JJ, Ing HH, Nelson LR, et al. Ten-year postoperative results of penetrating keratoplasty.
Ophthalmology 1998;105(10):1855-65.
22. Cohen RA, Chew SJ, Gebhardt BM, et al.
Confocal microscopy of corneal graft rejection.
Cornea 1995;14(5):467-72.
23. Cho BJ, Gross SJ, Pfister DR, et al. In vivo
confocal microscopic analysis of corneal allograft
rejection in rabbits. Cornea 1998;17(4):417-22.
24. Ghose M, McCulloch C. Amiodarone induced
ultrastructural changes in human eye. Can J
Ophthalmol 1984;19:178-86.
25. Ciancaglini M, Carpineto P, Zuppardi E, et al.
In vivo confocal microscopy of patients with
amiodarone induced keratopathy. Cornea
2001;20(4):368-73.
Tonometry
R RAMAKRISHNAN, SONAL AMBATKAR
Tonometry
Tonometry in reference to the eye is the measurement of intraocular pressure (IOP). A tonometer
is an instrument that exploits the physical
properties of the eye to permit measurement of
pressure without the need to cannulate the eye.
The first practical tonometer was invented by
Maklakov in 1885. Fick is credited with inventing
a second applanation tonometer employing a
fixed area produced by an adjustable force. This
instrument was a forerunner of the Goldmann
applanation tonometer (1954) which is today
considered the most accurate clinical tonometer.
From a functional standpoint, a normal IOP
is one that does not result in optic nerve damage.
All eyes do not respond similarly to a particular
IOP, therefore, a normal pressure cannot be
represented as a specific measurement. Various
studies of IOP distribution have shown a mean
IOP of 15.5 2.6 mm Hg and the upper limit
has been demonstrated to be 2 standard deviations above the mean IOP that is 20.5 mm Hg.
Types of Tonometers
The physical properties of a normal cornea
determine the limits of accuracy of tonometry.
When the cornea is deformed by a tonometer,
the resulting fluid displacement causes the

remainder of the globe to distend. The tendency
of the wall of the eye is to resist stretching, and
deformation of the cornea raises the IOP.
Tonometers in which the IOP is negligibly raised
during tonometry (less than 5%) are termed as
low-displacement tonometers. The Goldmann
tonometer displaces only 0.5 l of aqueous humor
and raises IOP by only 3%. Tonometers that
displace a large volume of fluid and consequently
raise IOP significantly are termed as highdisplacement tonometers. In a normal eye IOP
becomes more during Schitz tonometry. Highdisplacement tonometers are mostly less
accurate than low-displacement tonometers.
Types of Tonometry
Tonometry can be broadly classified into 2 types,
direct and indirect.
Direct Method
A catheter is inserted into the anterior chamber
of the eye and the other end is connected to a
manometric device from which the pressure is
calculated. Though this is the most accurate
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method available, it is not feasible in human
being because of its invasive nature.
Indirect Method
It is based on eyes response to an applied force.
The shape of corneal deformation is truncated

cone. It displaces large intraocular volume so
conversion tables based on empirical data is used
to estimate IOP. The prototype is Schitz
tonometer.
Applanation Tonometers
Palpation Method
Intraocular pressure (IOP) is estimated by
response of eye to pressure applied by finger
pulp (indents easily/firm to touch).
The indirect methods can be broadly divided
into contact and non-contact methods. Basic
types of contact tonometers differ according to
shape and magnitude of deformation.
Contact Tonometers
IOP measurement is performed by deforming the
globe and correlating the force responsible for
deformation to the pressure within the eye. Both
indentation and applanation tonometers effect
a deformation of globe but the magnitude varies
(Fig. 6.1).
Applanation tonometers are used to measure

force necessary to flatten a small, standard area
of cornea. The shape of corneal deformation is
simple flattening. The shape is constant so IOP
is derived from a mathematical calculation. They
are of 2 types on the basis of variable that is
measured.
Variable force: Area of cornea on applanation held
constant, force varies. Prototype is Goldmann
tonometer.
Variable area: Force applied to cornea held
constant, area varies. Prototype is Maklakov
tonometer. The volume displacement is sufficiently large to require a conversion table.
Noncontact Tonometer
Noncontact tonometer measures time required
to deform a standard area of corneal surface in
response to a jet of air.
Schitz Tonometer
Fig. 6.1: A Deformation of globe during indentation

tonometry, B Deformation of globe during applanation
tonometry
Indentation Tonometer
Indentation tonometer is used to measure the
amount of deformation or indentation of the globe
in response to a standard weight applied to the
cornea or the area flattened by a standard force.
Schitz tonometer (Fig. 6.2) consists of metal

plunger that slides through a hole in a concave
metal plate. The plunger supports a hammer
device connected to needle that crosses a scale.
The extent to which cornea is indented by plunger
is measured as the distance from the foot plate
curve to the plunger base and a lever system
moves a needle on calibrated scale. The indicated
scale reading and the plunger weight are
converted to an IOP measurement. More the
plunger indents the cornea, higher the scale
reading and lower the IOP
Tonometry
generated an empirical formula for linear
relationship between the log function of IOP
and the ocular distension. This formula has C
a numerical constant, the coefficient of ocular
rigidity which is an expression of distensibility
of eye. Its average value is 0.025.
Technique: Patient should be in supine position,
looking up at a fixation target while examiner
separates the lids and lowers the tonometer plate
to rest on the anesthetized cornea so that plunger
is free to move vertically (Fig. 6.3). A fine
movement of needle on scale is in response to
ocular pulsations. Scale reading is an average
of the extremes of these excursions. The 5.5 gm
weight is initially used. If scale reading is 4 or
less, additional weight is added to plunger.
Conversion table is used to derive IOP in mm
Hg from scale reading and plunger weight. The
instrument is calibrated before each use to check
scale (reading is zero).
Fig. 6.2: Schitz tonometer
The standard instrument has following

characteristics:
Foot plate has concavity of 15 mm radius
of curvature. The tonometer weighs 11 gm.
Plunger has 3 mm diameter, a weight of 5.5
gm including the force of the lever rests on top of
the plunger. Additional weights are added to
plunger to increase it to 7.5, 10, or 15 gm. The scale
reading is zero when plunger extends 0.05 mm
beyond foot plate curve. Each scale unit
represents 0.05 mm protrusion of the plunger.
Fig. 6.3: Technique of tonometry
Basic concept: The weight of tonometer on the

eye increases the actual IOP (Po) to a higher
level (Pt). The change in pressure from Po to
Pt is an expression of the resistance of the eye
(scleral rigidity) to the displacement of fluid.
Determination of Po from a scale reading Pt
requires conversion which is done according
to Friedenwald conversion tables. Friedenwald
Sources of error: Accuracy is limited as ocular

rigidity varies from eye to eye. As conversion
tables are based on an average coefficient of
ocular rigidity; eye that varies significantly from
this value gives erroneous IOP. High ocular
rigidity is seen in high hyperopia, long-standing
glaucoma, age-related macular degeneration,
and vasoconstrictor therapy. Low ocular rigidity
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is found in high myopia, advanced age, miotics,
use of vasodilators, after RD surgery (vitrectomy,
cryopexy, scleral band) and intravitreal injection
of compressible gas. The variable expulsion of
intraocular blood during Schitz tonometry may
influence IOP measurement. Repeated measurements lower IOP. Either a steeper or a thicker
cornea causes greater displacement of fluid
during tonometry and gives a falsely high IOP
measurement.
Variable Force Applanation Tonometers
Fig. 6.4: Goldmann applanation tonometry
Goldmann Applanation Tonometer (GAT)

Basic concept: Based on Imbert-Fick law, an
external force (W) against a sphere equals the
pressure in the sphere (P) times the area flattened
(applanated) by external force (A)
W = P A
Cornea being aspherical, wet, and slightly
inflexible fails to follow the law. Moisture creates
surface tension (S) or capillary attraction of tear
film for tonometry head. Lack of flexibility requires
force to bend the cornea (B) which is independent
of internal pressure. The central thickness of
cornea is about 0.55 mm and the outer area of
corneal flattening differs from the inner area of
flattening (A1). It is this inner area which is of
importance.
Fig. 6.5: Biprism in the Goldmann tonometer
When A1 = 7.35 mm2, S balances B and W

=P. This internal area of applanation is achieved
when the diameter of the external area of corneal
applanation is around 3.06 mm. Grams of force
applied to flatten 3.06 diameter of the cornea
multiplied by 10 is directly converted to mmHg.
biprism (Fig. 6.5) which is used to applanate

cornea. Two beam splitting prisms within
applanating unit optically convert circular area
of corneal contact in 2 semicircles. Edge of corneal
contact is made apparent by instilling fluorescein
while viewing in cobalt blue light. By manually
rotating a dial calibrated in grams, the force is
adjusted by changing the length of a spring
within the device. The prisms are calibrated in
such a fashion that inner margin of semicircles
touch when 3.06 mm of the cornea is applanated.
Biprism is attached by a rod to a housing which
contains a coil spring and series of levers that
are used to adjust the force of the biprism against
the cornea.
Instrument: Instrument is mounted on the end

of a lever hinged on the slit-lamp (Fig. 6.4).
Examiner views through the center of plastic
Technique: Cornea is anesthetized, tear film is

stained with sodium fluorescein. Cornea and
biprism is illuminated by a cobalt blue light.
Modified Imbert-Fick Law is W + S = PA1 + B
Tonometry
Fluorescein facilitates visualization of tear
meniscus at margin of contact. Fluorescent
semicircles are viewed through the biprism. Force
against the cornea is adjusted until the inner
edges overlap. Ocular pulsations create
excursions of semicircular tear meniscus and
IOP is read as the median over which arc glides.
This is the end point (Fig. 6.6) at which a reading
can be taken from a graduated dial which
indicates grams of force applied to tonometer
and so this number is multiplied by 10 to obtain
IOP in mm Hg.
Figs 6.7A and B: Vertical misalignment. To minimize this,

tonometer biprism should be rotated so that axis of least
corneal curvature is opposite the red line on the prism
holder. Other method is to obtain measurements with mires
oriented horizontally and vertically and to average these
readings
6. More than 6 D astigmatism produces an

elliptical area on applanation that gives
erroneous IOP. 4D with-the-rule and
against-the-rule astigmatism underestimate
and overestimate IOP, respectively.
7. Mires may be distorted on applanating on
irregular corneas.
Fig. 6.6: End point recording of IOP
Sources of error in applanation tonometry

1. Inadequate concentration of fluorescein in
precorneal tear film gives hypofluorescence.
2. Fluorescein may lose fluorescence in acidic
solution (quenching of fluorescence)
causing underestimation of IOP.
3. Wider meniscus or improper vertical
alignment gives higher IOP readings (Figs
6.7A and B).
4. Thin corneas underestimate and thick
corneas overestimate IOP.
5. For every 3D increase in corneal curvature,
IOP raises about 1 mm Hg as more fluid
is displaced under steeper corneas causing
increase in ocular rigidity.
Effect of central corneal thickness (CCT): Variations

in corneal thickness change the resistance of the
cornea to indentation so that this is no longer
balanced entirely by the tear film surface tension
thus affecting the accuracy of IOP measurement.
A thinner cornea may require less force to
applanate it, leading to underestimation of true
IOP while a thicker cornea would need more
force to applanate it, giving an artificially higher
IOP. The Goldmann applanation tonometer was
designed to give accurate readings when the CCT
was 520 m. As shown by Ehlers et al, there
can be under estimation or overestimation of IOP
when the corneal thickness is less or more than
520 micron, respectively. They interpolated
that deviation of CCT from 520 m yields a
change in applanation readings of 0.7 mm Hg
per 10 m. IOP measurements are also modified
after PRK and LASIK. Thinning of the central
cornea is believed to give lower readings on
applanation.
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Other Variable Force Applanation

Tonometers
Hand-Held Goldmann-Type
Tonometers
Perkins Tonometer
Perkins tonometer (Fig. 6.8) uses same prisms
as Goldmann but is counterbalanced so that
tonometry is performed in any position (Fig. 6.9).
The prism is illuminated by battery powered
bulbs. The force on the prisms is adjusted
manually. Being portable it is practical when
measuring IOP in infants / children and for use
in operating rooms.
Fig. 6.9: Tonometry with Perkins tonometer
Mackay-Marg Tonometer
Fig. 6.8: Perkins tonometer
Draeger Tonometer
Draeger tonometer is similar to Perkins but uses
different set of prisms and operates with a motor
adjusting the force on these prisms.
Basic concept: Force is required to keep the flat

plate of a plunger flush with a surrounding sleeve
against the pressure of corneal deformation.
Tonometer incorporates a 1.5 mm diameter
plunger affixed to a rigid spring that extends
10 m beyond the plane of surrounding rubber
sleeve. Movement of plunger is electronically
monitored by a transducer and recorded on a
moving paper strip. When the tonometer is placed
against cornea, the tracing that represents the
force applied to the plunger begins to rise. At
1.5 mm of corneal area applanation, tracing
reaches a peak and the force applied = IOP +
force required to deform the cornea. At 3 mm
flattening, force required to deform cornea is
transferred from plunger to surrounding sleeve,
creating a dip in tracing corresponding to IOP.
Flattening of >3 mm of area gives artificial
elevation of IOP. It is accurate in eyes with
scarred, edematous and irregular corneas.
Tonometry
Other Mackay-Marg-type Tonometers:
CAT 100 Applanation and Biotronic
Tonometers
They have an internal logic program which
automatically selects the acceptable measurement
and 3 or more good IOP readings are averaged
and displayed on screen.
Tonopen
Tonopen (Fig. 6.10) is a portable and battery
operated tonometer. It has the same principle
as that of Mackay-Marg tonometer. The tip has
a strain gauge that is activated when in contact
with cornea. The built-in microprocessor logic
circuit senses a trough force and records until
an acceptable measurement is achieved. Four to
ten such measurements are averaged to give a
final IOP which is displayed.
The probe tip is applied perpendicularly to

cornea until it is just indented. An audible click
indicates that the measurement is acceptable.
The process is repeated 4-10 times until a beep
indicates a statistically valid average reading.
Pneumatonometer
Pneumatonometer or pneumatic tonometer is
like Mackay-Marg tonometer. It has a core
sensing mechanism for measuring IOP while
force required to bend the cornea is transferred
to surrounding structure. The sensor is a air
pressure like electronically controlled plunger
in Mackay-Marg tonometer. It can also be used
for continuous monitoring of IOP. It gives
significantly higher IOP estimates.
Constant Force Applanation Tonometry

Maklakov Applanation Tonometer
With Maklakov applanation tonometer IOP is
estimated by measuring the area of cornea
flattened by a known weight. It consists of a
dumb-bell-shaped metal cylinder with flat end
plates of polished glass on either end with a
diameter of 10 mm. Tonometers weighing 5, 7.5,
10, and 15 gm are used to measure the IOP. Crossaction wire handle to support instrument on the
cornea is used. A thin layer of dye is spread
onto the bottom of either end plate and the
instrument is brought in contact with anesthetized
cornea in supine position for 1 second. A circular
white imprint on end plate corresponds to the
area of corneal flattening. Area is measured and
IOP is read from conversion table in the column
corresponding to the weight used.
Fig. 6.10: Tonometry with tonopen
Noncontact tonometer (NCT) was introduced

by Grolman. A puff of room air creates a
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constant force that momentarily flattens the
cornea. The time from an internal reference point
to the moment of flattening is measured and
converted to IOP. The corneal apex is deformed
by a jet of air. The force of air jet which is
generated by a solenoid activated piston
increases linearly over time.
normal, accuracy decreases with increase in IOP

and in eyes with abnormal cornea or poor
fixation. New NCT, Pulsair is a portable hand
held tonometer.
Devices under Investigation

Flush fitting silastic gel contact lens instrumented
with strain gauges that measures changes in
meridional angle of corneoscleral junction caused
by variations in IOP. A similar device using
a pressure transducer is made in form of a
cylindrical guard ring applanation tonometer.
A scleral gauge is embedded in an encircling
scleral band to measure the distension of globe.
An instrument using suction cups for
recording IOP up to 1 hour in supine position
is under investigation.
Fig. 6.11: Tonometry with noncontact tonometer
Original NCT has 3 subsystems:

1. Alignment system: It aligns patients eye in
3 dimensions.
2. Optoelectronic applanation monitoring system:
It comprises transmitter, receiver and
detector, and timer.
a. Transmitter directs a collimated beam
of light at corneal apex.
b. Receiver and detector accept only
parallel coaxial rays of light reflected
from cornea.
c. Timer measures from an internal
reference to the point of peak light
intensity.
3. Pneumatic system: It generates a puff of room
air directed against cornea.
When the reflected light is at peak intensity,
the cornea is presumed to be flattened. The time
elapsed is directly related to the force of jet
necessary to flatten the cornea and correspondingly to IOP. NCT is accurate if IOP is nearly
Comparison, Calibration and

Sterilization of Different Tonometers
Comparison
Goldmann Applanation Tonometer (GAT)
In eyes with regular corneas, GAT is generally
accepted as the standard against which other
tonometers must be compared. Even with GAT,
inherent variability must be taken in account.
Schitz Tonometer
Studies indicate that Schitz reads lower
than GAT even when the postural influence
on IOP is eliminated by performing measurements in supine position. The magnitude of
difference between the two tonometers and the
influence of ocular rigidity are such that Schitz
indicates only that the IOP is within a certain
range and is of limited value even for screening
purposes.
Tonometry
Perkins Applanation Tonometer
Perkins applanation tonometer compares
favorably against GAT. In one study, difference
between readings with the two instruments was
1.4 mmHg. It is subject to the same influence
of corneal thickness as the GAT. It is useful in
infants and children and is accurate in horizontal
as well as vertical position.
Draeger Applanation Tonometer

Comparative studies of Draeger applanation
tonometer with GAT have given inconsistent
results because of its more complex design.
Draeger tonometer is more difficult to use than
the Perkins. Patients acceptance to Draeger
tonometer is poor.
Mackay-Marg Tonometer (MMT)

Highly significant correlation is found between
MMT and GAT readings. The average mean
MMT values are often higher than GAT.
Mackay-Marg Type Tonometers

Tonopen has compared favorably against
manometric readings in human autopsy eyes
but it may cause a significant increase in IOP
during measurements. It has good correlation
with GAT readings within normal IOP ranges.
But most studies indicate that tonopen under
estimates IOP in the higher ranges and over
estimates in the lower range.
Pneumatic Tonometer
Pneumatic tonometer correlates well with GAT
readings. However, it gives significantly higher
IOP estimates.
Noncontact tonometer is reliable within the
normal IOP range, although its reliability is
reduced in higher IOP ranges and is limited

by abnormal corneas or poor fixation. Corneal
thickness has greater influence on NCT than on
GAT. The hand-held pulsair NCT has compared
favorably with Goldmann applanation readings
in normal and glaucomatous eyes. It tends to
read lower IOP above the normal range.
Tonometry on Irregular Corneas

Accuracy of GAT and Maklakov-type applanation tonometers and NCT is limited in eyes with
irregular corneas. MMT is considered to be
accurate in scarred or edematous corneas. As
MMT applanates a small surface area, the effects
of corneal resistance to deformation and surface
tension of tears are less than that with GAT.
Pneumotonometer has also been shown to be
useful in eyes with diseased cornea. Tonopen
compared favorably with MMT on irregular
corneas in a study.
Tonometry over Soft Contact Lens

MMT, pneumtonometer and tonopen can
measure the IOP through bandage contact lens
with reasonable accuracy although soft contact
lenses of different powers create a bias with
tonopen. Applanation tonometers are affected
by the power of the contact lens with high water
content and correction tables are developed to
compensate it. The power of soft contact lenses
influences the difference in IOP between the
paired readings by NCT.
Tonometry over Gas Filled Eyes

Intraocular gas significantly influences scleral
rigidity rendering indentation tonometry
unsatisfactory.
Pneumatonometer underestimates GAT
readings in gas filled eyes while Tonopen
compared favorably with GAT readings.
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Calibration of Goldmann Applanation
Tonometer
It is essential that Goldmann applanation
tonometer (GAT) should be calibrated periodically, at least monthly. Following checks are
necessary:
Check position 0: Turn the zero calibration
on the measuring drum downwards by the
width of one calibration marking, against
the index marker. When the feeler arm is
in the free movement zone, it should then
move itself against the stop piece in the
direction of the examiner.
Check position 0.05: Turn the zero calibration
on the measuring drum upwards by the
width of one calibration marking, against
the index marker. When the feeler arm is
in the free movement zone, it should then
move itself against the stop piece in the
direction of the patient.
Check position at drum setting 2: For checking
this position, check weight is used. Five
circles are engraved on the weight bar. The
middle one corresponds to drum position
0, the two immediately to the left and right
to position 2 and the outer ones to position
6. One of the marks on the weight
corresponding to drum position 2 is set
precisely on the index mark of the weight
holder. Holder and weight are then fitted
over the axis of the tonometer so that the
longer part of the weight points towards
the examiner.
Check position 1.95: The feeler arm should
move towards the examiner. Check position
2.05.The feeler arm should move in the
direction of the patient.
Check at measuring drum setting 6: Turn the
weight bar to scale calibration 6, the longer
part shows in the direction of the examiner.
Check position 5.9/6.1 as performed for
drum setting 2.
Sterilization
Schitz Tonometer
The tonometer is disassembled between each
use and the barrel is cleaned with 2 pipe
cleaners, the first soaked in alcohol and the
second dry. The foot plate is cleaned with
alcohol swab. All surfaces must be dried before
reassembling.
Goldmann Applanation Tonometer

A variety of techniques are described for
disinfecting the tonometer. Applanation tip
should be soaked for 5-15 min in diluted sodium
hypochlorite, 3% H2O2 or 70% isopropyl alcohol
or by wiping with alcohol, H2O2, povidone
iodine or 1: 1000 merthiolate. Other methods
of sterilization include: 10 min of rinsing in
running tap water, wash with soap and water,
cover the tip with a disposable film, and
exposure to UV light.
Tonopen
Tip is protected by a disposable latex cover.
Pneumatonometer
Tip should be cleaned with an alcohol sponge,
taking care to dry the surface before use.
Alternative is the use of disposable latex cover
over the tip.
Bibliography
1. Armaly MF. On the distribution of applanation
pressure. I. Statistical features and the effect
of age, sex, and family history of glaucoma.
Arch Ophthalmol 1965;73:11.
2. Bengtsson B. Comparison of Schitz and
Goldmann tonometry and tonography in a
population. Acta Ophthalmol (Copenh) 1972;50:
455.
Tonometry
3. Craven ER, et al. Applanation tonometer tip
sterilization for adenovirus type 8. Ophthalmology
1987;94:1538.
4. Drance SM. The coefficient of scleral rigidity in
normal and glaucomatous eyes. Arch Ophthalmol
1960;63:668.
5. Dunn JS, Brubaker RF: Perkins applanation
tonometer, clinical and laboratory evaluation.
6. Durhan DG, Bigliano RP, Masino JA: Pneumatic
applanation tonometer. Trans Am Acad
Ophthalmol Otolaryngol 1965;69:1029.
7. Finlay RD. Experience with the Draeger
applanation tonometer. Trans Ophthalmol Soc UK
1970;90:887.
8. Forbes M, Pico GJ, Goldmann B: A noncontact
applanation tonometer description and clinical
evaluation. Arch Ophthalmol 1974;91:134.
9. Friedenwald JS. Standardization of tonometers
decennial report. Trans Am Acad Ophthalmol
Otolaryngol 1954;58.
10. Friedenwald JS. Contribution to the theory and
practice of tonometry. Am J Ophthalmol 1937;
20:985.
11. Friedman E, et al. Increased scleral rigidity and
age-related macular degeneration. Ophthalmology 1989;96:104.
12. Glouster J, Perkins ES. The validity of the ImbertFick law as applied to applanation tonometry.
Exp Eye Res 1963;2:274.
13. Grolman B. Non-contact applanation tonometry.
Optician 1973;166:4.
14. Hollows FC, Graham PA: Intraocular pressure,
glaucoma, and glaucoma suspects in a defined
population. Br J Ophthalmol 1966;50:570.
15. Imbert A. Theories ophthalmotonometers: Arch
16. Kaufman HE, Wind CA, Waltman SR. Validity
of Mackay-Marg electronic applanation
tonometer in patients with scarred irregular
corneas. Am J Ophthalmol 1970;69:1003.
17. Khan JA, et al. Comparison of Oculab Tono-Pen
readings obtained from various corneal and
scleral locations. Arch Ophthalmol 1991; 109: 1444.
18. Krieglstein GK, Waller WK. Goldmann
applanation versus hand-applanation and
Schitz indentation tonometry. Graefes Arch Clin
Exp Ophthalmol 1975;194:11.
19. Kronfeld PC. Tonometer calibration empirical
validation: the committee on standardization of
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
34.
36.
37.
tonometers. Trans Am Acad Ophthalmol

Otolaryngol 1957;61:123.
Langham ME, McCarthy E. A rapid pneumatic
applanation tonometer: comparative findings
and evaluation. Arch Ophthalmol 1968;79:389.
Macro FJ, Brubakar RF. Methodology of eye
pressure measurement. Biorheology 1969;6:37.
Markiewitz HH. The so-called Imbert Fick law
(Correspondence). Arch Ophthalmol 1960;64:159.
McMillan F, Forster RK. Comparison of MackayMarg, Goldmann, and Perkins tonometers in
abnormal corneas. Arch Ophthalmol 1975;93:420.
Moses RA. Fluorescein in applanation
tonometry. Am J Ophthalmol 1960;49:1149.
Moses RA. The Goldmann applanation
tonometer. Am J Ophthalmol 1958;46:865.
Pepose JS, et al. Disinfection of Goldmann
tonometers against human immunodeficiency
virus type I. Arch Ophthalmol 1989;107:983.
Perkins ES. Hand-held applanation tonometer.
Br J Ophthalmol 1965;49:591.
Petersen WC, Schlegel WA. Mackay-Marg
tonometry by technicians. Am J Ophthalmol
1973;76:933.
Posner A. Practical problems in the use of the
Maklakov tonometer. EENT J 1963;42:82.
Posner A. An evaluation of the Maklakov
applanation tonometer. EENT J 1962;41:377.
Rootman DS, et al. Accuracy and precision of
the Tono-Pen in measuring intraocular pressure
after keratoplasty and epikeratophakia in scarred
corneas. Arch Ophthalmol 1988;106:1697.
Schmidt T. The clinical application of the
Goldmann applanation tonometer. Am J
Schwartz NJ, Mackay RS, Sackman JL. A
theoretical and experimental study of the
mechanical behavior of the cornea with
application to the measurement of intraocular
pressure. Bull Math Biol 1966;28:285.
Schields MB. The noncontact tonometer: Its value
and limitations. Surv Ophthalmol 1980;24:211.
Starrels ME. The measurement of intraocular
pressure. Int Ophthalmol Clin 1979;19:9.
Stepanik J. Tonometry results using a corneal
applanation 3.53 mm in diameter. Klin Monatsbl
Augenheidkld 1984;184:40.
Ventura LM, Dix RD. Viability of herpes simplex
type I on the applanation tonometer. Am J
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A NARAYANASWAMY, L VIJAYA
Gonioscopy
Gonioscopy, the visualization and assessment

of the anterior chamber angle, is an essential
procedure in the diagnosis and management of
glaucoma. The term gonioscopy was coined by
Trantas in 1907. Subsequently, Goldmann
introduced the gonioprism, and Barkan mastered
the art of gonioscopy and highlighted its role
in the management of glaucoma. All cases of
glaucoma should undergo a routine and periodic
gonioscopic evaluation. The procedure is fairly
easy to perform, but experience is needed in
accurate assessment and interpretation.
Optical Principles
The anatomy of the eye is such that the angle
recess is not visualized by routine instrumentation due to total internal reflection of rays
emerging from the angle recess. The gonioscope
was evolved to overcome this optical problem
of critical angle (Fig. 7.1).
Types of Gonioscopy
Direct Gonioscopy
Direct gonioscopy is performed with the aid of
Fig. 7.1: Optical principles of gonioscopy: a: Incident light

from the angle exceeds critical angle resulting in total
internal reflection and preventing visibility of the recess.
b and c: The gonio lens optically eliminates the cornea
as shown in the schematic diagrams and allows visibility
of the angle
concave contact lenses (e.g. Koeppe) placed over

an anesthetized cornea with the patient in supine
position and the space between the lens and
cornea filled with normal saline or methyl
cellulose as a coupling agent. Viewing is achieved
directly using a hand-held biomicroscope and
an illuminator. Alternatively, the operating
microscope can be used to evaluate the angle
of the anterior chamber by making appropriate
adjustments. Koeppes lenses are available in
diameters of 16 mm and 18 mm allowing easy
Gonioscopy
TABLE 7.1: CONTACT LENSES USED FOR GONIOSCOPY
Type
Lenses
Features
Direct
1. Koeppe
Diagnostic lens50 diopter concave lens available in two sizes for infants
(16 mm) and adults (18 mm)
Surgical lensavailable in various sizes and has blunted edges allowing
access for goniotomy
Surgical and diagnostic lens
Surgical lens for goniotomy
Diagnostic lens for evaluating neonatal angle
2. Barkan
3. Thorpe
4. Swan-Jacob
5. Layden
Indirect
1. Goldmann single
mirror and three
mirrors
2. Zeiss and Posner
four mirrors
3. Sussman four mirrors
4. Ritch trabeculoplasty
lens
Diagnostic and therapeutic lenses, provide excellent images with good

magnification and globe stability
Ideal diagnostic lenses, patient friendly and very valuable in evaluating
narrow angles and to perform indentation gonioscopy
Hand held four mirrors similar advantages as the Zeiss lenses
Four-mirrored lens with pairs inclined at 59 and 62 degrees. One of
each set has a convex lens over it providing magnificationboth diagnostic
and therapeutic
use in pediatric patients. This technique can be

practiced both in the outpatient clinic as well
as in the operation theatre. A major advantage
of this method is that it allows simultaneous
comparison of different quadrants of the angle.
Apart from the diagnostic value, lenses like the
Swan Jacob, Barkan and Thorpe aid in surgical
intervention (Figs 7.2 and 7.3).
Fig. 7.2: Koeppes lenses
Indirect Gonioscopy
Indirect gonioscopy employs reflecting prisms
(e.g. Goldmann lens) mounted in a contact lens
and angulated at appropriate degrees to evaluate
the angle structures using the slit-lamp. The most
popular lenses are the Goldmann type, Zeiss,
Posner and Sussman four mirrors (Table 7.1).
Goldmann lenses (Fig. 7.4) are of two types:
(i) Single mirroredhas a mirror angulated at
62, (ii) Three-mirrored lenshas mirrors at 59
(tongue-shaped, used to evaluate the angle), 67
Fig. 7.3: Surgical lenses: Barkan and Thorpe
Fig. 7.4: Goldmann lenses three and single mirror
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108

(midsized, used to view midperipheral fundus)
and 73 (long, used to view peripheral fundus
and ciliary body). The central wall has a diameter
of 12 mm and radius of curvature of 7.38 mm.
A newer modified version with 8.4 mm radius
of curvature eliminates the need of using a
coupling solution. The three mirrors also aid in
retinal evaluation and laser therapy.
Zeiss lens (has under holder), or Posner (has
a screw-in handle) four mirror has mirrors
angulated at 64 and are amongst the most
popular gonioscopy lenses. The Zeiss four mirror
(Fig. 7.5) eliminates the need for rotation to
evaluate the angle and its radius of curvature
is 7.8 mm, closer to the corneal curvature, thereby
eliminating the need for a viscous coupling agent.
The diameter of the lens is 9.0 mm which aids
in dynamic or compression gonioscopy, an
important technique in evaluating narrow angles
and angle-closure glaucomas.
4. Adequate anesthesia is ensured using either

0.5% topical proparacaine or 4.0%
lignocaine.
5. The patient and examiner should be in a
comfortable posture with adequate support
to examiners forearm and elbow to make
sure of good control and minimal pressure
over the eye throughout the procedure.
6. The lens is held in the examiners left hand
for evaluating the right eye and vice versa.
7. The three-mirror gonioscope is filled with
viscous solution and inserted as shown in
Figure 7.6. The four-mirror is applied directly
(Fig. 7.7).
Fig. 7.6: The inferior rim of three mirror gonioscope is

inserted in the lower fornix with patient in upgaze as shown
and swiftly tilted on to the cornea preventing loss of any
coupling fluid
Fig. 7.5: Zeiss four mirror lens
Protocol for a Routine Gonioscopy

1. Explain the procedure to the patient.
2. Reassure the patient and ensure cooperation.
3. Corneal surface is examined to rule out any
contraindication for gonioscopy (abrasion,
infection, significant corneal edema or
opacity).
Fig. 7.7: The four mirror gonioscope is applied gently

and directly on to the cornea. Fingers rested over cheek
to ensure adequate support and prevent inadvertent
pressure over the globe
Gonioscopy
8. The patient is asked to maintain a straight
gaze once the lens is in situ.
9. Low, but adequate illumination, and small
beams are focused on the mirror, with
viewing and illumination maintained in the
same axis. The illumination arm is moved
paraxial when needed to evaluate the nasal
and temporal recesses. Magnification and
illumination can be increased when needed
to evaluate finer details like new vessels
and foreign bodies.
One quadrant can be evaluated at a time
with the three mirror by sequential rotation
while with the four mirror gonioscope all
four quadrants can be evaluated without
rotation and with minimum adjustments of
the slit-lamp. Always remember the opposite
quadrant (e.g. with mirror at 7 oclock, the
1 oclock angle) is being evaluated and the
image is reversed but not crossed.
Other dynamic maneuvers like compression
and over the hill evaluation are subsequently
done. Over the hill maneuver involves asking
the patient to look in the direction of the
mirror; which in turn gives access to viewing
angle recess over the convex iris.
Compression techniques will be dealt with
subsequently.
10. Disinfection of lenses is necessary prior and
after every use because of the potential of
transmitting infection. Lenses can be swiped
dry with bacillocid (2% gluteraldehyde) or
alternatively lenses can be rinsed with soap
solution and water and allowed to dry.
Gonioscopic Anatomy and

Interpretation
Repeated and routine normal gonioscopic studies
are essential in adding to ones experience in
evaluating a pathological angle. A methodical
evaluation of each structure either from iris plane
Fig. 7.8: Gonioscopic landmarks of a normal angle:

1 Iris root, 2 Ciliary body band, 3 Scleral spur, 4 Trabecular
meshwork, 5 Schwalbes line, 6 Schlemms canal,
7 Parallelopiped effect
to Schwalbes line (Fig. 7.8) or from iris plane

to Schwalbes should curtail errors in
interpretation.
To start with, from the peripheral iris plane
one can follow upwards to the insertion of iris
root. The contour of iris has several variations.
The normal adult eye has a slightly convex
contour. The same may be exaggerated in
hyperopic eyes, where in the anterior segment
it is crowded. A flat iris configuration is
commonly associated with myopia and aphakia.
A flat iris configuration with a peripheral convex
roll or hump of iris that lies in close relation
to the trabecular meshwork and can be seen in
phakic normal eyes which often mimics a narrowangle and is referred to as plateau iris configuration.
Contours could also be concave and are
associated with high myopes and pigment
dispersion syndrome. The insertion of iris root,
may vary from a posterior, anterior or high
insertions, thereby determining the visibility of
the ciliary body band and the contour and depth
of angle recess. The ciliary body band is
composed of the anterior end of ciliary muscle
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110

and is seen as a slate gray or dark brown uniform
band when insertion of iris root is posterior,
anterior and high insertions preclude its view.
An unusually wide ciliary body band may be
seen in myopes and aphakes and may be confused
with angle recession, but comparative gonioscopy
and other signs of trauma help to distinguish
between the normal and the pathological.
The next anterior transition is the scleral spur,
the most prominent and most important
landmark, identification of which is vital in terms
of orientation of the angle. The scleral spur is
the posterior lip of the scleral sulcus and is
attached to the ciliary body band posteriorly and
to the corneoscleral portion of trabecular
meshwork anteriorly. It is visible as a glistening
opaque white line between the ciliary body band
and trabecular meshwork, however, identification at times may be difficult when the trabeculum
is nonpigmented. The scleral spur may be
obscured in the presence of dense pigmentation
of angle structures like in posttraumatic or
postsurgical situations. Iris processes, which are
fine uveal strands arising from anterior iris
surface and running upto the corneoscleral meshwork may also prevent a good view especially
when they are prominent, as seen in congenital
glaucomas. The spur is not visible in the presence
of peripheral anterior synechiae or appositional
angle-closure on routine gonioscopy.
The trabecular meshwork has a posterior
functional, more pigmented portion and a less
functional nonpigmented anterior portion. The
corneoscleral part of the meshwork extends from
the scleral spur to the Schwalbes line. The
pigmentation of the meshwork varies with the
kind of eyes, age and other pathological
conditions. Brown eyes and adult eyes tend to
have a deeper pigmentation compared to blue
eyes and younger individuals. A nonpigmented
trabecular meshwork may often present a tricky
situation as far as accurate assessment is
concerned, since its color and texture seems to
merge with the scleral spur. However, a careful

evaluation reveals it to be a more translucent
and less white structure. The parallelopiped effect
is a useful adjunct that can be used in situations
wherein the landmarks are indistinguishable.
This effect causes a narrow-slit beam of light
that is reflected from the anterior and posterior
corneal surfaces to collapse at the Schwalbes
line. Once this point is identified the other
landmarks can be assessed based on the distance
from the line.
The Schlemms canal is usually not visible,
but can be seen through a less pigmented
posterior trabeculum when reflux blood fills up
either due to raised episcleral venous pressure,
or rarely as a normal phenomenon. Excess
pressure over the globe especially with a threemirror gonioscope can also cause artifactual
filling up of the Schlemms canal with blood.
Schwalbes line as described before represents
the peripheral termination of the Descemets
membrane. Usually optically identified by the
parallelopiped method, it also at times appears
as a prominent white ridge known as posterior
embryotoxon, a misnomer. This ridge is better
appreciated when the patient looks in the
direction of the mirror and is more prominent
in the temporal quadrants. The line may
occasionally be pigmented and is referred to as
Sampaolesi line as seen in pseudoexfoliation and
pigment dispersion syndrome.
Pediatric Eye
The pediatric eye has definite but subtle variations
in its anatomy. The iris contour in a newborn
is usually flat and its insertion is posterior to
scleral spur with the anterior extension of ciliary
body band visible. This contour does eventually
become convex as the angle recess develops
in 6-12 months. The trabecular meshwork
is nonpigmented and appears thick and
translucent. Congenital glaucomas present with
Gonioscopy
TABLE 7.2: CLASSIFICATION SYSTEMS FOR GONIOSCOPY
System
Scheie (1957)
Shaffer (1960)
System basis
Extent of angle
structures visualized
Angular width of
recess
Insertion of iris root
Spaeth (1971)
Angular approach
to the recess
Configuration of
peripheral iris
Angle structures and classification

All structures visible
Angle recess not seen
Ciliary body band not seen
Posterior trabeculum obscured
Only Schwalbes line visible
Wide open
Grade I narrow
Grade II narrow
Grade III narrow
Grade IV narrow
Wide open (30-45)

Moderately narrow (20)
Extremely narrow (10)
Partly or totally closed
Grade
Grade
Grade
Grade
Anterior to Schwalbes line

Behind (posterior) to Schwalbes line
At scleral spur
Deep into ciliary body band
Extremely deep
0-40 degrees
A
B
C
D
E
Regular (slightly convex)

Quirk (posterior bowing)
Steep
r
q
s
3-4, closure impossible

2, closure possible
1, closure probable
0, closure present
anterior insertions of the iris directly on to the

trabeculum and at times the anterior iris stroma
sweeps upward in a concave fashion to insert
onto the trabecular meshwork.
Grading and Recording of

Gonioscopic Findings
Though multiple individual variations in
assessment and grading gonioscopic details are
being followed, it is important to follow a certain
protocol of documentation, which aids in follow
up of the disease process. Among the systems
described (Table 7.2), the Spaeths system is
thought to be complete as it covers details with
regard to angle width, iris insertion and
configuration. Any gonioscopic data should
contain: (a) width of angle recess, (b) iris contour
and insertion of iris root, (c) degree of
pigmentation and (d) presence of abnormal
structures in each quadrant. Figure 7.9 shows
a wide-open angle (Shaffers grade IV or Speaths
D40r) with regular iris contour and deep recess.
Fig. 7.9: Gonio-photograph of a grade IV Shaffers angle

(corresponds to SpaethD40r). (a) Iris root, (b) Ciliary
body band, (c) Scleral spur, (d) Trabecular meshwork.
Iris contour is regular with a deep recess
All the landmarksiris root, ciliary body band,

scleral spur and trabecular meshwork are visible.
When insertion of iris occurs at scleral spur, the
peripheral iris appears slightly convex, the angle
of the anterior chamber still remains open
(Shaffers grade III or Speaths C30r, Fig. 7.10).
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112
Fig. 7.10: Gonio-photograph of a grade III Shaffers angle

(corresponds to SpaethC30r). Landmarks are visible
upto scleral spur with a mild iris convexity
Compression Gonioscopy
Compression or indentation gonioscopy is a
simple and invaluable technique that one needs
to know to assess narrow angles (Fig. 7.11) and
chronic angle-closure situations. It helps
distinguish appositional angle-closure from
synechial angle-closure. The technique employs
exerting external pressure over the cornea using
the Zeiss, Posner or Sussman four mirror lenses;
thereby forcing the lens iris diaphragm
posteriorly and allowing to visualize the hidden
angle recess (Fig. 7.12).
The technique involves a routine assessment
of all quadrants, following which, if one
subsequently decides the angle is narrow, each
Fig. 7.12: The same angle on compression widens

to reveal landmarks upto scleral spur
quadrant is re-evaluated using a narrow slitbeam (to prevent miosis causing artifactual
opening of the angle recess), pressure is applied
directed towards the center of the eye. This results
in deepening of the anterior chamber in the area
of recess caused by bowing back of peripheral
iris along with stretching of the limbal scleral
ring and straightening of the angle recess;
following this one can see structures that were
not visible earlier, or confirm the presence of
peripheral anterior synechiae. Corneal folds often
distort the view but this can be minimized with
appropriate technique in application of pressure.
The physiological principles involved in
compression gonioscopy have been depicted in
Figure 7.13. Compression may not be effective
when intraocular pressures are beyond 40 mm
Hg as this limits the expansion of the limbal
scleral ring.
Common Gonioscopic Findings and

their Variations
Peripheral Anterior Synechia (PAS)
Fig. 7.11: The photograph shows a narrow angle

visible upto the Schwalbes line
The peripheral anterior synechia is a pathological

term referring to the adhesions of peripheral iris
to the anterior angle structures, most often the
functional trabecular meshwork, or rarely,
Gonioscopy
arising from the peripheral iris surface and
branching out in an arborizing and lacy pattern
onto the corneoscleral portion of trabecular
meshwork. Varying amounts of peripheral
anterior synechiae may also be associated
depending on the stage of disease process.
Pigmentation
Fig. 7.13: Compression gonioscopy: a: The narrow angle
appears closed on a routine gonioscopy, b: Compression
fails to allow visibility of angle structures due to PAS,
c: Compression widens the recess and allows a view
of all structures in the absence of PAS
extending to the Schwalbes line. Typically seen

associated with primary angle-closure glaucoma,
uveitic and other secondary angle-closure
glaucomas, PAS may often be confused with iris
processeswhich are normal fine lacy cords of
uveal tissue extending from the peripheral iris
to the trabecular meshwork. PAS on the other
hand are broad adhesions commonly localized
to quadrants with areas in between widening
with indentation technique of gonioscopy. An
angle that is closed 360 may often present a
dilemma but one can follow the slit-beam from
the posterior surface of the cornea which normally
does not meet the beam on the iris directly in
an angle that is open but instead lies alongside
the other. A direct continuation of the beam
without a break is suggestive of a closed-angle.
Clinical correlation and experience will often
help overcome this hurdle.
The trabecular meshwork has a varying amount

of pigmentation varying from 0 to 4, which is
a subjective grading that correlates to none (0),
faint (1), average (2), heavy (3), and very heavy
(4). Pigmentation increases with age under
normal physiological conditions. Excessive
pigmentation is usually pathological and is
associated with pseudoexfoliation syndrome,
pigment dispersion syndrome, traumatic and
uveitic glaucomas.
Other Abnormal Findings

A variety of surprises may be hidden in the angle
recess. Blood in Schlemms canal appears as a
uniform linear reddish hue just anterior to
pigmented trabecular meshwork and is
associated with raised episcleral venous pressure.
It can also be observed under normal conditions
and as an artifact when excess external pressure
is exerted during gonioscopy. Pseudoexfoliative
material, microscopic hyphema and hypopyon
can be visualized. Foreign bodies and emulsified
silicone oil globules are among the other things
that can be picked up by a careful gonioscopy.
Blood Vessels
Normally all vessels in the angle are restricted
to the ciliary body band and iris root and do
not extend to the scleral spur or trabecular
meshwork. Anomalous vessels are not rare, they,
however, can readily be distinguished from
neovascularization which are vessels usually
Conclusion
In conclusion, the diagnostic basis of any
glaucoma should be in correlation to the
gonioscopic findings whenever possible. The
management and prognosis of the disease
depends on a complete diagnosis that includes
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114

a routine and periodic gonioscopic evaluation.
Gonioscopy widens our scientific understanding
of the disease process and guides us to manage
the disease more effectively.
Bibliography
1. Epstein DL. Chandler and Grants Glaucoma
(3rd edn). Philadelphia: Lea and Febiger, 1986.
2. Fellman RL, Spaeth GL, Starita RJ. Gonioscopy:
Key to successful management of glaucoma.
In Focal points Clinical Modules for
Ophthalmologists, San Francisco, AAO 1984.
3. Kanski JJ, James AM, John FS. GlaucomaA

Colour Manual of Diagnosis and Treatment (2nd
edn). London, Butterworth-Heinemann, 1996.
4. Kolker AE, Hetherington J Jr. Becker-Shaffers
Diagnosis and Therapy of the Glaucomas (5th
edn). St Louis, Mosby, 1985.
5. Neil TC, Diane CL. Atlas of Glaucoma. Martin
Dunitz, 1998;39.
6. Palmberg P. Gonioscopy. In Ritch R, Shields
MB, Krupin T (Eds). Glaucomas (2nd edn). St
Louis, Mosby, 1996.
7. Shields MB. Aqueous humor dynamics. II.
Techniques for evaluating. In: Textbook of
Glaucoma (3rd edn). Baltimore, Williams and
Wilkins, 1992.
Optic Disk Assessment in Glaucoma
RAJUL PARIKH, CHANDRA SEKHAR
Optic Disk
Assessment in
Glaucoma
An estimated 67 million people worldwide have

glaucoma in the year 2000. At least 50% do not
know that they have the disease since it is usually
without symptoms.1,2 Rapid advances in imaging
technologies such as confocal scanning laser
ophthalmoscopy, scanning laser polarimetry and
optical coherence tomography for detection of
early glaucomatous damage have only moderate
sensitivity and specificity.3-5 New psychophysical procedures such as short wavelength
automated perimetry, frequency doubling
perimetry and motion automated perimetry
which are targeted at specific visual functions
have been shown to be more sensitive and specific
than standard automated perimetry for
identifying early glaucomatous damage. 6-8
However, these techniques may not be available
to all clinicians and have the limitations of all
subjective tests. Several studies have shown that
abnormalities in the appearance of the optic disk
may precede visual field defects.9,10 Conventional
stereoscopic clinical evaluation and imaging of
the optic disk with fundus photographs is still
the most frequently used and sensitive means
of diagnosing glaucoma. 11 With some training,
it is possible to clinically evaluate optic nerve
head and retinal nerve fiber layer stereoscopically
and detect early glaucomatous damage. The aim
of this communication is to describe the

morphological changes of the optic nerve in
glaucoma, highlight the techniques of clinical
evaluation of the optic disk and discuss the
differential diagnosis.
Methods of Optic Disk Examination

Traditionally, the direct ophthalmoscope has
been used for the evaluation of the optic nerve
head. Though it has the advantage of providing
a magnified view of the optic nerve head, it,
however, lacks stereopsis and can result in
missing of subtle changes. Therefore, the use of
the direct ophthalmoscope is to be strongly
discouraged.
A variety of contact and noncontact lenses
are available which allow stereoscopic view of
the fundus at the slit-lamp. Contact lenses such
as Goldmann lenses are relatively uncomfortable
for the patient, take longer time and the coupling
fluid can cause transient blurring and difficulty
in obtaining good quality fundus photographs.
Noncontact lenses include +60D, +78D, +90D
and Volk superfield lenses (Fig. 8.1). These
provide excellent stereoscopic and magnified
view of the optic disk.
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116
Fig. 8.1: Noncontact lenses: +60D, +78D

and Volk superfield lenses
It is important to draw the appearance of the

optic nerve head based on these methods. Though
drawing of the optic disk suffers from the
disadvantage of being subjective in nature, this
does offer a quick and inexpensive method of
evaluation of the optic nerve head in patients
with glaucoma during follow-up. In addition,
photographs may not be possible in all cases
such as patients with rigid miotic pupils and
those with significant media opacities. However,
wherever possible, photographs are an indispensable adjunct to clinical evaluation.
Fig. 8.2: Disk margin (black arrow) and cup margin

(white arrow)
Features of Glaucomatous Disk Damage

Cup-Disk Ratio
Early studies by Armaly et al have reported that
the vertical and horizontal cup-disk diameter
ratios are useful for the quantification of
glaucomatous optic neuropathy and for early
detection of glaucoma.12 The ratio has limited
value in the identification of glaucomatous
damage, because of the wide variability in the
size of the optic cup in the normal population.
Disk margin is defined by inner edge of white
scleral ring (outer arrows), and the optic cup
is the level at which neuroretinal rim (NRR) steeps
(inner arrow) (Figs 8.2 and 8.3). A large cupdisk ratio can be normal if the optic disk is large13
and a small cup-disk ratio may be glaucomatous
if the optic disk is small14 (Fig. 8.4). The problem
with estimating cup-disk ratio as a measure of
B
Figs 8.3A and B: Vertical disk diameter and
horizontal disk diameter
Fig. 8.5: Measurement of disk diameter with slitlamp biomicroscopy with use of noncontact lenses
B
Figs 8.4A and B: Cup-disk ratio in relation to optic disk
size. A Optic disk is small with small cup and still has
inferior notch (white arrow) with nerve fiber layer defect
(black arrows) B Cup-disk ratio in a large disk
glaucomatous damage is that it is difficult to

decide if the cup is physiological in a large disk
or pathological in a small or normal-sized disk.
In a recent study by Garway-Heath et al, vertical
cup-disk diameter ratio corrected for the optic
disk size was the best variable to separate between
normal subjects and patients of ocular
hypertension with retinal nerve fiber layer defect.15
Therefore, in the clinical description of the optic
nerve head, it is important to state the vertical
cup-disk diameter ratio in combination with the
estimated disk size. The disk diameter can be
easily measured by adjusting the slit-lamp beam
height to the edges of the disk while viewing
the disk with a 60D lens (Fig. 8.5).16 The measurement by this method is roughly equal to the
measurement obtained by the planimetry of disk
photographs by Litmanns correction. Measurements can also be made with other lenses by
multiplying the measured value with the appropriate magnification factor, Goldmann contact
lens X1.26 and Volk superfield lens X1.5.16
It is important to differentiate contour cupping
from color cupping. The margin of the cup should
be determined by the bend of the small vessels
Fig. 8.6: Asymmetry of cupping in relation to asymmetry

of disk size. The left optic disk is larger than right optic
disk and has a larger optic cup
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118
Fig. 8.7: HRT print out of the same optic disks shown in Fig. 8.6 showing
asymmetry of optic disk cup in relation to disk area
across the disk rim and not by the central area

of disk pallor.
Asymmetry of Optic Disk Cupping

Asymmetry of cupping is seldom seen in normal
eyes and until proven otherwise, must be taken
as an indication of early glaucomatous damage.
However, while assessing asymmetry, it is
important to rule out asymmetry of the disk size,
which may be due to anisometropia. This can
result in difference in the cup-disk ratio between
two eyes, in the absence of glaucoma (Figs 8.6
and 8.7).
Neuroretinal Rim Evaluation

Glaucomatous damage can be diffuse, focal or
a combination of both. Diffuse damage results
in symmetrical enlargement of the cup. Focal
damage usually involves a particular area of the
rim. Normally, according to the ISNT rule, the
inferior rim is the thickest followed by the
superior, the nasal and then the temporal (Fig.
8.8).17 During optic nerve head evaluation, one
Fig. 8.8: Shows ISNT rule, the inferior rim is the thickest
followed by the superior, the nasal and then the temporal
must look carefully for any areas of thinning

of the neuroretinal rim or for notching or in other
words extension of the cup into the rim tissue.
If the cup is especially deep in the notch, it is
known as a pseudo-pit. Notching and pseudopits are usually seen at the superior or inferior
poles. The width of the notch tends to correspond
to the extent of the visual field defect (Figs 8.9A
and B, and 8.10A and B). Optic rim pallor is
another important indicator of glaucomatous disk
B
Figs 8.9A and B: Relation between neuroretinal rim notch and visual field defect. The optic disk photograph
shows inferior notch (black arrow) with corresponding superior arcuate field defect
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120
B
Figs 8.10A and B: Relation between inferior notch (here inferior notch is wider than the one
seen in Fig. 8.9) and visual field defect. The optic disk photograph shows neuroretinal notch
(black arrow) with corresponding superior arcuate field defect

damage. In the glaucomatous optic disk, the pale
and translucent atrophic tissue may replace the
normal pink color of the neuroretinal rim which
can result in a field defect in the corresponding
opposite hemisphere.
Vascular Changes
Splinter hemorrhages on the optic disk are a
common finding in glaucoma patients (Fig. 8.11).
Various studies have shown that disk
hemorrhages in association with localized nerve
fiber layer defects and notches of the neuroretinal
rim are more common among patients of normal
tension glaucoma.18, 19 A possible explanation
for the difference in frequency has been suggested
by Jonas et al. They stated that the amount of
blood leaking out of a vessel into the surrounding
tissue depends on the intraocular pressure when
the bleeding occurs.19 High transmural pressure
gradient in normal pressure glaucoma leads to
larger disk hemorrhages. Also, since the
absorption rate of disk hemorrhages depends
on the size of the disk bleed, the hemorrhages
in patients of normal pressure glaucoma may
take a longer time to disappear and thus have
a higher chance to be detected than the disk
Fig. 8.11: Disk hemorrhage
hemorrhages in patients of high pressure

glaucoma.20
Hemorrhages in glaucoma usually appear
as splinter-shaped or flame-shaped hemorrhages
on the disk surface21 (Fig. 8.11). They usually
precede neuroretinal rim changes and visual field
defects. The defects corresponding to the location
of the hemorrhage may be expected to appear
weeks to year later.22 The presence of disk
hemorrhages is considered an indication for the
enhancement of treatment of glaucoma.
Configuration of Vessels
The retinal vessels on the optic nerve head can
provide clues about the topography of the disk.
Nasalization of the vessels and baring of
circumlinear vessels can be seen in glaucoma
as well as in other diseases of the optic nerve.
Bayoneting of the vessels can be seen if the rim
is absent or very thin. This causes the vessels
to pass under the overhanging edge of the cup
and then make a sharp bend as they cross the
disk surface. This convoluted appearance of the
vessels is called bayoneting.
Peripapillary Atrophy
The zone closer to the optic nerve head with
retinal pigment epithelium (RPE) and choroidal
atrophy and baring of sclera is called zone .
The more peripheral zone with only RPE atrophy
is called zone (Fig. 8.12). A highly significant
correlation has been reported between the
location of peripapillary atrophy and visual field
defects.23 Sometimes, these changes may represent
a congenital anomaly, especially in myopic eyes.
However, appearance of these changes de novo
or their presence in small, nonmyopic disks
should be viewed with suspicion. Peripapillary
atrophy may be focal or circumferential (Figs
8.13 and 8.14).
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122
Fig. 8.12: Peripapillary atrophy. The diagram shows atrophic

zone closer to the optic nerve head called zone and
the more peripheral zone called zone
Fig. 8.13: Peripapillary atrophy: Localized in the

temporal area of the disk
Retinal Nerve Fiber Layer Abnormalities

Examination of the nerve fiber layer is often useful
in detecting early glaucomatous damage among
patients of ocular hypertension with normal disk
appearance and normal visual fields. The
neuroretinal rim is formed by axons converging
from the retina to the scleral canal. Since the
axons are spread out in a thin layer in the retina,
even minor losses of the axons can be observed
in the retinal nerve fiber layer. In healthy eyes,
the nerve fiber layer appears opaque with
Fig. 8.14: Peripapillary atrophy: generalized
radially oriented striations. The small retinal

blood vessels have a blurred and crosshatched
appearance, as they lie buried in the nerve fiber
layer. The best way to see the nerve fiber layer
defect is through a dilated pupil with a
stereoscopic lens, at the slit-lamp, using white
or green light and a wide-slit beam. In the
presence of nerve fiber layer atrophy, the small
retinal blood vessels become more clearly visible
and appear unusually sharp, clear and well
focused (Fig. 8.15). The fundus in the affected
area appears darker and deeper red in contrast
to the silvery or opaque hue of the intact nerve
fiber layer. Defects may be in the form of a wedge
shape arising from the disk margin and widening
towards the periphery, are pathological (Fig.
8.16), while slit-like defects narrower than the
adjacent blood vessels may be physiological.
Diffuse areas of atrophy are less common in early
glaucoma and more difficult to identify.
Myopic Changes vs Glaucoma

Myopic disks can present difficulty in evaluation
for glaucoma due to the tilted disks, peripapillary
atrophy and shallow cupping. One needs to
Fig. 8.15: Retinal nerve fiber layer defect: Wedge-shaped RNFL defect can be seen
between two black arrows. It is more easily marked in red free photograph
Fig. 8.17: Myopic disk with primary open-angle

glaucoma
Fig. 8.16: Retinal nerve fiber layer defect. Wedge-shaped
RNFL defect reaching up to optic disk margin
carefully examine the disk to look for changes

in the contour of the blood vessels, as well
delineate the disk margin from the peripapillary
changes (Fig. 8.17).
Differential Diagnosis
In addition to glaucoma, other abnormalities can
cause excavation and or pallor of the optic disk
and it is, therefore, important to rule out these

possibilities before making the diagnosis of
glaucoma.
Physiological Cupping
Assessment of the size of the optic disk, careful
examination of the neuroretinal rim and the
retinal nerve fiber layer can help distinguish
physiological cupping from glaucomatous
damage in most cases.
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124

Optic Nerve Coloboma
Optic nerve colobomas typically demonstrate
enlargement of the papillary region, partial or
complete excavation, blood vessels entering and
exiting from the border of the defect and a
glistening white surface. The visual field defects
can be in the form of generalized constriction,
centrocecal scotomas, altitudinal defects, arcuate
scotomas, enlargement of the blind spot and ring
scotomas that can mimic those found in
glaucomatous eyes.
Morning glory syndrome is a variant of optic
disc coloboma and is characterized by a large
excavated disk, central core of white or gray glial
tissue surrounded by an elevated annulus of
variably pigmented subretinal tissue (Fig. 8.18).
The retinal vessels appear to enter and exit from
the margins of the disk, are straightened and
often sheathed.
Fig. 8.19: Optic disk photograph showing congenital

optic disk pits
in about one-third. Involvement is usually

unilateral in about 80% cases and the optic disk
is larger on the involved side. Approximately
55-60% of the eyes have a field defect in the form
of arcuate scotomas, paracentral scotoma,
altitudinal defect, generalized constriction and
nasal or temporal steps.24
In the absence of other indicators of congenital
anomaly (like associated fundus coloboma, the
differential diagnosis may be difficult and the
absence of progression on follow-up may be the
only indicator that the patient has a congenital
anomaly and not glaucoma.
Fig. 8.18: Optic disk photograph showing
characteristic morning glory syndrome
Congenital Optic Disk Pit

Congenital optic disk pits appear gray or
yellowish-white, round or oval, localized
depression within the optic nerve (Fig. 8. 19).
They are located within the temporal aspect of
the disk in over half of the cases and centrally
Anterior Ischemic Optic Neuropathy

A history of acute visual loss, initial swelling
of the optic disk, absence of marked cupping,
rise in ESR, presence of centrocecal scotoma or
altitudinal defects can help differentiate it from
glaucoma (Fig. 8.20). In the late stages the cupping
in some cases may be exactly the same as is
seen in glaucoma.
Fig. 8.20: Anterior ischemic optic neuropathy. The right-sided optic disk photograph is from patients with longstanding AION showing typical glaucomatous cupping
B
Figs 8.21A and B: A Optic disk photograph showing significant cupping, but with out of proportion pallor.
B Visual field defect showing a temporal hemianopia suggestive of pituitary tumor
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126

Neurological Causes
Pallor disproportionate to cupping, normal
intraocular pressure or unusual history of onset,
progression and age should arouse suspicion
of a neurological disorder causing optic disk
damage (Fig. 8.21).
Presence of visual field defects that respect
vertical midline and the pattern of the field defects
should be able to suggest the possible site of
the intracranial lesion.
Summary
In summary, the optic disk evaluation in
glaucoma is best done stereoscopically at the
slit- lamp with a dilated pupil using one of the
60D, 78D or 90D lenses. Changes in the neuroretinal rim, optic disk hemorrhages, peripapillary
atrophy and nerve fiber layer defects are more
important features than the cup-disk ratio. The
cup-disk ratio is to be documented and
interpreted along with the disk size and not in
isolation. The diagnosis of glaucoma will depend
on the presence of a visual field defect that
correlates with the anatomic changes on the optic
nerve head and the peripapillary retina.
References
1. Quigley HA. Number of people with glaucoma
worldwide. Br J Ophthalmol 1996;80:389-93.
2. Dandona L, Dandona R, Srinivas M, et al. Openangle glaucoma in an urban population in
southern India: the Andhra Pradesh Eye
Disease Study. Ophthalmology 2000; 107(9): 170209.
3. Zangwill LM, Bowd C, Berry CC, Williams J,
Blumenthal EZ, SanchezGoleans CA, Vasilie C,
Wainreb RN. Discriminating between normal
and glaucomatous eyes using the Heidelberg
retina tomograph, GDx nerve fibre analyser
and optical coherence tomograph. Arch
Ophthalmol 2001;119:985-93.
4. Bowd C, Zangwill LM, Berry CC, Blumenthal

EZ, et al. Detecting early glaucoma by
assessment of retinal nerve fibre layer thickness
and visual functions. Invest Ophthalmol Vis Sci
2001;42:2001-03.
5. Medeiros FA, Zangwill LM, Bowd C, Weinreb
RN. Comparison of the GDx VCC scanning
laser polarimeter, HRT II confocal scanning laser
ophthalmoscope, and stratus OCT optical
coherence tomograph for the detection of
glaucoma. Arch Ophthalmol 2004;122;827-37.
6. Johnson CA, Adams AJ, Casson EJ, Brandt JD.
Blue-on-yellow perimetry can predict the
development of glaucomatous field loss. Arch
Ophthalmol 1993;111:645-50.
7. Bayer AU, Maag KP, Erb C. Detection of optic
neuropathy in glaucomatous eyes with standard
visual fields using a battery of short wave-length
automated perimetry and pattern electroretinography. Ophthalmology 2002;109: 1009-17.
8. Sample PA, Bosworth CF, Blumenthal EZ, Girkin
C, Weinreb RN. Visual function-specific
perimetry for indirect comparison of different
ganglion cell populations in glaucoma. Invest
Ophthalmol Vis Sci 2000;41:1783-90.
9. Quigley HA, Dunkelberger GR, Baginski TA,
et al. Chronic human glaucoma causing
selectively greater loss of larger optic nerve
fibers. Ophthalmology 1988;95:357-63.
10. Sommer A, Pollack I, Maumenne AE. Optic disc
parameters and onset of glaucomatous field
loss: I Methods and changes in disc morphology.
11. Greaney MJ, Hoffman DC, Garway-Heath DF,
et al. Comparison of optic nerve imaging
methods to distinguish normal eyes from those
with glaucoma. Invest Ophthalmol Vis Sci 2002;
43(1):140-45.
12. Armaly MF, Saydegh RE. The cup/disc ratio.
13. Jonas JB, Zach F-M, Gusek GC, Naumann GOH.
Pseudoglaucomatous physiologic large cups.
Am J Ophthalmol 1989;107:137-44.
14. Jonas JB, Fernandez MC, Naumann GOH.
Glaucomatous optic nerve atrophy in small disks
with low cup-to-disc ratios. Ophthalmology
1990;97:1211-15.
15. Garway-Heath DF, Ruben ST, Viswanathan A,
Hitchings R. Vertical cup/disk ratio in relation
to optic disk size: its value in the assessment
16.
17.
18.
19.
of the glaucoma suspect. Br J Ophthalmol 1999;

82:1118-24.
Jonas JB, Dichtl A. Advances in the assessment
of the optic disc changes in early glaucoma.
Cur Opi Ophthalmol 1995;6:61-66.
Jonas JB, Gusek GC, Naumann GOH. Optic disc,
cup and neuroretinal rim size, configuration,
and correlations in normal eyes. Invest
Ophthalmol Vis Sci 1991;29,1151-58, Invest
Ophthalmol Vis Sci 1993;32.
Kitazawa Y, Shirato S, Yamamoto T. Optic disc
hemorrhage in low-tension glaucoma.
Ophthalmology 1986;93:853-57.
Jonas JB, Budde WM. Optic nerve head
appearance in juvenile-onset chronic highpressure glaucoma and normal-pressure
glaucoma. Ophthalmology 2000;107:704-11.
20. Jonas JB, Xu L. Optic disc hemorrhages in

glaucoma. Am J Ophthalmol 1994;118:1-8.
21. Drance S.M, Fairclough M, Butler DM, Kottler
MS. The importance of disc haemorrhage in
the prognosis of chronic open-angle glaucoma.
22. Heijl A. Frequent disc photography and
computerized perimetry in eyes with optic
disc haemorrhage. Acta Ophthalmol 1986;64:
274-81.
23. Jonas JB. Naumann GOH. Parapapillary
chorioretinal atrophy in normal and glaucoma
eyes. II. Correlations. Invest Ophthalmol Vis Sci
1989;30:919-26.
24. Brown GC. Congenital fundus abnormalities.
In: Duane TD (Ed). Clinical Ophthalmology 1991,
Philadelphia, J.B. Lippincott.
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DEVINDRA SOOD, PARMOD KUMAR
Basic Perimetry
Visual field is a part of space, seen at any given

moment. Changes in the visual field are produced
by a number of disease conditions which can
affect the visual system and often manifest
through changes in the visual field. Hence, it
is essential to determine the extent of the visual
field for the diagnosis and management of these
conditions.
The visual field is usually perceived with both
eyes. It is, however, measured separately for each
eye. The normal visual field extends up to 50
degrees superiorly, 70 degrees inferiorly, 60
degrees nasally and 90 degrees temporally. After
defining the visual field for each eye, the two can
be compared with each other for asymmetry or
compared to a normal reference test for any
abnormality and be examined together to look
for patterns suggestive of disease conditions.
Perimetry is the science of measuring the
peripheral vision (Peri= peripheral and
-metry" = measurement). Perimetry involves
placing the eye at the center of curvature of a
hemispherical or arc-shaped instrument. The test
objects have a constant angular size and are at
a constant distance from the eye. The visual field
has been compared to an island of vision in a
sea of blindness by Traquair in 1930. This island
of vision is a three dimensional structure. The
x and y co-ordinates represent the location of

points on the visual field.
At the fovea, the x and y co-ordinates are
0,0. The location of all points on the visual field
are described along the x and y axis, with respect
to fixation (Fig. 9.1). The blind spot is 15 degrees
temporal to fixation. The z axis represents the
height of the hill island of vision at a given
co-ordinate (x,y) and corresponds to the retinal
sensitivity at that point. Greater the sensitivity
at a given point, greater is the height of the island
Fig. 9.1: A point on the island of vision is marked

along the x and y axis
Basic Perimetry
of vision. Since sensitivity is maximum at the
fovea, the height of the hill island of vision
(z) is also maximum at the fovea. The retinal
sensitivity drops to sea level 15 degrees temporal
to fixation (blind spot).
Types of Perimetry
Kinetic Perimetry
Perimetry aims to draw the map of the island
of vision, such that it is a true representation
for each eye and also aims to present it in a
way which is clinically useful. Earlier methods
defined the outer limits of the visual field by
moving objects from the non-seeing area to the
center. This technique of perimetry, called kinetic
perimetry, it utilizes a moving object of a fixed
size and intensity (e.g. Tangent screen or
Goldmann perimeter) to define the boundary of
the island of vision at a fixed height. This line
representing the outer boundary for a given size
of the test stimulus is called isopter. An isopter
is synonymous to a horizontal slice through the
hill island of vision.
Manual kinetic perimetry allows large areas
to be traversed in a fairly short order. One can
move quickly over areas of little interest and spend
relatively more time in examining critical regions.
Equipment is inexpensive and durable. Since the
perimetrist is constantly communicating with
the patient, the patient is more comfortable.
However, reproducible and reliable examinations
require technical skill and early or subtle changes
are more likely to be overlooked on manual kinetic
perimetry. Isopters which are stylized representations of the visual field, making quantification
and statistical analysis difficult.
Static Perimetry
The outer boundary of the island of vision can
also be determined by measuring the retinal
sensitivity (z) at each point (x,y). This technique

of perimetry is called static perimetry because the
test location is fixed, while the intensity of the
test object of known size is varied, e.g. Tubinger,
Octopus and Humphrey perimeters. Static
perimetry provides a vertical slice through the
hill island of vision.
Because of the difficulty, inability and a
potential for lack of reproducibility with kinetic
perimetry, static perimetry is preferred for
detecting and following subtle non-geographic
defects in the diagnosis and follow-up of
glaucoma patients. One can perform effective
static perimetry with the tangent screen or the
Goldmann perimeter. However, manual static
perimetry is tedious, cumbersome and at times
boring. Both the patient and the examiner find
it difficult to concentrate for 30 to 90 minutes
at a stretch. Automated /computerized perimetry
presents targets at a random sequence
undecipherable by the patient. It can test the
same patient with the same methodology year
after year and still does not get bored. Kinetic
testing is difficult to computerize particularly
with regard to the decisions regarding same
speed and direction of presentation. A static test,
on the other hand is relatively straight forward,
since the target does not move, the machine has
only to choose a site, target intensity and then
record whether the patient responds, yes or no.
Computers have revolutionized perimetry by
allowing precise repetition and meticulous
attention to detail, testing the patients response
under optimal conditions repeatedly by allowing
a binary yes/no answer from the patient. All
this makes perimetry tailor made for computerization.
Stimulus Presentation
During static visual field measurement the
stimulus can be presented by projection or nonprojection. In the projection system a simple
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130

computer video monitor is used to present dark
or light combinations of stimuli against a diffuse
background. This system has the advantage of
being more flexible and allows kinetic color
perimetry. Drawbacks pertain to the mechanical
aspects of presenting and moving the test target
such as mechanical failures, periodic maintenance and servicing. Also, the combination of
mirrors, shutters and the rotational unit produces
an unsuitable clinking noise with each projection.
This was used to advantage in earlier models,
to assess the reliability of a given field (false
positives). Newer models elicit the false positive
response by omitting the light stimulus and
assessing the pace of the patient to the rhythm
of the testing.
In the non-projection system stimuli are
generated by the turning on and off of Light
Emitting diodes (LED) which are placed into the
surface of the perimetric bowl. Advantages of
LEDs include silent operation, no moving parts,
multiple stimuli presentation and inexpensive
and durable equipment. However, in the LED
system stimuli are fixed in the bowl surface at
the time of manufacture, inability to vary stimulus
size and color, test site location or resolution
pattern. Further fixed LED positions cannot be
expanded to accommodate new programs. LEDs
have a condensed light output. Slight variations
in positioning and mounting of the LED result
in different directional light intensities. All LEDs
need to be calibrated individually. This needs
to be done at the factory and on a routine basis.
In the non-projection system a high resolution,
flat video monitor can also be used to present
the stimuli. In this method, the patient fixes on
a pseudo-infinite target and stimuli are presented
throughout the visual field. With this method
of presentation, test site location is infinitely
variable, kinetic perimetry is possible, and
stimulus presentation is without the audible click.
Additionally the video monitor projection does
away need for a perimeter bowl and the projection
device allows greater flexibility and durability.

They also occupy less space. However, video
monitor systems are able to assess only the central
30 degrees.
Projected stimuli are usually white and of
variable size and intensity. The size of the stimuli
in automated perimeters is similar to that used
for Goldmann perimeter. There are five different
sizes designated by Roman numerals I to V. One
very often uses stimulus size III. Failure to
recognize target size III necessitates testing with
stimulus size V. However, tests using stimulus
size V cannot be processed statistically by
STATPAC 2 on the Humphrey perimeter.
In static perimetry, the patient has to respond
to a stimulus of predetermined size, color and
location projected for a fixed duration at a given
intensity level. The patient responds with the
button in two ways: stimulus seen or stimulus
not seen. Any such response is only suggestive
but not actual proof, that the light was seen or
not seen. For a stimulus of a fixed size and
location to be seen depends on its intensity. This
probability of a stimulus of fixed size and location
when plotted against the intensity of the stimulus
is called probability of seeing curve. That is to say,
the intensity of the stimulus where it is seen
50% of the time and missed 50% is called threshold.
Similarly, the intensity at which the stimulus
is seen 95% of the projected times, is called
suprathreshold. A low intensity stimulus which
is seen only 5% of the times when projected is
called infrathreshold.
Bracketing
Determining the threshold for each point in the
field would require thousands of stimulii of
varying intensity. However, the number of stimuli
for threshold determination has been conveniently reduced by a testing algorithm which
is also accurate. At a given point on the visual
field, the patient responds to a given stimulus
Basic Perimetry
Fig. 9.2: The probability of seeing curve
Fig. 9.3: Threshold determination at the point P

(Staircase technique)
intensity (P1). The intensity of the stimulus is

then decreased in steps of 4 dB till the stimulus
is not seen (3). The threshold lies between 2 and
3. The intensity of the stimulus is then increased
in steps of 2 dB till the patient is able to perceive
the stimulus. Herein the threshold for the point
is lying between 4 and 5, and is a more accurate
assessment of the threshold value at that point.
This technique of threshold determination is
called 4-2 bracketing (Staircase technique). In the
Octopus perimeter, the thresholding strategy
continues, until a third reversal, in steps of 1
dB, called 4-2-1 algorithm (Fig. 9.3).
Normal threshold values are dependant on
the location of the point on the visual field and
also the age of the patient.
Fovea, the most sensitive point of the visual
field corresponds to 0 degree of eccentricity. As
the point moves from the fovea, the threshold
value (sensitivity) decreases by 0.3 dB for every
Fig. 9.4: Effect of location and age on threshold
131
132

degree of eccentricity outside the macula.
Sensitivity drops to zero, 15 degrees temporal
to fixation (blind spot). Sensitivity also decreases
with the age; 0.6-1dB per decade of life. Since,
threshold is age-related, the patients date of birth
should be correctly entered as the results are
compared to age-matched normals.
The intensity of light which reflects off the
surface is expressed as apostillbs (unit of
luminance). The sensitivity of the human visual
system varies from 1 to more than 1,000,000
apostillbs (asb). The maximum stimulus intensity
of the Octopus Field Analyzer is 1000 asb and for
the Humphrey Field Analysis is 10,000 asb. Hence,
large numbers representing the listed sensitivity
on the printout would be cumbersome. A
convenient way of expressing threshold values is
in terms of a relative logarithmic scale where the
intensity of the stimulus is varied by powers of 10
1
1dB =
log unit (asb)
Increasing dB numbers on the printout imply
that dimmer stimuli have been perceived.
Thresholds corresponding to a dimmer stimulus
mean greater retinal sensitivity. In a report of
the measured thresholds, large dB values
correspond to better sensitivity and small dB
numbers indicate reduction in sensitivity.
Testing Strategy
With the inherent ability to vary the intensity
of the light stimulus, static perimeters explore
the visual field in three ways:
1. Suprathreshold screening.
2. Threshold related screening.
3. Full threshold determination.
Suprathreshold screening: Very bright stimuli
(suprathreshold) intense enough to be seen easily
by most normal people are presented. The patient
has simply to respond (yes / no) to the presence
of the target. The role of such examinations is

related to quick screening of large populations
and also to define gross pathology quickly.
However, such examinations can miss early
changes suggestive of glaucoma.
Threshold related screening: Herein, the intensity
of the light presented is 5dB brighter than the
actual threshold at the test point in question.
This allows the entire field to be screened quickly.
Threshold related screening is at best a variant
of suprathreshold tests which allow for an
approximation of the true sensitivity of the visual
field. It can be used as a screening test for
detection and follow-up of known pathologies.
Threshold determination: A more time consuming
way of determining the sensitivity of the visual
field is by determining the threshold value at
each point by the bracketing technique described
earlier. After presenting a light stimulus the
machine waits for a yes / no response. If the
stimulus is not seen, the intensity of the light
seen is increased in steps of 4dB till it is visible
(machine records this as suprathreshold level).
Subsequently, light stimuli are decreased in steps
of 2dB till the stimulus is not seen (infrathreshold). The actual threshold is between the
suprathreshold and infrathreshold.
Newer Strategies
Threshold determination at each point of the
visual field is tedious and time consuming.
Because by definition threshold is tested by the
staircase algorithm, where every patient can see
only half of the stimuli presented, newer
techniques aim to make the procedure as short
as possible, to ensure that the patient maintains
concentration and thus provides better reliability.
Swedish Interactive Thresholding Algorithm (SITA)
is similarly based on the fact that a response
at one location has implications at the point tested
Basic Perimetry
and also its neighboring points. Just as one tested
point is normal, other points on the visual field
are likely to be normal too.
Tendency Oriented Perimetry (TOP) is available
on the Octopus perimeter and takes advantage
of each response of the patient five-fold. It tests
and adjusts the location where the stimulus is
presented and assesses the threshold of the four
neighboring locations by interpolation.
Several threshold tests are available on the
two commonly available Octopus and Humphrey
perimeters. In each test a certain number of points
can be tested. The number of points tested in
a given test is actually a compromise between
the time applied and precision, which depends
on the type of damage looked for as well as the
diagnostic and therapeutic implications resulting
therein. The response at each thresholded point
is compared with a group of normal individuals.
The likelihood of such a response in this
population of normal patients is expressed as
a probability symbol for each tested point. These
probability symbols increase in significance from
a set of 4 dots to a black box, p<5%, <2%, <1%
and 0.5%. A black box indicates that few normal
subjects will have that score; it does not necessarily correspond to an absolute defect. Many points
with p<0.5% are relative defects; their actual
threshold is available from the raw data.
Test Programs
The standard programs on the Humphrey are
the 30-2, 24-2, 10-2 and the macular grid program.
In the 30-2 the central 30 degrees of the visual
field are tested. It consists of 76 points 6 degrees
apart on either side of the vertical and horizontal
axes, such that the innermost points are three
degrees from fixation. In the 24-2 program 54
points are examined. It is near similar to the
30-2 except the two peripheral nasal points at
30 degrees on either side of the horizontal axis
are included while testing the central 24 degrees.
The 10-2 program tests 68 points 2 degrees apart

in the central 10 degrees. This program helps
to assess and follow-up fixation characteristics
in patients with an advanced disease along with
the macular test which examines 16 points in
the central 5 degrees, each being 2 degrees apart.
The efficiency and results of an examination are
reflected by the location of the points tested.
The two commonly used programs on the
Octopus are the G1X and the G2 which test 59
locations in the central 30 degrees. Here the test
points are concentrated in the central field,
arcuate region and nasal midperiphery to maximize detection of significant changes. Fixation
characteristics are assessed with the macular
program M2X which tests 45 locations in the
central 4 degrees, which are 0.7 degrees apart.
Automated perimetry provides a large
amount of data which is quantifiable, reproducible and amenable to statistical manipulation.
However, the magnitude of the data makes
interpretation complex, but a logical, consistent
and sequential approach helps to make this less
complex.
The earliest injury in open-angle glaucoma
is localized to the nerve fiber bundle, usually
in the paracentral nasal region. The initial defect
may be seen as a fluctuation in a cluster of points
or as a relative defect with normal surroundings.
This small area of increased scatter or threshold
instability is often overlooked at the initial
examination, since it does not meet the criteria
for a valid visual field loss. Based on the other
clinical data, a subtle area of unstable sensitivity
may be suspected as being glaucomatous. It
becomes more manifest when progression occurs
and a serial review of fields shows that the area
in question has changed with time. Progression
of visual field defects occur in several ways
increase in density of scotomas, expansion of
areas of depression and the development of new
ones. Uncontrolled glaucoma will eventually
affect all areas of the field.
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The challenge in automated perimetry is to
locate and document areas of subtle glaucomatous damage and carefully follow any
progression. Finally a diffuse generalized
depression affecting the entire visual field is rarely
associated with early glaucoma, and is usually
due to other conditions such as cataract or
uncorrected refractive errors. Visual fields are
usually analyzed by using a printout that
contains different elements of data. Although
several different visual field analyzers are in
current use, there are sufficient similarities in
the printout to permit interpretation and
comparison of the results. However, difference
between instruments does not permit direct
correlation of their absolute scores.
Gaze monitoring is a high precision gazetracking system on the newer Humphrey models
which uses real time image analysis to measure
the distance between the center of the pupil and
the first corneal reflex. It is unaffected by head
motion. A continuous record is available on the
printout.
An upward deflection is indicative of eye
movement during stimulus presentation.
Downward deflections imply that the gaze could
not be detected. The 750 model of the Humphrey
perimeter also offers head-tracking wherein the
chin rest is automatically moved in increments
of 0.3 mm to bring the head back to the initially
gaze tracked position and the Vortex monitor
wherein a beep as well as a message is produced
on the screen when the patients head moves
back by more than 7 mm.
Statistical Analysis
The Statpac program introduced first in 1987
and then upgraded to Statpac Plus in 1988, was
derived from a group of normal patients and
helped answer the question: Are the field in
question normal or not? It introduced the Global
Indices along with the Single Field Printout,
Change Analysis and the Overview format. In

1989 Statpac-2 was introduced. It was formed
from a database of patients known to have visual
field loss due to glaucoma which was otherwise
stable.To detect early changes of glaucoma,
groups of points in the superior and inferior
hemispheres were also compared to produce the
Glaucoma Hemifield Test.
An interpretation of the single visual field
performed with the Humphrey visual field
analyzer (Humphrey Instruments, Inc, San
Leandro, C.A) and the Octopus 1 2 3 visual
field analyzer (Interzeag AG , Switzerland) is
presented.
Components of Automated Visual Field

Humphrey Single Field Printout
There are eight parts to the single field printout
(Fig. 9.5). Each has to be examined serially before
drawing a conclusion.
First assess the reproducibility ( Zone-1 ) of
the concerned fields (Consistency). At the onset,
check the printed information at the top of the
page, to ensure listing of the correct patient, the
type of test done (30-2, 24-2, 10-2), eye in question
and date of birth (the software package
statistically compares the patients response with
age corrected normal population). The recorded
visual acuity, refraction and pupil size are
important parameters as they all can affect the
data. When pupils are miotic, or smaller than
2.5 mm, dilatation is required so as to prevent
generalized depression from occurring. The
decision to dilate patients with large pupils rests
with the clinician, but consistency for all visual
fields must be maintained.
Next scans the reliability indices (Zone-2).
Fixation losses are noted as the ratio of the number
of times the patient responded when he saw a
target placed in the blind spot against the total
number of times fixation was tested. In automated
Basic Perimetry
Fig. 9.5: The Humphrey single field printout is divided into eight zones. Each must be reviewed sequentially
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perimetry fixation is assessed and monitored by
i. Sensors,
ii. Closed circuit TV monitors
iii. Heijl-Krakau method.
Sensors are used to detect minute shift in eye
position. They are highly sensitive to slight
movement in eye position but are expensive, too
sensitive, such that insignificant physiological
fixation shifts induced by respiration, systole
and involuntary head movements get registered
as fixation losses.
Closed circuit TV monitor displays the image
taken by an infrared camera. This allows the
examiner to view the patients eye and judge
and assist in fixation quality. Advantages of this
system are continuous monitoring of fixation
throughout the test with no extra time spent in
monitoring fixation per se (Blind Spot Projection
Technique). However, continuous video
monitoring is expensive, prone to hardware
failure and there exists a potential for the machine
to disregard fixation losses in patients with fairly
good but not excellent fixation.
Heijl-Krakau method: In this method, the
machine assumes or plots the blind spot at the
beginning of the test and then retests after every
eight to twelve stimuli by projecting a suprathreshold stimuli in the blind spot. A positive
response indicates fixation loss. This, however,
does not work well when significant field loss
is adjacent to or involving the blind spot.
When fixation losses are more than 20%, it
is bracketed (XX) and is indicative of questionable
reliability. However, not all fixation losses are
due to unsteady gaze. A pseudo-loss of fixation
is seen when there is an improper location of
the blind spot, or when the initial blind spot
is present near the edge of a scotoma, so even
though it is presented throughout the test, it is
occasionally visible. Also, a head tilt or change
in head position occurring during the test will
lead to a faulty blind spot location. Finally a
patient who is continually responding even when

a light is not flashed will have a number of fixation
losses. For these reasons the fixation loss score
is not considered in isolation, but rather compared
to the other reliability scores.
False positives (FP) result when the patient
responds to the audible click of the perimeter
with no stimulus projected (trigger happy). It
is also expressed as a ratio of the number of
times the patient responds to a pause in the testing
sequence without presentation of the target
against the total numbers of pauses. It is the
single most significant reliability indicator.
Bracketing occurs when FPs are 33% but often
15-20% rate can also destroy the credibility of
a field. A high rate can also occur due to a poor
understanding of the test requirements by the
patient. A high FP ratio , will be accompanied
by a high positive mean defect, white areas on
the gray scale indication of very high threshold
levels (white scotomas), a high number of fixation
losses and a message of abnormally high
sensitivity on GHT.
False negatives (FN) are expressed as a ratio,
and occur when the patient does not respond
when a point previously thresholded is retested
with a brighter stimulus. High FN ratio occurs
when the patient tires as in the later part of the
examination, when he changes his internal
criterion on whether or not he sees a point or
when the edge points of a scotoma are tested.
A 33% FN ratio is considered excessive and makes
the test suspect. However, the presence of a
scotoma and a high number of FN, with all other
reliability measures being normal, is indicative
of a reliable field.
Foveal threshold measures over 30 dB for a
visual acuity of 6/12 or better. A normal foveal
value and a poorly recorded acuity indicates
need for a refraction or mild amblyopia. Likewise
a good visual acuity and a depressed foveal value
suggest early damage.
Basic Perimetry
The Gray scale (Zone-3) is a rough indicator
of the extent of field damage, but can be
misleading. Each point on the gray scale is
represented by a symbol of varying darkness
which corresponds to the threshold level at that
point. These are not indicative of disease. A
normal elderly patient will have a darker gray
scale than a younger patient because of reduced
sensitivity in aging eyes. Additionally, there are
a fewer points tested in the periphery, each of
which occupies a larger space on the gray scale.
For these reasons, the gray scale should not be
the sole criterion for assessing the visual field.
The Total deviation plot (Zone-4) is created
by subtracting the actual raw data from the
expected value for age matched controls, at each
point. This depending on whether the patient
did better or worse than expected is expressed
as a positive or negative number. The corresponding probability symbols seen below the data
indicate the statistical probability of finding such
a point in normal subjects. These probability
symbols increase in significance from a set of
4 dots to a black box, p<5%, <2%, <1% and 0.5%.
The presence of a black box indicating that a
few normal subjects will have that score, it does
not necessarily correspond to an absolute defect.
Many points with p<0.5% are relative defects
their actual threshold is available from the raw
data.
The Pattern deviation plot (Zone-5) based on
further calculations, is derived from the total
deviation data and the overall depression of the
visual field. It highlights focal changes which
are concealed within diffuse changes, after
making adjustment for the height of the hill of
vision. Whereas the statistical significance,
expressed as probability symbols, is measured
for each point, the total deviation and pattern
deviation probability maps are analyzed by
taking the entire field into account and identifying
how clusters of affected points occur, the number
of points involved, their density and location.
The Pattern and Total Deviation need to be

compared and a difference if present should be
explained. Corneal opacity, cataract and small
pupil are the usual causes.
Raw data / numeric data (Zone-6): It is the
actual threshold score for each thresholded
point. Areas flagged in the Pattern and Total
Deviation plot should be inspected carefully for
confirmatory signs like double thresholded
points of abnormal or foci of high local fluctuation. This should be followed by a geographic
survey of the entire numeric data.
Global indices (Zone-7) are presented in the
lower right hand corner of the printout and
include:
Mean deviation (MD): It is the weighted score of
all the points on the total deviation plot. It takes
into account both the severity of loss and amount
of field affected. A positive MD indicates that
the patient scored better than expected for his
age, a negative number indicates that the score
was worse than expected.
Pattern standard deviation (PSD): It measures
the extent to which the damaged points vary
from the expected hill of vision (localized loss).
Short term fluctuation (SF): Though listed under
global indices it is a good indicator of intra test
reliability. It measures the variation at each point
on repeated thresholding in the same test. A SF
from a patient with poor reliability scores is high,
further indicating a poor test taker.
Corrected pattern standard deviation (CPSD): It
is calculated with the help of SF to adjust the
PSD. It is a more accurate indicator of the extent
of damage.
Glaucoma Hemifield test (Zone-8) is a
sophisticated analysis of 5 geometric point
clusters in the superior and the inferior arcuate
regions whose probability maps are compared
with one another. It is very sensitive and specific
at detecting asymmetry between these regions
as well as symmetric deviations from normal
data. The GHT can be within normal limits,
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Fig. 9.6: Glaucoma hemifield test
outside normal limits, borderline sensitivity,

generalized reduction or abnormally high
sensitivity (Fig. 9.6).
Octopus Single Field Printout

The commonly used seven in one printout is near
identical to the Humphrey single field printout
(Fig. 9.7). Again, a systematic and sequential
approach helps in interpretation. As before there
are eight parts to the single field printout. Each
has to be examined serially before drawing a
conclusion.
Reproducibility (Zone-1): Before looking at other
components of the printout, one needs to identify
the field in question to the concerned patient.
One quickly checks the name and date of birth
as printed on the upper part of the printout. Test
parameters such as the size of the stimulus and
pupil, type of test strategy, and test program used
are also looked at along with the eye and date
of examination.
Reliability factors (Zone-2): To assess the
reliability of the concerned examination, one
assesses the catch trials just beneath zone I and
also the reliability factor listed below, with the

visual indices. False positives (FP) result when
the patient responds to the audible click of the
perimeter with no stimulus projected. It is also
expressed as a ratio of the number of times the
patient responds to a pause in the testing
sequence without presentation of the target
against the total numbers of pauses. False negatives
(FN) are expressed as a ratio, and occur when
the patient does not respond when a previously
thresholded point is retested with a brighter
stimuli. Each of these should be less than 10%.
The reliability factor (value) is determined by
the outcome of the catch trials and ideally it
should be less than 15%.
The Octopus 1-2-3 takes a video photograph
of the pupil and stores this in its memory. If
the eye deviates or the lid closes, the machine
registers the loss of fixation and disregards the
patients response till fixation is restored. Loss
of fixation for more than two seconds halts the
program. Hence the Octopus printout does not
document fixation losses.
Gray scale (Zone-3): This is the most colorful
part of the printout but like its counterpart in
the Humphrey single field, it is the least informative since it is obtained by the interpolation of
the actually tested sensitivities. Lighter colors
are suggestive of higher sensitivities and darker
areas suggest depression. Hence only a cursory
look is required. Black depicts an absolute loss
of sensitivity.
Comparison (Zone-4): It is synonymous with the
total deviation plot on the Humphrey single field
printout. The lower left part of the printout, one
on top of the other, is the comparison display,
with a numeric display above a probability map.
The comparison values are the difference
between the patients test results and age-matched
normals. The + symbol indicates a normal
sensitivity. The probability map is displayed
graphically below this. Defects are marked as
symbols of different shades. Darker the marking,
Basic Perimetry
Fig. 9.7: Octopus 1-2-3 seven in one printout like the Humphrey single field has eight
zones which need to be viewed systematically
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less likely it is to being normal. Values tagged
as p<0.5% mean are less than 0.5% of the normal
population may show such a defect without it
being significant. Comparison values represent
the total depression of the visual field.
display is best assessed by removing the normal

short term fluctuation from the loss variance. This
gives us the corrected loss variance (called loss
variance on the Humphrey single field printout)
which is more sensitive to localized defects.
Corrected comparison (Zone-5): It is synonymous

with the pattern deviation plot on the Humphrey
single field printout. The corrected comparison
represents the localized defect after removing the
generalized depression of the visual field from
the total depression. Similar to the comparison
they are represented by values, + for normal
sensitivity and the probability map is displayed
graphically below this.
Bebies curve (Zone-8): In the presence of a local

defect, it is often difficult to quantify an additional
diffuse defect in a particular visual field. The
cumulative curve was introduced by Dr. H. Bebie
in the late 1980s to help assess the overall
condition of the visual field at a glance. In the
Bebies curve test locations are arranged
according to the extent of their difference from
the normal values. The individual test locations
are arranged on the x-axis, and the defects in
decibels on the y-axis. The test locations with
the least difference are found on the left side
of the figure, while those with the greatest are
on the right side. With this graphical representation, it is simple to differentiate localized from
diffuse damage.
Numeric data/raw data (Zone-6): They represent

the actual thresholded points from which the
entire statistical calculation is done. Close to
fixation, values are in their late twenties or early
thirties. In the mid periphery, threshold values
are in their mid twenties and in the late teens
in the periphery.
Visual field indices (Zone-7): They were first
introduced on the Octopus perimeters in 1985
and include:
Mean sensitivity is the average of retinal
sensitivities that are measured at all points.
Mean defect (called mean deviation on the
Humphrey printout) is the average defect of all
thresholded points from the age-matched
normals, as shown in the comparison chart. It
is indicative of the height of the hill island of
vision.
Loss variance (called pattern standard
deviation on the Humphrey printout) is obtained
from individual deviations of all measured
locations with the mean defect value. These are
indicators of localized damage.
Short term fluctuation is a reliability factor
suggestive of an intra test variation. A value of
more than 2.5 is significant. The difference
between individual deviations on the numeric
Analysis of Single Field Printout

After ensuring good reproducibility the visual
field is analyzed using each of the eight areas
alone or in combination. The reliability indices
give an indication of the credibility and accuracy
of the fields. The gray scale gives a rough over
view of the field, but is not used in the actual
field interpretation. Any suspected change must
be confirmed by inspecting other parts of the
printout. The total deviation and pattern deviation (Comparison and Corrected Comparison on
the Octopus printout) should be compared in
tandem. A difference between them if seen must
be explained. The pattern deviation symbols are
used in the interpretation of the field with the
arrangement and severity of the points or clusters
analyzed. The greater the number of points
involved and greater the depression the more
severe the defect is. After a quick look at the
Basic Perimetry
numeric data, the global indices (visual field
indices on the Octopus printout) are analyzed
next, with the mean deviation (mean defect on
the Octopus printout) being an indicator of the
overall depression of the field. The pattern
standard deviation (loss variance) or corrected
pattern standard deviation (corrected loss
variance) is considered significant when a score
of p < 5% is noted. The short term fluctuation
is analyzed as a part of the reliability indices
and with the total and pattern deviation symbols.
The glaucoma hemifield test is analyzed at the
end, a reading outside normal limits is
significant. The interpretation should also
include allowance for artifacts such as drooping
lid, prominent brow, or improper positioning of
the patient/trial lens. Other mimics of glaucomatous field loss include retinal and neurological
disorders along with disorders affecting the
clarity of the ocular media. These need to be
ruled out by a detailed ocular examination.
The minimum criteria for the diagnosis of
glaucoma are listed in Table 9.1.
TABLE 9.1: MINIMUM CRITERIA FOR
DIAGNOSIS OF GLAUCOMA
1. Three or more non-edge points in the pattern deviation
plot with sensitivity reduce to level of p < 5% or
worse, with at least one point <1%
2. Glaucoma hemifield test is outside normal limits.
3 Corrected pattern standard deviation p <5%
Criteria should be fulfilled on at least two occasions
Non-characteristic visual field defects (Figs

9.8 to 9.11) must be substantiated by clinical
examination of the retina and optic nerve head.
The first visual field test in an inexperienced
patient should be taken with caution. After first
test the patient becomes more proficient; the
resulting improvement in the visual field is
known as learning curve. It is, therefore, desirable
to test two or more visual fields before proper
interpretation. To be clinically significant, the
visual field should be reproducible.
While assessing single field printout, the

presence of miotic pupil and media opacities
should be taken into consideration because they
can cause generalized depression of visual field.
The interpretation should also include allowance
for artifacts such as position of the patient,
correcting lens (Fig. 9.12), drooping of the lid
and prominent brow. It is not rare to find that
visual field changes in neurological disorders
(Fig. 9.13) may mimic the glaucomatous field
defects.
The visual field examination is a useful tool
to study the course of an eye disease as well
as to monitor the therapy. Periodic visual field
testing is usually recommended for all glaucoma
patients especially with a view to evaluate the
desired target intraocular pressure. In spite of
good control of the pressure, the patients visual
fields may show deterioration on follow-up (Fig.
9.14) while in some patients the fields remain
stationary (Fig. 9.15). Assessment of progression
is difficult because of the long-term fluctuations.
One needs to repeat the field test when in doubt.
In clinical practice the recent fields are compared
with the earlier baseline fields to judge the
progression.
Conclusion
In conclusion automated perimetry is an
extremely useful tool which has also become the
standard technique for evaluating the visual field
in patients with glaucoma or glaucoma suspects.
Interpretation of the results is difficult and
requires experience in addition to a detailed
understanding of the underlying principles of
automatic static perimetry and the applied
statistical analysis.
A word of caution is necessary. Automated
perimetry should never be used in isolation.
Treatment of patients requires combining the
results of automated perimetry with an
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Fig. 9.8: Humphrey single field 24-2 SITA standard test of the left eye of a 53 year old patient. Reliability factors
have been expressed as a percentage. The visual field is markedly depressed in the inferior hemisphere on the
gray scale and total deviation plot. Andersons criteria are fulfilled. The height of the hill island of vision represented
by the mean deviation is significantly reduced. Clinical correlation with the amount of optic disk cupping is necessary
to determine the cause of such a defect
Basic Perimetry
Fig. 9.9: Humphrey single field 30-2 full threshold test of the left eye of a 64 year old patient. High false positives
are bracketed. The gray scale and the total deviation plot show a marked depression of the visual field. However,
only a cluster of points on the pattern deviation plot (p<2%) in the central 10 degrees are seen. No probability
symbols are seen alongside the CPSD and the Glaucoma Hemifield test is showing a borderline/generalized reduction
in sensitivity
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Fig. 9.10: Octopus 1-2-3 seven in one single field printout of the left eye of a 61 year old male patient showing
an early inferonasal step. There are a number of adjacent points in the inferonasal quadrant on the corrected probability
plot, depressed to 5%, one of which is depressed to less than 1%. The left part of Bebies curve shows a localized
depression. The corrected loss variance is 8.4. This field needs to be correlated clinically
Basic Perimetry
Fig. 9.11: Octopus 1-2-3 seven in one single field printout of the left eye of a 61 years old male patient to assess
fixation characteristics. Here the catch trials are suggestive of poor reliability. The gray scale and comparisons
are suggestive of depression of the inferior part of the 10 degrees being tested. Within the central 4 degrees of
this program, each point is 0.7 degrees apart. This helps to assess fixation characteristics better. One of the four
fixation points is depressed p < 2%. The Bebies curve is initially suggestive of normal points corresponding to
the superior part of the field. A sudden drop in Bebies curve is due to the cluster of depressed points in the
inferior part of the field. The CLV is also significant. This field is suggestive of extensive damage in the inferior
hemisphere which is threatening fixation and needs to be correlated clinically
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Fig. 9.12: Humphrey single field 24-2 full threshold test of the left eye of a 52 years old patient. A ring scotoma
on the gray scale and the pattern deviation plot is evident. Andersons criteria are also fulfilled. Such visual field
loss could be due to glaucoma or retinitis pigmentosa. However, the fundus findings were normal and on repeating
the field test (with proper positioning of the lens) the changes in the pattern deviation plot disappeared (Lens rim
artifact)
Basic Perimetry
Fig. 9.13: Humphrey single field 30-2 full threshold test of the right eye of a 59 years old patient. The gray scale
and the total deviation plot show a depression of the visual field. Here the gray scale shows a marked temporal
depression as is evidenced on the pattern deviation plot. Such defects which respect the vertical meridian are
neurological in origin. In this patient the other eye also showed a temporal hemianopia
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Fig. 9.14: Change probability analysis showing deterioration in fields over a period of time
Basic Perimetry
Fig. 9.15: Overview printout showing stable fields
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examination of the complete eye especially the
retina, optic nerve and visual pathway.
Bibliography
1. Caprioli J. Automated perimetry in glaucoma.
Am J Ophthalmol 1991;111:235.
2. Fankhauser F. Problems related to the design
of automatic perimeters. Documenta Ophthalmologica 1979;47(1):89.
3. Flammer J. The concept of visual field indices.
Graefes Arch Clin Exp Ophthalmol 1986;224:389.
4. Heijl A, Lindgren G, Olsson J. A package for

the statistical analysis of visual fields. Doc
Ophthalmol Proc Ser 1987;49:153.
5. Humphrey Field Analyzer Users guide.
Humphrey Instruments, Inc. San Leandro, 1994.
6. Octopus Visual Field Digest. 4th ed. Switzerland,
Interzeag AG.
7. Johnson CA, Keltner J. Automated suprathreshold static threshold perimetry. Am J Ophthalmol
1980;89:731.
8. Kaiser HJ, Flammer J. Visual Field Atlas A
guide and atlas for the interpretation of visual
fields. University Eye Clinic, Basel, 1992.
Ophthalmoscopy
PUKHRAJ RISHI, TARUN SHARMA
10
Ophthalmoscopy
A comprehensive eye examination is a must for

a complete assessment of the anterior and
posterior segments of the eyebe it a diagnostic
or preoperative evaluation. Although there are
several methods of eye examination viz slit-lamp
biomicroscopy, gonioscopy, perimetry, tonometry,
ultrasonography, ophthalmoscopy remains an
important tool for a complete evaluation of the
posterior segment of the eye. In December 1850,
Helmholtz announced the invention of an eyemirror, which was the original ophthalmoscope.
It was mounted with a holder for one lens, and
lenses had to be changed constantly for eyes
of different refraction. Rekoss introduced a
revolving disk carrying a series of lenses.
Fig. 10.1: Optics of image formation in an

emmetropic eye
overlap. In the emmetropic eye this can happen

only if the light source and the observers pupil
are optically aligned. Under normal conditions
this does not happen, hence the pupil normally
appears dark (Fig. 10.2).
Principles of Ophthalmoscopy
The basic principle of ophthalmoscopy is shown
in Figure 10.1. If the patients eye is emmetropic,
light rays emanating from a point in the fundus
emerge as a parallel beam. If this beam enters
the pupil of an emmetropic observer the rays
are focused on the retina and an image is formed.
This is called direct ophthalmoscopy.
The fundus can be seen only when the
observed and the illuminated areas of the fundus
Fig. 10.2: The light source and the observers pupil

are not optically aligned
The illuminating and the observing beams

are aligned using a semi-reflecting mirror or a
prism allowing fundal view (Fig. 10. 3).
Indirect Ophthalmoscopy
Ruete introduced indirect ophthalmoscopy in
1852. There are several types of indirect
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152

scopy. Indirect ophthalmoscopy is carried out
in a dark room with fully dilated pupils.
The equipments required for slit-lamp indirect
ophthalmoscopy includes slit-lamp and
condensing lens. The condensing lens may be
either noncontact or contact lens.
Fig. 10.3: The light source and the observers pupil
are optically aligned
ophthalmoscopes are available. One must

understand optical principles of indirect
ophthalmoscopy to carry an ocular examination
(including fundus angioscopy). The indirect
ophthalmoscope can be used in the treatment
of disorders of the posterior segment.
Noncontact lenses: They are plus powered with

two convex aspheric surfaces. The +60D version
has the greatest magnification and is best used
for the disk and macula. The +78D version is
a commonly used diagnostic lens and the +90D
is good for small pupils. They are available in
clear or blue-free, yellow retina protector glass.
They are comfortable to the patient and minimize
the risk of phototoxic retinal damage due to
prolonged exposure to the focused beam.
Contact lenses: Goldman, Mainster, SuperQuad,
Equator Plus, Area centralis, Super Macula lenses
are often used. Field of view and image magnification obtained by these lenses are listed in Table
10.1.
Method of Examination
Fig. 10.4: Optics of indirect ophthalmoscope
There are five indirect ophthalmoscopy

techniques. These are, slit-lamp indirect, head
mounted indirect, monocular indirect, modified
monocular indirect and penlight ophthalmo-
For examination, minimal slit-lamp intensity can

be used in a dark room. Always focus the oculars
to accommodate any examiner refractive error,
then set the pupillary distance, remove all filters
TABLE 10.1: FIELD OF VIEW AND IMAGE MAGNIFICATION OBTAINED BY DIFFERENT CONTACT LENSES
Lens
Field of view
Image mag.
Laser spot
Working distance
Super Quad 160
160/165
.5x
2.0x
contact
Equator Plus
114/137
.44x
2.27x
contact
Quad Pediatric
100/120
.55x
1.82x
contact
QuadrAspheric
120/144
.51x
1.97x
contact
PDT Laser
115/137
.67x
1.5x
contact
Trans Equator
110/132
.7x
1.44x
contact
Area Centralis
70/84
1.06x
.94x
contact
Super Macula 2.2
60/78
1.49x
.67x
contact
mag: magnification
Ophthalmoscopy
and keep the magnification to the lowest setting,
usually X6-X10. The illumination of the slit-lamp
should be adjusted for an intermediate slit height
and a 2 mm width, and then placed in the straight
ahead position between the oculars (zero degrees
or co-axial). Before examination, ensure that the
condensing lens surfaces are clean. Hold the
lens vertically between the thumb and index
finger of the left hand to examine the patients
right eye and vice versa.
Examination Procedure
Instruct the patient to fixate straight ahead, to
stare wide and to blink normally. Center the beam
in the patients pupil and focus on the cornea.
Now the lens is placed in front of the patients
eye, directly in front of the cornea so the back
surface just clears the lashes. Examiners fingers
may be placed on either the brow bar or the
patients forehead. Using the joystick, focus on
the fundus image by slowly moving away from
the cornea, keeping the beam centered in the
pupil. Once the retinal image is focused, the
magnification may be increased. Scan across the
entire lens keeping it steady. In order to view
the peripheral retina, ask the patient to change
fixation into the nine cardinal positions of gaze.
The lens is realigned and refocused the slit-lamp
as necessary. To reduce interfering reflections,
tilt the lens or move the illumination arm upto
10 degrees on either side, once the fundus has
been focused. For fine tuning of the fundus view,
lateral and longitudinal adjustments of the lens
may be made to optimize the field of view. When
viewing finer fundus details, intensity and
magnification of slit-lamp should be increased.
Head Mounted Binocular Indirect

Ophthalmoscopy
Binocular indirect ophthalmoscopy (BIO) is a
technique used to evaluate the entire ocular
Fig. 10.5: Optics of binocular indirect

ophthalmoscopy
fundus. It provides for stereoscopic, wide-angled,

high-resolution views of the entire fundus and
overlying vitreous. Its optical principles and
illumination options allow for visualization of
the fundus regardless of high ametropia or hazy
ocular media.
Light beams directed into the patients eye
produce reflected observation beams from the
retina. These beams are focused to a viewable,
aerial image following placement of a high pluspowered condensing lens at its focal distance
in front of the patients eye. The resultant image
is real, inverted, magnified, laterally reversed,
and located between the examiner and the
condensing lens. The observer views this image
through the oculars of the head-borne indirect
ophthalmoscope.
An indirect ophthalmoscope (Fig. 10.6)
consists of a head band for comfortable placement, light source with variable illumination and
an adjustable mirrored surface in the main
housing and knobs to align the low plus powered
eyepieces (+2.00 to +2.50 D) with the examiners
interpupillary distance. A 20 D condensing lens
(Fig. 10.7A), a pair of scleral depressors (Fig.
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154
Fig. 10.6: Indirect ophthalmoscope
10.7B) and fundus drawing sheet (Fig. 10.7C)

are needed for a proper indirect ophthalmoscopy
and documentation.
Proper placement and adjustment of the
binocular indirect ophthalmoscope (BIO) is an
important step in the examination. Place the loose
BIO onto the head and position the bottom of
the front headband one index finger width above
the eyebrows. Tighten the crown strap until this
headband position begins to stabilize then
position the back head strap on or below the

occipital notch and tighten until secured. Now
the knobs that control the instruments main
housing (oculars and light tower) should be
loosened and fixate straight ahead and level in
vertical position the oculars and aligned
tangential to or slightly angled downward from
the ocular surface; this should maximize
observers visual field and minimize horizontal
diplopia. Horizontally align each ocular by
closing one eye and fixating a centrally positioned
thumb of an outstretched hand. Turn on the light
source and fixate straight ahead on a wall at
40 to 50 cm looking at the projected light source.
Use the mirror knob to vertically place the light
source at the upper one-half to one-third of the
field.
The headset is adjusted and the voltage set
to mid-range (occasionally the sneeze reflex may
start from the periphery first). The choice of
condensing lens depends upon the need for a
panoramic view or detail; a 30 D provides
panoramic view while fundus details can be
obtained with 14 D. Stereopsis is important and
depends on the choice of lens. A full stereopsis
is obtained with 14 D, three-quarter with 20 D
and one-half stereopsis with 30 D. A 30 D lens
can be used to get a view of fundus in patients
with small pupil. The condensing lens should
be held between the tip of the flexed index finger
and the ball of the extended thumb of the non-
Figs 10.7A to C: A 20 D condensing lens, B A pair of scleral depressors and

C Fundus drawing sheet
Ophthalmoscopy
dominant hand and the scleral depressor with
the dominant hand. The extended third finger
acts as the pivot. The more convex surface should
be toward the observer and the white-ringed edge
closest to the patient so as to avoid bothersome
light reflexes. These reflexes can be made to move
in opposite direction from each other by slightly
tilting the lens. Condensing lenses have their
surfaces coated to reduce such reflexes. The lens
must be smudge free.
The patient should have atleast some idea
of what to expect in the examination. Although
the patient may be examined in either sitting
or supine position, it is best to recline the patient
on a couch with the face directed towards the
ceiling to avoid stooping. The couch or table
should be just high enough to reach the
examiners hips. The examiner stands opposite
to the clock hour position to be examined. The
patient is instructed to keep both the eyes open
and fixate towards his outstretched hand which
points to the meridian of interest.
From a working distance of 18 to 20 inches,
direct the light beam into the pupil, producing
a complete red pupillary reflex. Pull backward
on the lens, maintaining the central position of
the pupil reflex, until the entire lens fills with
the fundus image. Fine adjustments are made
in the lens tilt and vertex distance to produce
a distortion-free full lens view. The patient must
be repeatedly urged to open the fellow eye. Good
cycloplegia is the most important single factor
in getting co-operation in this regard. The eye
with inadequate cycloplegia is very photophobic.
All the vital elements involved in the
visualization of the fundus, namely observers
macula, the eyepiece of the ophthalmoscope,
center of the condensing lens, patients pupil and
the object observed in the fundus must be kept on
an axis to maintain the fundal view. In order to
develop and achieve a continuous sweeping
picture of the fundus, a major retinal blood vessel
must be picked out from the posterior pole and

followed as anteriorly as possible by the
observers movements alone. This vessel should
be then followed back to the optic disk. This
maneuver needs constant practice to master it.
The problem of orientation in the fundus may
be solved by learning to accurately draw the
image exactly as we see in the condensing lens.
The drawing chart may be placed inverted over
the patients chest. Positioning 180 degrees away
from the area of interest, the observer must think
in terms of anterior in the fundus or posterior
in the fundus (or central and peripheral). Draw
the image seen in the lens on that part of the
fundus chart that is closest to the observer.
Since 30% of the retina lies anterior to the
equator, failure to study this region will result
in overlooking serious pathology in many cases.
Scleral depression not only allows for an easy
and complete view of the ora serrata and the
pars plana but also allows a better evaluation
of the retinal topography making lesions such
as horseshoe tears or vitreo-retinal traction more
visible. It is of particular value in differentiating
a retinal hemorrhage from a retinal break, in
recognizing a raised from a depressed lesion
and in detecting whether a foreign body lies on
or anterior to the retina. The absence of an
overhanging orbital margin superonasally makes
initial attempts at scleral depression easier. The
depressor is applied to the superior lid, without
pressure, at the tarsal margin. The patient looks
up and the depressor slides posteriorly parallel
to the surface of the globe, as the lid retracts.
The depressor is gently pressed against the globe
at the equatorial region and a grayish mound
is seen to come up in view from the inferior part
of the fundus. In viewing the ora, it is sometimes
necessary to tilt the condensing lens somewhat
forward, into a plane more nearly parallel to
the iris. It must be remembered that scleral
depression is a dynamic technique.
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Fundus Drawing: Color Code
(Peter Morse)
Color Code Red
Solid
Retinal arterioles
Neovascularization
Vascular abnormalities or anomalies
Vortex vein
Attached retina
Hemorrhages (Pre-intra-and sub-retinal)
Open interior portion of retinal break (Tears,
holes)
Normal foveola (Drawn as red dot).
Cross lines
Open portion of giant tears or large dialysis
Inner portion of chorioretinal atrophy
Open portion of retinal holes in inner layer
of retinoschisis
Inner portion of the areas of retina.
Color Code Blue
Solid
Detached retina (Fig. 10.8)
Retinal veins
Outlines of retinal breaks (Tears, holes)
Outline of ora serrata (Dentate processes, ora
bays)
Meridional, radial, fixed star-shaped and
circumferential folds
Vitreoretinal traction tufts
Retinal granular tags and tufts (Cystic, noncystic)
Outline of flat neovascularization
Outline of lattice degeneration (Inner chevrons
or Xs)
Outline of thin areas of retina
Intra-retinal cysts (with overlying curvilinear
stripes to show configuration).
Cross lines
Inner layer of retinoschisis
White with or without pressure

Detached pars plana epithelium anterior to
separation of ora
Outer surface of retina seen in rolled edge
of retinal tears, inverted flap of giant retinal
tear.
Stippled or circles
Cystoid degeneration.
Interruped lines
Outline of change in area or folds of detached
retina because of shifting fluid.
Color Code Green
Solid
Opacities in the media (Cornea, anterior
chamber, lens, vitreous)
Vitreous hemorrhage
Vitreous membranes
Hyaloid ring
Intraocular foreign bodies
Retinal opercula
Cotton wool patches
Ora serrata pearls
Outline of elevated neovascularization.
Stippled or dotted
Asteroid hyalosis
Frosting or snowflakes on cystoid,
retinoschisis, and lattice degeneration.
Color Code Brown
Solid
Uveal tissues
Pars plana cysts
Ciliary processes (Pars plicata)
Striae ciliaris
Pigment beneath detached retina
Subretinal fibrosis demarcation lines
Choroidal nevi
Malignant choroidal melanomas
Metastatic and other choroidal tumors
Choroidal detachment.
Ophthalmoscopy
Outline
Chorioretinal atrophy beneath detached
retina
Posterior staphyloma
Edge of buckle beneath detached retina.
Color Code Yellow
Solid
Intraretinal edema
Intraretinal or subretinal hard yellow
exudates
Deposits in retinal pigment epithelium
Detached macula in some retinal separations
Retinal edema as a result of photocoagulation,
cryothreapy or diathermy
Long and short posterior ciliary nerves
Retinoblastoma.
Stippled or dotted
Drusen
Color Code Black
Solid
Pigment within the detached retina (lattice,
flap of horse-shoe tear, paravascular
pigmentation)
Pigment in choroid or pigmented epithelial
hyperpigmentation in areas of attached retina
Pigmented demarcation lines at the attached
margin of detached retina or within detached
retina
Hyperpigmentation as a result of previous
treatment with cryothreapy, photocoagulation or diathermy
Completely sheathed retinal vessels.
Outline
Partially sheathed vessels (lattices, retinoschisis)
Edge of buckle beneath attached retina
Long posterior ciliary nerves and vessels
(Pigmented)
Short posterior ciliary nerves and vessels
Chorioretinal atrophy.
Fig. 10.8: Showing a long-standing, partial, rhegmatogenous

retinal detachment with demarcation lines and intraretinal
macrocyst. A horse-shoe tear, lattice degeneration and
a retinal dialysis are also seen. An improperly placed
scleral buckle effect is made out. Pars plana is detached
nasally. Retinoschisis with inner layer hole is seen in
inferotemporal periphery. Pars plana cysts are seen
inferiorly
Indirect Ophthalmoscopy in
Operating Room
Many problems may be encountered whilst
operating and performing an indirect ophthalmoscopy. The fundus to be examined is usually
a difficult one, with a retinal detachment and/
or PVR. The cornea may become edematous or
abraded during the course of surgery. Particular
care must be taken in patients having undergone
LASIK surgery to prevent dislocation of corneal
flap. The fundus picture may change with each
step in surgery. The advantages of indirect
ophthalmoscopy in the operation room stem from
its safe working distance from the sterile
operating field, in accurate localization of all
retinal breaks and other fundus landmarks by
scleral depression. It helps in obtaining a fine
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needle aspiration biopsy and treatment of
choroidal or retinal tumors.
Indirect ophthalmoscopy is a valuable tool
in the examination of children and uncooperative
adults: Since the field of view is much larger
with an indirect ophthalmoscope, fundus
examination is possible even in moving eye. A
quick comparison with the other eye is also
possible. Children would generally react more
favorably to the more impersonal distance of
indirect examination. It is also useful equipment
in examining the anterior segment for rubeosis
and tumor seedings in children with advanced
retinoblastoma.
Fundus angioscopy, and transillumination
with the help of a probe (Fig. 10.9) can be performed using indirect ophthalmoscopy; which
helps in differentiating various types of fundus
mass lesions. Nystagmus, aniridia, albinotic
fundus, partial vitreous hemorrhage, fundus
coloboma, microphthalmos and persistent
hyperplastic primary vitreous can be diagnosed
with the help of indirect ophthalmoscope.
Fig. 10.9: Transillumination probe
Monocular Indirect Ophthalmoscopy

Monocular indirect ophthalmoscopy combines
the advantages of increased field of view (indirect
ophthalmoscopy) with erect real imaging (direct
Fig. 10.10: Monocular indirect ophthalmoscope
ophthalmoscopy). By collecting and redirecting

peripheral fundus-reflected illumination rays,
which cannot be accomplished with the direct
ophthalmoscope. The indirect ophthalmoscope
(Fig. 10.10) extends the observers field of view
approximately four to five times. An internal lens
system then reinverts the initially inverted image
to a real erect one (Fig. 10.11), which is then
magnified. This image is focusable using the
focusing lever/eyepiece lever. It gives a field of
view of approximately 30 degrees, yet it is
important that the patient looks in 6 to 8 different
directions to see as much of the fundus as possible.
The optical system of the monocular indirect
ophthalmoscope (MIO) has a lens which erects
the image and allows seeing things as they
actually appear anatomically. It also gives a
greater working distance from the patient of 5
to 6 inches. The MIO has a yellow filter that
allows one to see deeper details of the retina
at about the level of the choroid. The cost of the
MIO is nearly equal to that of a good binocular
indirect ophthalmoscope and of course it does
not allow a stereoscopic view of the retina.
Ophthalmoscopy
Fig. 10.11: Optics of monocular indirect ophthalmoscopy
To examine the right eye, remove the patients
spectacle correction, stand to the patients right
side, and ask him to fixate straight ahead and
level with the left eye. The observer should wear
his refractive correction. The iris diaphragm lever
is pushed fully to the left to maximally increase
the aperture size. Center the red dot on the filter
dial to open the aperture for normal viewing.
The observer's head should be against the
forehead rest and align the eye through the
instrument with the patients right eye. Then
position several inches in front of the patient
and focus through the pupil onto the fundus
using the thumb and focusing lever. Adjust the
focus and iris diaphragm to produce a clear
maximally illuminated fundus view. Continue
to approach the patient until the observers
knuckle lightly touches the patients cheek, as
the working distance decreases, fundus
magnification increases. Angle the light slightly
nasally to illuminate and visualize the optic disk.
Modified Monocular Indirect

Ophthalmoscopy
A thorough fundus examination is important
and required in all young patients with strabismus or amblyopia in order to rule out organic
causes of amblyopia prior to the initiation of
treatment. The patient co-operation obtained with
head mounted binocular indirect ophthalmoscope (using a 20 D lens), and slit-lamp
biomicroscope (using a 90 D) is usually difficult
or impossible on younger children. Also the
magnification of the fundus may be inadequate
to allow accurate evaluation of posterior pole
details. The direct ophthalmoscope is often the
best available instrument for detailed retinal
examination in young patients.
However, children often become frightened
as the examiner approaches closely, as is
necessary with the direct ophthalmoscope and
co-operation is lost. Additionally children often
fix the ophthalmoscope light and track it as the
examiner moves it, allowing examination of the
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macula but not of the disk. The field of view
is small and the magnification is more than is
usually necessary. This will prevent the examiner
from seeing the large area of fundus. To avoid
these difficulties the direct ophthalmoscope can
be used in conjunction with a 20 D condensing
lens. This combination provides a moderately
magnified and wider angle view of the posterior
pole. This avoids the close proximity between
the patient and examiner required when using
a direct ophthalmoscope alone. This technique
is called modified monocular indirect ophthalmoscopy and has been noted for its ability to provide
a good view of the retina through a small pupil.
To begin the examination a red reflex is visualized
through the direct ophthalmoscope held approximately 18 cm from the patients eye. A 20 D lens
is then placed 3 to 5 cm in front of the patients
eye in the path of the ophthalmoscope light beam,
the examiner then needs to move slightly toward
or away from the patient until a clear image of
the retina is observed.
An inverted, aerial image of the retina is
produced, located between the observer and the
lens. The apparent magnification will gradually
increase as the examiner moves closer to this
image (i.e. closer to the patient), allowing more
detailed examination. Moving closer to the image
obtains a magnification of X4 to X5. As the
examiner moves closer additional lenses in the
ophthalmoscope are needed, to keep the image
clear depending on the accommodative needs
of the examiner. A viewing distance of approximately 18 cm from the patient is optimal,
providing suitable magnification and a wide
field of view
A disadvantage of the technique, as with
conventional direct ophthalmoscopy is the lack
of a true stereoscopic view, however, lateral
movement and rotation of the direct ophthalmo-
scope during the examination gives good

parallax clues to depth.
Penlight Ophthalmoscopy
This is a very old, basically a bedside technique
that originally utilized a penlight and a high plus
lens. The patient must be dilated to get as much
binocularity as possible and large field of view. The
ophthalmoscope is held just below the eyes and
its light directed into the patients eye. The
patients eye is viewed from over the top of the
ophthalmoscope while a 20 D lens is placed
approximately 3-4 cm from the patients eye. The
light leaving the condensing lens must come to
focus within the pupil allowing the fullest field of
view of the retina, approximately 30 degrees. The
image is inverted and laterally reversed and located
between the ophthalmoscope and the condensing
lens. The degree of stereopsis depends on how fully
the pupil is dilated and ones ability to converge
and accommodate on the image. It gives a larger
field of view than a MIO though less magnification.
This is an alternative method to examine small
infants. Should the bulb burn out in a BIO one has
an alternative means to get a good view of the
peripheral fundus? Do not put hands on the
patients shoulder or head. Instead, use the back
of the chair to steady yourself.
Direct Ophthalmoscopy
Direct ophthalmoscope (Fig. 10.12) is most
commonly used instrument in ophthalmic
practice. The ophthalmologist must familiarize
oneself with the use of the direct ophthalmoscope
in an appropriate manner.
Before being able to recognize the abnormalities in fundus, one must know what normal looks
like. It is advisable to examine as many of your
colleagues as possible both inside and outside
clinic hours. Good observational and recording
skills can be developed with practice.
Ophthalmoscopy
Fig. 10.12: Direct ophthalmoscope
Direct ophthalmoscopy is best carried out in a
dark room with fully dilated pupils. One must
be familiar with the color coding of the lens wheel
and the various apertures and filters. Instruct
the patient to look at a distant target (the white
spot light on the vision chart) and to pretend
to still see it even if obscured with your head.
The patient may blink as required. Your left eye
and left hand should be used to examine the
patients left eye. The field of view of the fundus
is increased when examiner goes closer to the
patients eye. When patients with low myopes
or low hyperopes are to be examined, it is better
to remove their glasses. However, for myopes
and hyperopes above 3.00 DSph and for
astigmats above 2.50 DCyl, it is advisable to keep
the glasses on in order to overcome problems
associated with magnification, minification and
distortion. The extra reflexes produced by the
spectacle lenses will at first prove distracting
but can be overcome with practice.
Using a large diameter aperture, examine the

external features of the eye including pupils. With
a +1 or +2 D lens in the ophthalmoscope, view
the pupils at a distance of 40 to 66 cms from
the patient. Look for media opacities. To find
the location of the opacity, note movement of
the opacity with relation to the movement of the
ophthalmoscope, using the pupillary plane as
a reference point. If the opacity moves in the
same direction as the ophthalmoscope, the opacity
is located behind the iris. If the opacity moves
in the opposite direction to the ophthalmoscope,
the opacity is located in front of the iris.
Using the ophthalmoscope as a light source,
which is held tangential to the iris one looks
for any shadow that appears on the nasal side.
If the nasal irido-corneal angle has no shadow,
it denotes a wide-open angle. However, as this
shadow increases in width relative to the overall
cornea size, the angle seems narrow.
Dial up +10 DSph lens in the lens wheel
and observe the eye from a distance of 10 cm.
Study the red reflex to detect any media opacity.
The position of opacity can be inferred from its
parallax with respect to the pupil. When the
patient looks up and the opacity appears to move
in the same direction within the red-reflex then
it is located anterior to the pupil plane (i.e. in
the cornea or in the anterior chamber). Opacity
that remains stationary lies in the plane of the
pupil but when it moves in the opposite direction
to that of the patients gaze it lies posterior to
the pupil plane (i.e. the posterior lens or vitreous).
It may be easier to move yourself slightly from
side to side rather than ask the patient to move
his eye to achieve the same effect. During
ophthalmoscopy it is advisable to keep both eyes
open and suppress the image from the other eye.
It may take some practice to accomplish this.
It is better to move closer to the patient and
gradually reduce the power of the lens in the
wheel and focus on the crystalline lens, the
vitreous and finally the fundus. The power of
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lens necessary to focus on the fundus will depend
on patients and observers uncompensated
refractive error and accommodation. Once a blood
vessel on the fundus is located, move along it
and locate the point at which it branches. Then
move your field of view in the direction in which
the apex of the branch is pointing till you reach
the optic disk.
If one controls his accommodation it allows
for an estimation of the patients refractive error
by focusing the optic disk. Retinal blood vessels
should be examined in each quadrant after
locating the disk. Artery to vein ratio (A/V),
arteriolar light reflex (ALR), branching of vessels
to all four quadrants and crossing phenomenon
must be assessed.
Once again focus the disk and move nasally
to view the macula. In this position you may
obscure the fixation target, cause the pupil to
constrict, dazzle the patient and notice some
troublesome corneal reflections. These factors
make the macula a difficult area to visualize.
It may be useful to use a smaller aperture beam.
The patient should not be asked to look into
the light when viewing the macula through an
undilated pupil. The patient will accommodate
and this together with the bright light from the
ophthalmoscope will make the pupil even smaller
reducing the ability to view the whole macular
area.
Finally ask the patient to look in the eight
cardinal directions to view the peripheral fundus.
You will need to adjust the lens in the wheel
slightly as the periphery is closer to you than
the optic disk requiring more focusing power
(plus lens). The red-free filter makes small
macroaneurysms and small hemorrhages
standout more clearly. It can also be helpful in
estimating the C/D ratio. It is also used to
differentiate between retinal nevus and choroidal
nevus. The retinal blood supply and its retinal
pigment epithelium (RPE) act like a red filter.
Therefore, a nevus that lies behind the retina

and located in the choroid will not be seen when
viewed with the red-free filter. On the other hand
a nevus located on or in the retina will still be
seen with the red-free filter in place. A cobaltblue filter is useful in detection of nerve fibers
drop out.
The direct ophthalmoscope gives a magnification of approximately X15 and a field of view of
6.5 to 10 degrees. The formula M= 60 D/4 holds
well for up to + or 10 Ds of refractive error.
Hruby Lens Direct Ophthalmoscopy

The use of the slit-lamp biomicroscope allows
a stereoscopic view of the retina. The auxiliary
lenses provide high magnification with excellent
resolution. The Hruby lens (-55 D) produces an
upright virtual image that is not laterally
reversed.
Patient co-operation can be enhanced by attention
to his comfort and with the use of a fixation
device. Once the illuminated slit is imaged in
the patients pupil, the Hruby lens is introduced
in front of the patients eye as close as possible
without contacting the cornea or lashes.
This mode of direct ophthalmoscopy can
provide a very high level of magnification, even
greater than that of the monocular hand held
direct ophthalmoscope. The actual level of
magnification depends on that available through
the slit-lamp. Stereopsis is provided to a greater
degree than all other examination techniques.
The main disadvantage of this technique is
the field of view. It is smaller than all other
examination methods with the exception of direct
monocular ophthalmoscopy (less than two disk
diameters for an emmetropic patient). More
dilation is required than in other binocular
Ophthalmoscopy
techniques. The quality of the image is easily
degraded by media opacities; however, increasing
the slit-lamp illumination can reduce this
problem. As the magnification is so high, small
movements of the observer, lens, or patient have
an immediately noticeable effect on image quality.
Wide-Angle Viewing System

Retcam
The Retcam (Fig. 10.13) has a 3 CCD chip video
camera. It is lightweight, easy to position and
has a long cable for easy patient access. It has
five changeable lenses: 130, 120, 80, 30 and
Potrait. It has a large LCD display with 20
seconds of real time video per clip and a frameby-frame or real time video review. It has a lighted
control panel, a dual DVD-RAM for easy backup, multi-image data recall and display, side
by side image comparison, high resolution 24
bit color image, instant-digital image capture and
Fig. 10.14: Wide-angle fundus photograph (Retcam) of

a premature infant showing retinopathy of prematurity with
a demarcation ridge clearly made out
Fig. 10.15: Fundus photograph (Retcam) of a premature

infant showing retinopathy of prematurity with laser
photocoagulation marks. Preretinal hemorrhage is seen
beyond the superotemporal vascular arcade
is US FDA approved. It provides a 130 view

for easy screening for retinopathy of prematurity
(Figs 10.14 and 10.15), integrated image and
patient management capabilities, comprehensive
photodocumentation, fluorescein angiography
and built-in software for reporting, storage and
archiving.
Panoret
Fig. 10.13: Retcam viewing system
Panoret (Fig. 10.16) is a high resolution, wideangle retinal camera based on an innovative
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Fundus illumination may, however, be limited
in heavily pigmented eyes. DVD recording is
possible. DICOM 3.0 connectivity is available
for telemedicine.
Bibliography
Fig. 10.16: Panoret
transscleral illumination concept using a fiber

optic bundle, where no pupillary dilatation is
necessary. Coverage angles are 50 and 100 with
interchangeable front lens assembly. It is
computer assisted in auto-light, auto-brightness
and contrast control along with auto-disk storage.
1. Yanoff M, Duker JS, Augsburger JJ, et al (Eds).

Ophthalmology (2nd edn). St. Louis, Mosby,
2004.
2. Benson WE, Regillo CD: Retinal detachment
Diagnosis and Management (3rd edn).
Lippincott-Raven, Philadelphia, 1998;75-99.
3. Regillo CD. Brown GC, Flynn Jr HW. Vitreoretinal DiseaseThe Essentials. Thieme, New
York, 1999;41-49.
4. Schepens CL, Hartnett ME, Hirose T: Schepens
Retinal Detachment and Allied Diseases (2nd
edn). Butterworth-Heinemann, Boston, 2000;99129.
5. Rosenthal ML, Fradin S: The technique of
binocular indirect ophthalmoscopy. Highlights
of Ophthalmology 1967; 9:179-257.
6. Michels RG, Rice TA, Wilkinson CP. Retinal
Detachment (2nd edn). Mosby, St. Louis, 1997;
347-70.
7. Havener WH, Gloekner S. Atlas of Diagnostic
techniques and Treatment of Retinal
Detachment. Mosby, St. Louis, 1997;1-51.
Ophthalmic Photography
SADAO KANAGAMI
11
Ophthalmic
Photography
Among all types of medical photography, the

speciality of ophthalmic photography is perhaps
the most difficult to master as it requires in-depth
knowledge of not only the ocular structures, and
the disease process of the eye, but it also requires
special photographic skills in regard to the
equipment needed to record ocular pathology
on silver base media or electronic medium.
Captured ophthalmic images often have a direct
influence not only on the diagnosis but also on
the treatment choice as in the case of fundus
fluorescein angiography (FFA) or indocyanine
green angiography (ICGA). The responsibility
of accurately capturing this information needed
by the treating ophthalmologist becomes critical
and weighs heavily on the shoulder of the
ophthalmic photographerespecially with the
advent of teleophthalmology where images may
be captured hundreds of miles away from the
treating ophthalmologist. The ophthalmic
photography differs greatly from biological
photography in general as the images captured
by the ophthalmic photographer are part of the
treatment decision process or utilized in the
management of ophthalmic patients. Recent
trends in ophthalmic photographic equipment
include computerized equipment that further
adds to the long list of specialized technique
and changes in ophthalmic imaging.
Some of the ophthalmic photography and

imaging equipments include the following in the
long list of tools used in our field.
35-mm Camera
A 35-mm camera with a motorized drive to
automatically advance the film should be fitted
with a long macro lens (135 mm to 150 mm or
a medical lens such as the Nikon Medikor lens)
in order to keep facial distortion to a minimum.
This is very important especially when taking
photographs in the speciality area of oculoplasty.
A macro lens should be selected to include fields
of one eye to full face; a second macro lens could
include head/shoulder to full body (Fig. 11.1).
The selected 35-mm camera should also be fitted
Fig. 11.1: Macro lens for closeup photography
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with either a double-sided macro flash or a builtin ring flash. These macro flashes are typically
meant for short range (less than one meter)
photography for optimum illumination. When
photographing oculoplasty patients for full body
photography, a studio flash set-up is still the
recommended approach.
Fundus Camera
Mydriatic Fundus Camera
Conventional non-corneal contact mydriatic
fundus camera (Fig. 11.2) can range between 20
and 60 degrees view of the ocular fundus. The
ophthalmic photographer can choose the angle
of view that will best reflect the needs of the
photodocumentation, for example, in imaging
the optic nerve for glaucoma one would use a
view of 20 degrees, while in the case of a large
melanotic choroidal tumor one would select a
wider 60 degree field of view. Mostly, these retinal

cameras capture full color images of the retina
as well as having capabilities of capturing
monochromatic and angiographic images
(fluorescein and ICG). Determining the exposure
level of electronic flash is completely different
from the regular 35-mm camera used in external
photography. Usually, these values are predetermined (factory setting) by the angle of view
selected on the retinal camera as well as the film
sensitivity used. Other determining factors for
flash intensity can be the use of a plus diopter
setting and angiographic or monochromatic
selections (such as cobalt-blue and red-free).
Typically, retinal cameras have two or more
camera backs; a 35-mm camera for color or
monochromatic black and white film, a polaroid
camera and in some cases certain retinal camera
manufacturers offer optional video camera
(analog or digital) to show the images on the
monitor and store them in imaging software program on the computer system.
Non-mydriatic Fundus Camera
Fig. 11.2: Fundus camera
As the name suggests, the non-mydriatic fundus

camera does not require the use of mydriatic
agents to dilate the patients pupil. The nonmydriatic fundus camera usually requires a
natural dilation of 4 mm; this can be a limiting
factor on patients over the age of 60 years old
that typically do not naturally dilate well. These
fundus cameras are usually very easy to operate
as they have no viewfinder but instead they use
a large 4-inch monochromatic TV monitor (or
in some more modern non-mydriatic cameras,
an LCD screen) where the patients fundus can
be seen by way of an infrared video alignment
camera. Since the viewing lamp utilizes infrared
wavelength, the patient is not aware of the
examination process. The flash illumination,
when using a low LUX video charged couple
device (CCD) camera, is usually very low as these
Fig. 11.4: ICG angiogram

Fig. 11.3: Non-mydriatic fundus camera
cameras have a very high sensitivity. The lower

the LUX level of the color CCD camera, the faster
the pupillary recovery time and thus, the faster
the photographic procedure. There are many
manufacturers of non-mydriatic fundus cameras
some have the ability to capture angiographic
images. When one uses mydriatic cameras in
the mode of non-mydriatic, these cameras are
usually confined for mid-phase only as a waiting
period of at least one minute must be allowed
to permit full pupillary recovery time. Nonmydriatic cameras can download their captured
images to a computerized filing system. Often,
non-mydriatic cameras (Fig. 11.3) are used to
photograph diseases of the posterior segment
of the eye.
The camera is very small and light weighted,
it can be easily taken outside of the clinic. Fundus
images have been stored on a personal computer
directly from the camera using USB cable and
an exclusive software.
Indocyanine Green Angiography

Indocyanine green angiography (ICGA) can be
performed with near-infrared illumination using
a retinal camera. ICGA examines the dynamic

flow circulation of the choroidal vessels and
adjunct structures (Fig. 11.4). Typically, a retinal
camera that has been designed with special filters
uses a black and white near-infrared CCD video
camera (analog or digital) and records static megapixel images stored in a computer bank or
dynamic images on videotapes as in the case
of the scanning laser ophthalmoscope (SLO).
Digital Hand-held Fundus Camera

Digital hand-held fundus camera is recently
introduced. This camera is designed for digital
images, therefore, it becomes light and easy to
operate compared to the previous model. The
fundus images are displayed on a small LCD
monitor and can be checked. These images can
be stored on a memory card.
There is an adapter for indirect images. The
adapter is very useful while taking the fundus
photographs of the premature babies (Fig. 11.5).
Photo Slit-lamp (Kowa Attachment)

The hand-held Kowa Genesis camera has a
special attachment (Fig. 11.6) that allows for
anterior segment photodocumentation using a
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Fig. 11.7: Gonio photography
Fig. 11.5: Digital hand-held fundus camera
gonioscopy, topical anesthetic agent and a

transparent gel such as Gogniosol should be
used. A lens that has anti-reflection coating
should be preferred.
Use of gonioscopic lenses need special
techniques, however, combined with the use of
a video camera it makes it easier to preview the
captured field as opposed to capturing on
conventional 35-mm film and waiting for the
film to be processed to evaluate the photographic
technique. However, using video-captured image
does not equal the quality of 35-mm film
(resolution, hue, color, contrast) but most
surgeons agree that the trade-off of immediacy
in seeing the images is well worth than the
quality of the 35-mm film. For publication a
conventional 35-mm film can also be used in
conjunction with the video images.
Portable Slit-lamp with Video Camera

Portable slit-lamp is very useful when taking
pictures of bed-ridden patients and/or small
children. This slit-lamp can adapt a very small
video camera and can take patients anterior
segment photographs or video images.
Fig. 11.6: Kowa genesis with slit-lamp attachment
slit-adapter. It allows the user to take images

on either 35-mm film, video or fully digital backs.
Once the adapter is connected, it is possible to
capture conventional anterior segment images
including of gonioscopy (Fig. 11.7). For
Photography in Operating Theatre

There are two main ways of capturing images
in the operating theatre, the first consists of
positioning the camera next to the operator using
a bedside approach, while the other technique
is to attach a camera directly to the operating
microscope and have the operator take all images
using one of the optical pathways of the
microscope (right or left). Using this technique
means that the photography port will be taken
through a 70/30 type of prism and that the
operator will have to look through only the optical
pathway that is occupied by the camera. Using
this technique will ensure the operator that what
he/she sees is actually captured. Additionally,
using this technique will give a good preview
of the non-stereo image that is captured by the
recording device since only one optical pathway
is equipped with a recording device (usually the
right optical pathway is best). It is critical that
the microscope should be set for focusing the
recording device and not the operators actual
diopteric correction. If this is not done, captured
images may not be sharp. The operator will also
notice that the field viewed and the field
photographed is not exactly the same area
(usually the photographed field is smaller) but
with practice and years of experience, very good
results may be achieved. It is critical as in any
other type of photography that the primary lens
(lens close to the patients cornea) should be free
of artifacts such as: dust, fingerprints, water
stains, fluorescein stains. Attentive care should
be given to the lens cleaning techniques to avoid
possible damage to the costly lens. If this is not
done, the quality and color of the captured images
will be very low with color shift and low contrast
images as well as poor optical resolution.
Specular Microscopy
Photography of the corneal endothelial cells can
be easily performed using a slit-lamp photomicroscope and resulting images can be analyzed
using a computer program. Typically, these
images can show the borders of the cells that
reflect the light towards the high magnification
microscope lens when used in conjunction with
specular illumination methods. This illumination

can be achieved by using the illumination tower
set at 45 degrees (incident light) from the apex
of the cornea while observing the return light
(reflected light) through the objective when the
observation tower is set at 45 degrees from the
opposite side of the illumination tower. Recent
trends in specular microscopy are the use of noncontact specular microscope that causes little
trauma to the patient and risk of cross contamination is less because no corneal applanation
is required with the system.
In Figure 11.8 one can easily compare the size
and/or the arrangement of the endothelial cells.
With innovative imaging technology the use of
non-contact specular microscopy can be easily
observed on large monitor obviating the use of
prints or photography on silver highlight film base.
Fig. 11.8: Specular photography: endothelial cells
In the past, the role of the ophthalmic

photographer was limited to the capturing of
the endothelial cells of the cornea. Today,
however, the role of the ophthalmic photographer
has evolved to include the analysis of the corneal
cells using a computer program (Fig. 11.9).
Imaging System
In 1990, the field of ophthalmic photography
was introduced to electronic imaging technology.
At first, only two companies in the United States
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accepted daily routine tool of major universities
and HMO type practices. The electronic imaging
has mostly replaced all film based angiography
(especially true for ICG) avoiding the long
darkroom delays. Although this technology is
not comparable to film based technology, yet as
far as resolution and gray scale, it does offer
certain advantages, such as, instant results
viewable on large CRT screens, image processing
or enhancement, transfer of images through the
internet for teaching, screening or second opinion
(teleophthalmology).
Advantages
Fig. 11.9: Noncon robo
were in the forefront of this newly introduced

technologyKOWA VK-2 system (Fig. 11.10),
Topcon ImageNet and Ophthalmic Imaging
Systems (OIS). Soon thereafter, a flurry of imaging
systems appeared mostly in PC base and mostly
disappearing in a year or two. In the past ten
years, this new technology has grown to be an
Imaging system has following advantages:

1. Captured images are displayed on a monitor
immediately,
2. Displayed images are large, so the patients
who are dilated or have low vision can
appreciate them,
3. Images may be reviewed by the treating
ophthalmologist as they are being captured,
4. Prints can be produced immediately on thin
paper so it is easy to put on a patients chart,
and
5. Images may be stored in the computer data
base system for easy review and follow-up.
Disadvantages
Fig. 11.10: Digital imaging system: KOWA VK-2 system
Imaging system has following disadvantages:

1. The computer systems are quite expensive
and technology changes rapidly making
systems obsolete in one year,
2. Computer, large CRT screen and printer
require additional space,
3. Operation of the computer and system
software requires training and maintenance,
and
4. Quality of image is not yet comparable with
35-mm film.
Imaging systems in ophthalmology typically
means that the conventional ophthalmic camera
recording device such as the 35-mm or polaroid
type back is replaced with a charged couple
device (CCD) that may be either analog (video
signal) or digital (higher resolution than video
signal). These CCDs usually can add significantly to the cost of the fundus or slit-lamp camera
especially if they are digital in nature. Digital
CCD can be either a single chipped red, green
and blue chipped or could be 3 chipped, one
for each of the RGB wave lengths. The latter is
far more expensive than the single chip but the
color separation with the three-chip-CCD is
superior. The area of sensitization of the CCD
chip (usually varying from inch-to-inch) being
much smaller than of the 35-mm surface (24 mm
36 mm) or of the polaroid sheet, the light (flash
intensity) required to expose the light sensitive
CCD is significantly less than that of traditional
film base emulsion to expose the same area of
the eye. Much like the film base emulsion, CCD
comes in a variety of sensitivity calculated in
LUX values. The lower the value in front of the
LUX, the more sensitive (and usually more
expensive) the CCD is. However, it can also be
said that the more sensitive the CCD is, the more
electronic noise (comparable to large grain
when referring to film) can be produced (comparable to higher sensitivity film such as 1,600 or
3,200 ISO). More recently, ophthalmic manufacturers: have introduced non-mydriatic retinal
cameras with purely digital recording devices.
Non-mydriatic cameras are usually equipped
with two CCD, one is a black and white infrared
low resolution used for alignment of the patients
retina (image is viewable on a small CRT screen
located on the base of the non-mydriatic retinal
camera), while the second is used to actually
capture the color image of the retina through
the naturally dilated pupil in a dimly lit room.
One of the main advantages of the low light CCD
chip used in the non-mydriatic camera is that
retinal images can be captured sequentially
without having to wait 4 to 5 minutes as with
instant type photography (polaroid). The
captured retinal images typically do not affect
seriously the natural dilation of the pupil.
Pupillary recovery is usually very fast as opposed
to when using instant type film. Additionally,
some non-mydriatic retinal cameras can capture
ICG angiography since in some cases the infrared
cameras used higher resolution.
Photograph of Both Eyes

To take the photographs of ocular movements
especially in case of strabismus, amblyopia, and
ocular muscle disorder, eye gaze position in 9
directions should be captured (Fig. 11.11). To
Fig. 11.11: Eye gaze position in nine directions
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achieve this type of photography, simply place
the patients head in a straight forward position
referred to as primary gaze. Having selected a
long lens such as 135-mm macro or 150-mm macro
combined with a ring flash, and patient is asked
to fixate at a gaze of 30 degrees in each oclock
position such as 12 oclock, 1:30, 3, 4:30, 6, 7:30,
9 and 10:30 and take photographs in each of
these positions. Make certain that the patient
maintains his or her head in the primary straight
forward position and avoid side-to-side head
shifts or frontal and backward tilts. When taking
photographs in downward gazes (4:30, 6, 7:30
o'clock), an assistant should help in lifting the
eyelids in order to expose those gaze positions.
For an overall even illumination, the use of a
ring flash should be used, as the ring flash will
create a ring pattern on the patients corneas,
will be equidistant and could be considered as
a Heirshberg ring. The long macro lens (135150-mm macro) will avoid facial distortion and
give accurate facial renderings.
Photography of Face and Skin

For full-face photography of patients (Fig. 11.12),
the practice of using a long 135 to 150-mm macro
lens still applies in order to maintain correct
facial proportions and avoid the distortion
created by wider-angle non-macro lenses. It is
important that the patient wipes the facial sweat
or heavy make-up used by some women as well
as any ocular ointment used onto the eyes prior
to taking photographs. This practice will avoid
getting any unwanted or irregular flash reflexes.
Typically, it is a good idea to use an electronic
set of flashes mounted as in a photo studio. This
type of illumination helps to accentuate areas
of interest by creating shadows. If no flash is
available, it is possible to use natural outdoor
sunlight illumination but caution should be used
not to over-expose the area of interest and use
a standard blue or gray background. To document
Fig. 11.12: Face and skin photograph
proptosis, the best position is to capture the image

from above the patients head using two macrotype electronic flashes set at 90 degrees from the
patient. This technique will create the appropriate
shadows that will help define areas of interest
to the oculoplastic surgeon.
Photography of Pupil
In some cases of neuro-ophthalmology, it is
important to document the pupillary changes
of patients and to differences between the right
and the left pupil (as both may dilate differently
from each other under similar Lux conditions).
The best way to record these differences is to
use a black and white camera that is mounted
on a tripod (for added steadiness) and have the
patient place his chin in a chin-rest (also for
added steadiness). The room is then darkened
and about 5 minutes is needed to allow for each
pupil to either dilate or constrict depending on
the particular condition of the patient (at times
a flash light, white light, may be used to provoke
a specific pupillary reaction that is recorded on
video). Analog iris recorders are available that
use infrared CCD cameras in combination with
an infrared illumination system that is not
perceivable to the patient and where the patients
pupil does not react. Images are then recorded
as either a series of still images or as a string
of segments (continuous video images) that are
then transferred to a computer for numeric
processing. Typically when performing these
studies, no mydriatic agents are used unless
otherwise indicated by the examiner.
External Photography
When taking photographs of the cornea and the
lens, the choice instrument is a photo slit-lamp
since it has the correct optical magnification and
the appropriate flash to accomplish the task at
hand. However, when a photo slit-lamp is not
available, a 35-mm SLR camera with macro lens
and electronic flash or even a fundus camera
(using a plus diopter) may be used. External
close-up photography of one eye for the purpose
of documentation of ocular trauma or tumors
can be taken with a macro type lens (usually
a long lens) and a side macro flash (usually
mounted on either side of the front of the macro
lens) to avoid disturbing flash reflexes often found
when using a ring flash type systems. Careful
evaluation of where the flash reflex will fall is
critical in obtaining useful photo-documentation.
Many macro type electronic flashes have what
is called a modeling light that is mounted directly
next to the flash tube. These modeling lights will
illuminate the field of interest and give a good
idea of where the flash reflexes will show-up
when the photograph is captured. Since the
cornea and sclera are highly reflective surfaces,
special attention needs to be given to the
illumination technique. It is possible to limit these
reflections by using polarizing filters on the flash
and lens, however, the reflexes will only partially

disappear and the iris detail is made very dark.
Conventional 35-mm SLR Camera

When using a 35-mm macro lens for ophthalmic
photo-documentation, it is critical to select a lens
that will keep the true perspective of the area
of interest. Nikon Corporation introduced a
special macro lens with intergraded ring type
macro flash tube. This special macro lens called
Nikor Medikor lens, it comes in two focal lengths.
This lens works somewhat differently in that
the photographer selects the required magnification on the lens and then simply focuses by
physically moving towards or away from the
patient. Other possible choices for macro lenses
are:
One eye
135 to 150 mm macro lens
Two eyes
Full face
Torso
Full body
Use of Fundus Camera in External

Photography
The hand-held fundus camera (Kowa Genesis)
may be especially useful in close-up external
photography as the system uses a powerful
distortion-free macro lens along with a co-axial
illumination in the fundus camera that produces
a small reflex on the cornea or sclera. This camera
is particularly well suited in the pediatric
population (Fig. 11.13).
Some table-top retinal cameras are also well
suited for external (single eye) photo-documentation of the eye; these retinal cameras are usually
fitted with a frontal concave lens. To capture
the images, simply position the patient in the
chinrest as you would for conventional retinal
photography and select a plus diopter setting
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Fig. 11.13: Photograph of external eye with handheld fundus camera
Fig. 11.15: Fluorescein stain photography
(as well as in some cases selecting a higher

magnification lens) by focusing the retinal camera
until the images becomes clear. Film type and
flash exposure is the same as for regular fundus
photography (Fig. 11.14). For taking fluorescein
stain photography of the cornea or sclera, the
retinal camera may be the most useful instrument
since it already has both the exciter and barrier
filter in place (Fig. 11.15). When performing iris
angiography, again the retinal camera is best
suited for this purpose not only due to the filters
but also because these cameras are equipped
Fig. 11.16: Anterior segment fluorescein angiogram
with an internal timer that is critical for fluorescein studies requiring dynamic flow analysis
(Fig. 11.16). Black and white films ISO 400 or
instant type (polaroid or Fuji) film can be used
and processed in a similar way as for retinal
angiography.
Optical System of Fundus Camera
Fig. 11.14: Photograph of external eye with table-top

fundus camera
Fundus cameras optical system can be compared

to the Galilean type telescope and is characteristic
by incorporating an internal co-axial type
illumination and electronic flash. The light
emitted through the objective of the camera lens
is a ring-shaped image. The distance from this
ring to the surface of objective lens is referred
to as the working distance and is of great
importance in taking good artifact-free fundus
photographs. The actual position of this ringshaped light can be best observed by looking
from the side of the fundus camera. To keep this
relative position constant is one of the most
important and basic points in fundus photography to insure good color saturation and
artifact-free photography (Fig. 11.17).
agent to achieve best possible pupillary dilation

(optimally a pupillary dilation of over 8 mm is
desirable). The objective lens should be clean
and free from dust and smear. Any dust particles
must be carefully removed with a manual blower
while smear should be removed with lens
cleaning paper. Check that the film is correctly
loaded and flash intensity control is properly
set according to the film sensitivity as well as
the retinal pigmentation. Also adjust the eyepiece
diopter scale to match the operators diopteric
correction (Fig. 11.18). Adjust the height of the
motorized camera table as well as the operators
and patients stool so both may be as comfortable
as possible in front of the fundus camera
(Fig. 11.19).
Fig. 11.17: Working distance
Fundus Photography
Preparatory Operations
Prior to starting the photographic session, the
patients eye must be dilated with a mydriatic
Fig. 11.18: Diopteric correction
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Fig. 11.19: Comfortable position
Operational Procedures
The patient rests his/her chin on the chin rest
and presses his/her forehead lightly against the
forehead bar. Adjust the patients lateral canthus
with the head rest of the fundus camera and
align the patients eye with the illumination beam
and optical pathway of the fundus camera. If
necessary, adjust the optical table for optimal
patient comfort.
Looking through the viewfinder of the fundus
camera, focus the camera until you obtain a sharp
image of the posterior segment of the eye. Slightly
adjust the joystick (left-right-forward and
backward) to set the camera to a position in which
the subjects eye is evenly illuminated. It should
be free from flares and reflections. One should
try to achieve maximum color saturation. Ask
the patient to gaze at the fixation target until
you have the desired area of the fundus in your
viewfinder. It is important for operator to ask
the patient to keep both eyes open throughout
the entire photographic session. Also make
certain that the eyelids as well as eyelashes
should not obstruct the light passage. The light
Fig. 11.20: Beam pathway
beam should be projected entirely into the pupil

to avoid artifacts to be recorded on the film (Fig.
11.20).
If pictures are taken before the above
conditions are fully satisfied, reflections and/
or artifacts will be produced and it will result
in a lower picture quality and poor contrast.
Once all these conditions have been fully satisfied,
capture the image with a minimum delay,
otherwise the patient may be tired and lose
fixation and concentration. When the patient is
asked to keep his eye open for over 30 seconds,
the tear film starts breaking and cornea gets dry
causing a low contrast photograph. It is important
to always keep in mind that the patients comfort
and well-being is critical in order to achieve good
photo-documentation. Speak slowly and clearly
explain the photographic procedure to the patient
in order to lessen his or her anxiety.
Fluorescein Angiography
Ophthalmic photography is unique because the
medical photographers also perform dynamic
flow studies of the iris, retina or choroid using
dyes such as sodium fluorescein or indocyanine
green. These studies provide a vital piece of
information needed by the treating ophthalmologist in order to understand the vision problems
of a patient. Fluorescein angiography (FA) is often
more complex than conventional color retinal
photography. This, however, is not the case, the
main differences between color retinal photography and angiography are a set of filters
(usually a set of exciter and barrier filter) and
remembering the correct sequence of the flow
study (area to be photographed in the early, mid
or late phase that are usually recorded with a
timer).
Principle of Sodium Fluorescein

Angiography
Sodium fluorescein is mainly used to perform
dynamic flow studies of the integrity of retinal
vessels (in some cases, sodium fluorescein may
also be used in the study of the vascular integrity
of the anterior segment). Once the pupils are
sufficiently dilated, a solution with a concentration of 10% (2.5 cc of volume) or 25% (1 cc
of volume) of sodium fluorescein is injected in
the patients vein. Injection volume should be
carefully controlled in children or patients
weighing less than 100 pounds. When using
a concentration of 10% of sodium fluorescein,
a recommended dose of 0.066 cc per kg should
be used. It not only avoids adverse reactions but
gives a good fluorescence standard in the
dynamic flow study. The dye travels throughout
the bodys circulatory system (first throughout
the veins) including the retinal vessels. When
observing the retina with a cobalt blue light
(referred to as the exciter light set at about
Fig. 11.21: Fluorescein absorption and emission
490 nm), sodium fluorescein reflects a green

fluorescence towards the film plane of the retinal
camera. Before arriving to the film plane, that
green fluorescence passes through a yellow
barrier filter (referred as the barrier filter) that
removes all unwanted blue light that may interfere with the true appearance of the fluorescence
found at about 520 nm. These exciter filters (cobalt
blue set at 490 nm) and the barrier filter (sharp
cut-off filter set at 520 nm) must be matched
perfectly in order to render true fluorescence
images of the retinal vessels (Fig. 11.21).
Film Type and Development

The amount of fluorescence perceived by the film
when properly excited by cobalt blue illumination
is somewhat low; therefore, a highly sensitive
black and white film such as ISO 400 film should
be used. When processing this black and white
film (in total darkness), use a medium to high
contrast fresh developer in conjunction with an
extended processing time in a solution set at
20C/68F. Push process is a technique that is
used in angiography to see more detail on the
film produced by the fluorescence; this technique
consists of processing the exposed sensitive film
for an extended period of time (50 to 100% longer)
or to process the film in a warmer solution say
2 to 4 degrees centigrade higher.
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Photographic Procedures
Fluorescein angiographic study consists of
several phases based on time sequence.
Depending on the particular ocular disease,
dynamic flow studies vary between 3 and 15
minutes. Fluorescein angiography has following
phases:
1. Preinjection or control photograph: It is a
photograph in which both the exciter and
barrier filters are in place and a photograph
is taken without the presence of sodium
fluorescein. This is usually done to determine
the presence of pseudo-fluorescence or autofluorescence such as in the case of drusens.
Fig. 11.22: Arterial/venous phase of FA
2. Arterial and venous phase: This is the early

phase of the angiogram study usually within
14 to 30 seconds after injection of sodium
fluorescein (Fig. 11.22).
3. Mid-phase: When all retinal vessels have been
filled (stained) with sodium fluorescein (from
30 seconds to 120 seconds).
4. Late phase: This is the last phase and varies
in duration depending on the disease of the
patient. In diabetic retinopathy, this phase
may vary from 3 to 5 minutes, whereas in
some ocular tumors, it may last as long as
15 to 20 minutes (Fig. 11.23).
Fig. 11.23: Late phase of FA
The fluorescein angiography helps in

understanding various retinal diseases and
abnormalities. One needs to study carefully the
retinal drawing of the patients chart and look
for notes or direction from the retina specialist
to understand the areas of interest and the main
phase of the study (early, mid or late). It is critical
to follow precisely the retina specialists notes
to understand the diseased eye to be first studied
(right or left eye). How soon the retina specialist
needs to evaluate the results of the angiogram?
Does the retina specialist need to treat the patient
with laser immediately after the angiographic
study? This is referred to as a STAT angiogram.
A good practice is to carefully study the diseased
retinal areas when performing color photography, usually done prior to an angiography.
Once you understand the ocular disease, you
can start the angiographic procedure with a good
plan. Number of images in each phase, early,
mid and late phases as well as area of interest,
are dependant on a particular study. It is,
however, important to get different results from
what were initially anticipated. In fact, at times,
angiographic pattern may be completely different
from what was anticipated, a retinal vessel that
was thought to be leaking may be intact and
Fig. 11.24: Nerve fiber layer with blue filter
Fig. 11.26: Choroidal pigment with red filter
a normal one may be found leaking. Anticipating

the unexpected findings comes with years of
angiographic experience and a good set of
standardized angiographic protocol.
may be very useful while documenting a patient

with glaucoma to demonstrate nerve fiber
dropout. A green filter (referred to as red-free)
will cut out all red-light making those areas black
(red is seen as black) creating a nice high contrast
image of the posterior pole. Red filters will allow
the longer wavelengths of the visible spectrum
to penetrate deep into the ocular structures to
reveal the choroidal vascular pattern (choroidal
vessels appear as white while retinal vessels
will appear as black Fig. 11.25) and a choroidal
nevus or melanoma (Fig. 11.26). These photographs, in particular those taken with red-free
light, are very suitable for printing use.
Monochromatic Fundus Photography

Various monochromatic wavelengths penetrate
at different layers of the eye revealing specific
structures as well as foreign bodies in those
layers. With the appropriate monochromatic
wavelength filter (cobalt blue filter), it is possible
to isolate the first layer of the retina where you
can find the nerve fiber layers (Fig. 11.24). This
Anterior Segment Photography with

Photo Slit-lamp
Fig. 11.25: Red-free photography
The anterior segment is usually photographed

with a photo slit-lamp biomicroscope (Fig. 11.27).
It is similar to the clinical slit-lamp biomicroscope
that is used in our daily work; with the exception
that it incorporates a camera (static or motion
such as video) and an electronic flash light.
Needless to say, photographers need a good
understanding of the clinical instrument before
they can become skillful in capturing clinically
useful images of the anterior segment (Fig. 11.28).
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Fig. 11.27: Photo slit-lamp
Different from fundus photography, photo slitlamp biomicroscopy is perhaps the most
challenging type of photography in the field of
ophthalmology. It requires a good understanding
of the ocular structures; disease process as well
as illumination techniques to illustrate the area
of interest to the clinician. The illumination is
of key importance.
Since pathology varies greatly and may
appear differently for each case, simple changes
of slit-width, height angle of the illumination
tower or even the use of diffuser, the same
pathology may show itself quite differently in the
final picture. It becomes essential to select most
suitable lighting technique for each situation.
This challenge is perhaps what gives the
photographer greatest pleasure in taking pictures
of best area of interest.
In observing through the slit-lamp the
reflections from the cornea and lens are not so
offensive. However, same reflections may become
disturbing and even harmful in hiding areas of
interest when taking photographs. Adjust the
illumination tower angle to avoid unwanted
reflections. When using auxiliary light (often
Fig. 11.28: Slit-lamp photograph of lens with various

nuclei
referred to as fill light), it is necessary to pay

attention to avoid the reflection that light may
produce on the cornea. Carefully place the area
of interest in the field to be photographed while
making certain that you are using the best
possible form of illumination. Use appropriate
magnification to ensure that not only the area
of interest is captured but you leave enough room
to have a point of reference for follow-up photographic sessions (for example, in photographing
an iris melanoma; use of medium magnification
would allow for a portion of the iris to be seen
for identification that the mass is located at 12,
3, 6 or 9 oclock and provides an idea about
the size of the mass.
Bibliography
1. Fogla Rajesh, Rao KS. Ophthalmic photography
using a digital camera. Indian J Ophthalmol
2003;51:69-72.
2. Kwan A. A simple slit-lamp digital photographic
system. Eye News 2000;6:18-21.
3. Prasad S. Digital video in a surgical setting.
J Cataract Refract Surg 2004;30:2302-03.
R KIM, S MANOJ
12
Fluorescein
Angiography
The study and diagnosis of retinal, macular and

choroidal pathologic lesions have been greatly
revolutionized with the advent of fundus
fluorescein angiography (FFA). From an initial
laboratory tool, it has now become a useful
diagnostic tool that has aided the diagnosis and
monitoring of the treatment of retinal vascular
and macular diseases. Although the retina can
be readily examined by direct and indirect
ophthalmoscopy and slit-lamp biomicroscopy,
the fluorescein angiography provides a valuable
addition to these techniques. Over the last 40
years, it has been successfully utilized in many
research studies, controlled clinical trials and
national collaborative studies and its usefulness
and popularity have increased. With the
development of high quality retinal fundus
cameras, digital imaging and photographic
filters, high resolution angiography of the retina
and choroid is now possible.
History
The technique of using intravenous fluorescein
to evaluate the ocular circulation was probably
introduced 40 years ago by Mac Lean and
Maumenee, who described the direct observation
of the dye and its characteristics by slit-lamp

biomicroscopy and ophthalmoscopy. Chao and
Flocks provided the earliest description of
fluorescein angiography in 1958. Finally, it was
introduced into clinical use in 1961 by Novotny
and Alvis, who demonstrated the photographic
documentation of the fluorescein dynamics. Over
the last 3 decades advances have occurred in
this sphere, with the development of high quality
photography equipment, photographic filters,
newer printing techniques, stereophotography
and digital imaging which has made possible
the generation of high resolution angiography
of the retina and choroid.
Basic Principles
The basic principle of FFA is based on the understanding of luminescence and fluorescence.
Luminescence is the emission of light from any
source other than high temperature. When light
energy is absorbed into a luminescent material,
a few electrons are elevated into a higher energy
state. Spontaneous decay then occurs of
these electrons into their lower energy states.
When this decay occurs in the visible spectrum,
it is called luminescence. Fluorescence is
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luminescence that is maintained only by
continuous excitation. In fluorescence, excitation
at one wavelength occurs and is emitted
immediately through a longer wavelength.1, 2
Properties of Sodium Fluorescein

Sodium fluorescein (C20H12O5Na) is an orange
red crystalline hydrocarbon with a low molecular
weight (376.27 daltons) and readily diffuses
through most of the body fluids and through
the choriocapillaris, but it does not diffuse
through the retinal vascular endothelium or the
pigment epithelium. Fluorescein is eliminated
by the liver and kidney within 24-36 hours,
though traces may be found even for one week.
Retention may be increased if renal function is
impaired.1
The dye absorbs light in the blue range of
the visible spectrum with absorption peaking
at 465 to 490 nm. It emits light from 500 to 600
nm with a maximum intensity at 520 to 530 nm
(green-yellow). Even though the excitation and
emission spectra are quite close, as long as
suitably matched excitation and barrier filters
are used, only substances capable of fluorescence
are detected. When fluorescein is injected
intravenously 80% becomes bound to protein
while 20% remains free in the blood stream and
is available for fluorescence. The blue flash excites
the unbound fluorescein within the blood vessels
or the leaked out fluorescein. The blue filter shields
out all other light and allows through only the
blue excitation light. Structures containing
fluorescein within the eye emit green-yellow light.
The blue light is reflected off of the fundus
structures that do not have fluorescein. The blue
reflected light and green-yellow fluorescent light
are directed back toward the film of the fundus
camera. Just in front of the film a filter is placed
that allows the green-yellow fluorescent light
through but keeps out the blue reflected light.2
Technique and Equipment

The materials needed for fluorescein
angiography are as follows:
1. Fundus camera and auxiliary equipment
2. 23 gauge scalp vein needle
3. 5 ml syringe
4. Fluorescein solution
5. 20 gauge 1 inch needle to draw the dye
6. Armrest for fluorescein injection
7. Tourniquet
8. Alcohol
9. Bandage
10. Standard emergency equipment (Fig. 12. 1)
Fig. 12.1: Emergency set
Equipment
The traditional fluorescein angiography unit (Fig.
12.2) has two 35 mm cameras, one for color
fundus photography while the other (black &
white) for fluorescein angiography. Most fundus
cameras take 30 photographs (magnification of
X2.5 on a 35 mm film), which are adequate for
a detailed study of posterior pole lesions
especially macular diseases. Many camera units
provide variable magnification at 20, 30 and 50
degrees. The 50 view is most useful for lesions
involving a large area of the fundus. The flash
unit and powerpack recharges rapidly enough
to allow angiophotographs to be taken at 2 second
intervals. The motor drive in most equipments
advance the film automatically and the timer
records the interval between the various phases
of angiography and is vital especially in
conditions when the arterial perfusion pressure
is low. The equipment has 2 filters. The exciter
filter transmits blue light at 465 490 nm, the
absorption peak of fluorescein excitation. The
barrier filter transmits light at 525 to 530 nm
the emitted peak of fluorescein.
Fig. 12.2: Fundus camera
The most frequently used film for FFA is

Kodak 400 ASA (black and white). Various
developing solutions are available but the best
developing time for a particular camera and
power pack combination is variable. After the
film is developed, the negatives can be counter
printed into either film (transparency) or paper
(print). On the negative, areas of flourescence
appear black and on positive film or paper it

is white. Usually a roll of 35 mm negative film
used for FFA has 36 frames.1
Digital Angiography
Commercial digital angiography imaging systems
have been available for over 15 years and continue
to improve in quality each year. Although
photographic film is still capable of capturing
greater detail than current digital systems, digital
imaging offers some distinct advantages over the
more traditional film-based angiogram. Instant
access to the electronic images increases efficiency
and promotes better patient education by
reviewing images on a monitor with the patient.
Image enhancement and manipulation is easily
achieved with imaging software. Lesions can be
measured, or digital overlays used to identify
changes in lesion size in serial photographs.
Images can be stored on magnetic media like
CD-ROMs and transmitted electronically to
remote sites equipped with a computer for
viewing. Digital systems also offer the additional
advantage of shortening the learning curve for
novice angiographers. Having instant feedback
allows the angiographer to adjust exposure
settings and camera alignment to correct any
flaws in technique.
Cutting edge microelectronics and optical
designs of unmatched performance enable the
present day digital cameras to take retinal images
of exceptional resolution with stunning speed
and simplicity. Digital imaging system like the
IMAGE-net digital imaging system achieves
faster, more efficient acquisition, storage, retrieval
and analysis of images. These imaging systems
also incorporate a full range of image enhancement programs (sharpness, color, contrast) that
can be of great help in precisely evaluating
difficult pathologies. For easy and precise
photography, digital cameras are now provided
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with alignment dots which provide easy
confirmation of working distance and are
extremely helpful for pre-injection positioning.
Also synchronized accessory detection capability
and operating sensors guarantee a perfect image
every time during fast photography. Precise and
delicate control of flash intensity is vital to obtain
maximum detail in digital imaging. Multi-step
adjustment of flash intensity is provided with
most of the modern cameras, which enables
optimized results during angiography. The
refractive error of the patient can influence the
quality of the images obtained especially the large
refractive errors. To adjust for variations in the
refractive errors, diopter compensation knobs are
provided in the modern camera units for accurate
photography. For example 0 setting for 10 to
+6 diopter, setting for 9 to 23 diopter, + setting
for + 5 to + 23 diopter and a setting for +22
to +41 diopter (ocular anterior photography).
Maximal dilatation is critical for optimal images.
Modern angiography units now have a threestep illumination diaphragm changing system
for patients pupil size. Despite these advantages,
the high initial cost of digital systems has
prevented them from being employed universally.
Fluorescein Solution
Solutions containing 500 mg of fluorescein are
available in vials of 10 ml of 5% fluorescein or
5 ml of 10% fluorescein, 3 ml of 25% fluorescein
solution (750 mg) is also available. With a greater
volume the injection time increases, with a
smaller volume, more fluorescein remains in the
dead space between the arm and the heart.
Therefore, 5 ml of 10% solution (500 mg)
fluorescein is generally preferred.
The venous dead space between the hand
or the antecubital vein and the heart may be
as much as 5 to 10 ml, leading to sluggish or
reduced flow of fluorescein into the central
circulation. The fluorescein can be flushed with
5 to 10 ml of normal saline. An alternative is

to elevate the patients arm above the level of
the heart using an adjustable armrest, which
reduces the fluorescein transit time to the heart.2
Procedure for Fundus Fluorescein

Angiography
After informed consent and explaining the
procedure to the patient, the patients eyes are
dilated. The FFA-set namely fluorescein solution
in the required concentration, scalp vein needle,
5 ml syringe and the emergency tray (Fig. 12.1)
is prepared. The fundus camera (Fig. 12.2) is
kept ready after cleaning the lenses, loading the
film and test focusing. Patient identification
photographs are then taken. Modern digital
cameras with imageNet software maintain a data
sheet of patients. The patient is positioned and
the camera aligned (Fig. 12. 3). Color photography
of both eyes is first done and then switched over
to black and white photography for FFA. Redfree photograph of the posterior pole is taken.
Insert the scalp-vein needle and inject the
fluorescein dye and the timer is started as soon
as the dye is injected. Take pre-injection
photographs and start fluorescein photography
from the first appearance of the dye.
Fig.12.3: Digital fluorescein angiography

in progress
Follow an angiography plan depending on
the case. No standard and comprehensive plan
is possible to evaluat e all the possible retinal
vascular and macular diseases. However, the
photographer should use his own judgment to
follow a particular order in shooting the various
quadrants during flourescein angiography. For
example, in central serous retinopathy or
choroidal neovascular membrane, it is important
to take early films and posterior pole photography
is sufficient. In macular disorders, concentrating
on the posterior pole during angiography is often
adequate. Diabetic and other vascular diseases,
however, require a detailed fundus study where
the first few photographs are taken of the
posterior pole and then each peripheral quadrant
is specially taken in a clock-wise fashion from
the superior quadrant onwards. Photography of
the peripheral retina demands patience,
precision and skill due to problems in patients
compliance, light reflexes and awkward camera
placements.
At the end, reassure the patient and explain
the side effects namely discolored skin and urine.
If the patient develops nausea or vomiting or
signs of allergic response the procedure is stopped
and necessary steps taken.1
Stereophotography
Stereophotography facilitates interpretation by
allowing the images of both eyes to be viewed
simultaneously in depth. It helps us in interpreting the condition under study with respect to
its relationship to the various layers of the eye.
Adequate stereophotographs can be achieved
with a pupillary dilation of 4 mm although
dilation of 6 mm or more is preferred. The first
photograph is taken with the camera positioned
as far to the photographers right of the pupils
center. The second photograph of the pair is taken
with the camera held as far to the photographers
left of the pupils center. This order is extremely
important because the photographs are taken

and positioned on the film so that the angiogram
is read from right to left. Most of the modern
cameras have a stereo lock, which can be activated
to take stereophotographs. Specially made
stereo viewers are available to read the stereo
images.
Side Effects and Complications

Adverse reactions to intravenous fluorescein
angiography have ranged from mild to severe.3,4
Mild reactions (1 in 20) are classified as those
with transient effects that resolve completely
without requiring any specific treatment. The
most common side effects are nausea and
vomiting. Moderate adverse reactions (1 in 63)
require medical intervention and majority have
a good recovery. They include pruritis, urticaria,
syncope, thrombophlebitis, pyrexia and local
tissue necrosis. Severe reactions (1 in 1900) are
those requiring intensive intervention and have
a variable recovery and at times fatal. They
include laryngeal edema, bronchospasm,
anaphylaxis, shock, myocardial infarction,
cardiac arrest and convulsion.
Nausea
Nausea occurs in about 3-15% of patients and
is the most frequent side effect. It is most likely
to occur in patients under 50 years of age or
when fluorescein is injected rapidly. It begins
about 30 seconds after injection and lasts for
2 to 3 minutes and then disappears slowly.
Vomiting
Vomiting occurs in about 0-7% of patients nearly
40 to 50 seconds after injection. When patients
experience nausea or vomiting, they should be
reassured that the unpleasant and uncomfortable
feeling will subside rapidly.
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Hyperventilation is often known to relieve these
symptoms. Restriction of food and water for 4
hours prior to fluorescein angiography may
reduce the incidence of vomiting. Promethacine
hydrochloride 25 or 50 mg by month may be
given about one hour before injection especially
in predisposed individuals.
Pruritus
Pruritus or itching is one of the most frequent
allergic reaction (1 in 82), usually occurring 2
to 15 minutes after the fluorescein injection. Oral
or intravenous antihistamics are often beneficial.
Extravasation of the Dye and Local

Tissue Necrosis
Extravasation of dye is extremely painful and
serious. Toxic neuritis caused by infiltration of
the extravasated fluorescein along the nerve in
the antecubital area can result in considerable
pain. An ice pack or injection of local anesthesia
is very effective. If extravasation occurs
immediately it is best to place the needle in
another vein and reinject a full dose of fluorescein.
Vasovagal Attacks
Vasovagal attack is caused more by patient
anxiety than by the actual injection of fluorescein.
Shock and Syncope

Some patients may experience bradycardia,
hypotension, reduced cardiovascular perfusion,
sweating and the sense of feeling cold.
Anaphylaxis
Anaphylaxis to fluorescein may range from hives
to laryngeal edema, bronchospasm or cardiovascular collapse. Hives may occur 2 to 15
minutes after the fluorescein injection. Although

hives usually disappear within few hours, an
antihistamine such as diphenylhydramine
hydrochloride may be administered intravenously for an immediate response. Severe
reactions involving the respiratory (1: 3800),
cardiac (1: 5300) system and seizures (1: 13,900)
can occur and may be fatal (1: 221,781).
There are no known contraindications to
fluorescein injections including patients with a
history of heart disease, cardiac arrhythmias or
cardiac pacemakers. However, the dye is to be
used with caution or avoided in patients with
advanced renal failure or in patients with history
of drug allergy. Intradermal testing of diluted
sodium fluorescein may be required in such
patients with history of drug allergy/cross
reaction. Although there has been no report of
fetal complications from fluorescein injections
during pregnancy, it is the current practice to
avoid angiography in women who are pregnant,
especially in the first trimester.
Basic Anatomic Considerations

The inner retina contains the retinal blood
vessels, the larger vessels in the nerve fiber layer
and the retinal capillaries in the inner nuclear
layer. The normal retinal vessels both the large
and capillaries with their tight endothelial
junctions (inner blood retinal barrier) are
impermeable to fluorescein leakage. The outer
retina is the primary interstitial space of the
retina, where edematous fluid, deep hemorrhages
and hard exudate accumulate, is nourished by
the underlying choroidal circulation. Normally
this layer does not have fluorescein because the
retinal pigment epithelium (RPE) tight junctions
(outer blood retinal barrier) prevent the leaking
fluorescein from the choroid to reach the retina.
The larger choroidal vessels do not leak
fluorescein but the choriocapillaris show
fluorescein leakage. Fluorescein freely permeates
through the Bruchs membrane up to the RPE.
The RPE blocks to a great degree the visualization
of the choroidal fluorescence. The watershed zone
refers to the vertical zone of slightly delayed filling
choriocapillaris passing through the papillomacular region and/or the disk, which represents
the border area between the two main posterior
ciliary arteries. The choriocapillaris by virtue of
its lobular arrangement has a patchy filling,
gradually filling in a transverse fashion with
one lobule spilling over into another.
The foveal avascular zone (FAZ) represents
the area of the macula devoid of any retinal
capillaries and measures about 400-500 microns
in diameter. Because most of the optic disk is
fed by the ciliary system, fluorescein appears
simultaneously at the optic nerve head and
the choroid before it is apparent in the retinal
arteries.
Normal Fundus Fluorescein

Angiography
Fluorescein angiography is basically a serial
study of the vascular pattern of the retina and
the choroid at specific time intervals. Prior to
dye injection, one or two photographs should
be taken of each eye to test the technical quality.
Any evidence of fluorescence that appears on
the film at this stage in a normal eye is due to
suboptimal matching of filters (pseudofluorescence).
The first appearance of fluorescein in the eye
depends on the arm to retina circulation time,
which is approximately 10 to 12 seconds in young
patients and 12 to 15 seconds in older patients.
The circulation time is greater in the presence
of any disease that affects the myocardium and
large vessels, causing congestion in the pulmonary and systemic circulation or obstruction in
the vascular system.
Phases
Fluorescein angiogram consists of five phases
according to the appearance of dye in the retinal
circulation.
1. The prearterial phase: The choroidal larger
vessels and choriocapillaris begin to fill with
dye. Fluorescein usually appears approximately
one second before in the choroidal circulation
as compared to the retinal circulation. Early
choroidal fluorescence is faint, patchy and
irregularly scattered throughout the posterior
fundus. It is interspersed with scattered islands
of delayed fluorescein filling. This early phase
is referred to as the choroidal flush. When
adjacent areas of choroidal filling and non-filling
are quite distinct, the pattern is designated as
patchy choroidal filling (Fig. 12.4).
Within the next 10 seconds due to extreme
choroidal fluorescence, the angiogram becomes
very bright. The macula does not show choroidal
fluorescence because of the taller, more pigmented
pigment epithelium present in the fovea and,
therefore, remains dark throughout the angiogram.
If a cilioretinal artery is present, it fills at
the same time as choroidal circulation and even
Fig. 12.4: Prearterial phase of angiogram showing

presence of cilioretinal artery (arrow)
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before the central retinal artery fills up with
fluorescein (Fig. 12. 4). The central retinal artery
begins to fill about 1 to 3 seconds after choroidal
fluorescence or approximately 10 to 15 seconds
after injection. The less dense the concentration
of pigment in the pigment epithelium, the greater
the time will be between the visibility of choroidal
fluorescence and the filling of the retinal vessels.
2. The arteriovenous phase: The arterial phase
of the angiogram occurs at 12 to 15 seconds after
injection of the dye (Fig. 12.5). This is followed
by the arteriovenous phase a few seconds later
and is characterized by complete filling of the
arteries and capillaries and the first evidence
of laminar flow in the veins (Fig. 12.6). The
vascular flow/ blood stream is faster in the center
of the lumen than on the sides and so the unbound
fluorescein appears to stick to the side creating
the laminar pattern of venous flow. The dark
central lamina is non-fluorescent blood that comes
from the periphery, which takes longer to
fluoresce because of its more distant origin.
3. The venous phase: This begins as the arteries
are emptying and the veins are filled with dye.
In the next 5 to 10 seconds fluorescence of the
Fig.12.6: Early venous phase of the angiogram

showing laminar flow of the dye
two parallel laminae along the wall of the retinal

veins becomes thicker. At the junction of two
veins, the inner lamina of each vein may merge.
This creates three laminae, one in the center and
one on either side of the veins. As fluorescein
filling increases in the veins, the laminae
eventually enlarge and meet, resulting in complete
fluorescence of the retinal veins (Fig. 12.7)
Fig. 12.7: Venous phase of the angiogram showing

both veins and arteries filled with dye
Fig. 12.5: Arterial phase showing the dye filling the arteries,
background choroidal fluorescence is also seen
Fluorescence of the disk emanates from the

posterior ciliary vascular system, both from the
edge of the disk and from the tissue between
the center and circumference of the disk. Filling
also comes from the capillaries of the central
retinal artery on the surface of the disk. Because
healthy disk contains many capillaries, the disk
becomes fairly hyperfluorescent on the angiogram.
The perifoveal capillary net cannot always
be seen on the fluorescein angiogram. It can be
best seen in young patients with clear ocular
media about 20 to 25 seconds after a rapid
fluorescein injection (Fig. 12.8). This is called
the peak phase of the fluorescein angiogram.
Loss of portions of the perifoveal capillary
net is believed to be responsible for the decrease
in visual acuity in patients with macular disease,
diabetic maculopathy and other conditions. The
perifoveal net is an important landmark when
considering laser therapy.
Fig. 12.8: Peak phase of the angiogram showing the

foveal avascular zone and the perifoveal vascular net
in the patients with diabetic retinopathy and choroidal
neovascularization in the macular area
4. Transit phase: The aggregate of the arterial,

arteriovenous and venous phases is commonly
referred to as the transit phase of the angiogram.
The transit phase represents the first complete
passage of fluorescein in blood through the retina
and choroid. At the end of the transit phase
fluorescein remains in the choroid and sclera
due to leakage from the choroidal vessels and
choriocapillaris. The transit time is shortest in
the region of the macula and longest in the more

peripheral portions of the retina.
Approximately 30 seconds after injection, the
first high concentration flush of fluorescein
begins to empty from the choroidal and retinal
circulations.
5. Recirculation phase: During this phase
fluorescein at a lower concentration continues
to pass through the circulation of the fundus
(Fig. 12.9). About 3 to 5 minutes after injection,
the choroidal and retinal vasculature slowly
empties the fluorescein and the vessels become
gray. Vessels of most normal patients almost
completely empty fluorescein in approximately
10 minutes.
Fig. 12.9: Recirculation phase of the angiogram showing

decreased fluorescence in the retinal vessels
The large choroidal vessels and retinal

vessels do not leak fluorescein. The extravasated
fluorescein from the choriocapillaris diffuses
through the choroidal tissue, Bruchs membrane
and sclera. Leakage of fluorescein with retention
of the dye in tissues is designated as staining.
In the later phase of the angiogram, staining of
Bruchs membrane, choroid and especially sclera
may be visible if the pigment epithelium is lightly
pigmented. Fluorescein also leaks from the vessels
of the ciliary body, so that in the venous and
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recirculation phases of the angiogram,
fluorescein appears in the aqueous and vitreous.
Excitation of fluorescein in the vitreous during
this phase of the angiogram illuminates the
interior of the eye, producing pseudofluorescence
of any white or highly colored structures within
the eye, such as myelinated nerve fibers and scars.
In certain conditions such as diabetes or
inflammatory conditions of the retina and
vitreous, the accumulation of fluorescein in the
vitreous is greater than normal due to a breakdown of the blood-retinal barrier resulting in
vitreous haze and poor visibility of retinal
structures. In some diabetic patients, it may be
necessary to wait for several days for fluorescein
to clear from the vitreous to obtain a good
subsequent study.
Abnormal Fluorescence Angiography1,5-7

The abnormal fluorescence is primarily of two
types: hypofluorescence and hyperfluorescence.
Hypofluorescence is a reduction or absence of
normal fluorescence, whereas hyperfluorescence
is abnormally excessive fluorescence.
Hypofluorescence
Hypofluorescence1,5 is an abnormally dark area
on the positive print of an angiogram. There are
two causes of hypofluorescence namely blocked
fluorescence and vascular filling defect.
Hypofluorescence
Blocked fluorescence
Vascular filling defect
Blocked Fluorescence
Blocked fluorescence1,5 is also called as masked,
obscured or negative fluorescence or transmis-
sion decrease. It indicates a reduction or absence

of normal retinal or choroidal fluorescence
because of a tissue or fluid barrier located anterior
to the respective retinal or choroidal circulation.
To differentiate blocked fluorescence from a
vascular filling defect, the hypofluorescence on
the angiogram must be correlated with the
ophthalmoscopic view. If material is seen
ophthalmoscopically that corresponds in size,
shape and location to the hypofluorescent area
on the angiogram then blocked fluorescence is
present. If there is no corresponding material,
then it is probably due to a vascular filling defect
and fluorescein has not perfused the vessels.
Moreover, vascular filling defects have a pattern
that follows the anatomical distribution of the
vessels involved.
Blocked retinal fluorescence
Any opacification in front of the retinal vessel
involving the cornea, anterior chamber, iris, lens,
vitreous or the most anterior portion of the retina
or disk will reduce fluorescence. The vitreous
opacification is often caused by vitreous
hemorrhage. Other causes like asteroid hyalosis,
inflammatory debris, vitreous membranes or
opacification secondary to amyloidosis may
prevent visualization of fundus details.
The precapillary arterioles and large retinal
vessels are located in the nerve fiber layer and
the capillaries are located deeper in the inner
nuclear layer. When material lies in front of the
nerve fiber layer it will block both planes of retinal
vessels. When material lies beneath the nerve
fiber layer or within or in front of the inner nuclear
layer it will block only the retinal capillaries
leaving the large retinal vessels unobstructed.
If a blocking material lies deeper than the retinal
vascular structures, deep to the inner nuclear
layer, it will not block the vessels but will block
the choroidal vascular fluorescence.
The most common cause of blocked retinal
vascular fluorescence is retinal hemorrhage
Figs 12.10A to C: A Fundus photograph shows a subhyaloid hemorrhage (black arrow), B Mid AV phase shows
blocked retinal and choroidal fluorescence corresponding to the hemorrhage and an area of capillary non-perfusion
(white arrow), C Late venous phase shows the persistence of capillary non-perfusion (white arrow)
Note the disc hyperfluorescence has increased denoting a NVD
(Fig. 12.10). Nerve fiber layer hemorrhage, which

is usually flame-shaped, blocks the smaller retinal
vessels lying deeper in the retina but only
partially blocks the larger retinal vessels in the
nerve fiber layer.5
Blocked retinal fluorescence
Anterior segment material
Vitreous material
Inner retinal material
Blocked choroidal fluorescence
Blocked choroidal fluorescence occurs when fluid,
exudate, scar or hemorrhage lie deep to the retina
and in front of the choroidal vasculature.
i. Deep retinal material

Fluid, hard exudate, hemorrhage and pigment can
block the choroidal fluorescence. Deposition of
edema fluid usually occurs in the outer plexiform
layer. When it reaches a certain volume it tends to
form spaces between compressed nerve fibers and
Mllers fibers causing cystoid retinal edema.
Retinal edema blocks choroidal fluorescence in the
early phase of the angiogram but later it fluoresces.1
ii. Subretinal material
Blood under the retina will cause complete
blockage of choroidal fluorescence with the
retinal fluorescence showing normally.
Subretinal hemorrhage has irregular margins
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192
Figs 12.11A and B: Geographical helicoid pigment epitheliopathy (GHPC) resolved lesion with
pigmentation. A Shows the scar tissue with pigmentation (black arrow), B Shows the late phase
of the angiogram with hypofluorescence corresponding to the pigmentation and hyperfluorescence
(staining) of the scar (black arrow)
(between photoreceptors and pigment

epithelium) whereas sub-pigment epithelial
hemorrhage is often round and well demarcated.
Accumulated pigments (Fig. 12.11), like melanin
from diseased retinal pigment epithelium can
also cause blocked choroidal fluorescence.1
Blocked choroidal fluorescence
Deep retinal material
Subretinal material
Sub-RPE material
Choroidal material
Vascular Filling Defect

Vascular filling defect results from vascular
obstruction, atrophy or absence of vessels. The
retinal disk or choroidal vessels may be involved.
A vascular filling defect of the disk can be easily
made out. The absence of retinal vessels is also
readily apparent. If the retinal vessels are visible,
the hypofluorescence must be choroidal in origin.
Stereoscopic photography can help in differentiating the plane of involvement.4
Retinal vascular filling defects
Retinal vascular filling defects are most
commonly associated with diabetes and
atherosclerosis (Fig. 12.12). In the fluorescein
angiogram the retinal arteries fill first, then the

retinal capillary bed followed by the retinal veins,
and, therefore, it is easy to differentiate arterial
and venous occlusion. Also the blocked vessel
can usually be traced in the angiogram.1
Vascular filling defects of the disk
The capillaries on the disk may not fill due to
congenital absence of disk tissue, atrophy of disk
tissue and its vasculature, or because of vascular
occlusion (Fig. 12.13). All these conditions show
early hypofluorescence with late hyperfluorescence resulting from staining of the involved
tissue.
Choroidal vascular filling defect
This is usually caused by obstruction of tissue
and has the following characteristics:
1. Normal retinal vascular flow
2. Depigmentation of the pigment epithelium
3. Reduction of choroidal blood flow, and
4. Hypofluorescence in the early phases caused
by loss of the normal ground glass choriocapillaris fluorescence.
The most common form of choroidal vascular
filling defect has been termed patchy choroidal
filling. Areas adjacent to the foci that are filling
show early hypofluorescence but eventually fill
normally usually 2 to 5 seconds later.
Figs 12.12A to C: A Fundus photograph of inferotemporal BRVO showing superficial hemorrhages (white arrow)
and blocked vascular segment (black arrow), B,C Early and Mid AV phase of angiogram showing blocked fluorescence
corresponding to the hemorrhage (white arrow) and area of capillary non-perfusion (black arrow) corresponding
to the blocked vascular segment
Figs 12.13A and B: Anterior ischemic optic neuropathy. A Fundus photograph showing disk edema,
B Late AV phase of the angiogram showing hypoperfused segment of the disk (black arrow)
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194

Pre-injection fluorescence1
PCAPosterior ciliary artery
Hyperfluorescence
They are abnormally white areas on the positive
print of an angiogram. The common possible
causes are:
1. Pre-injection fluorescence
2. Transmitted fluorescence
3. Abnormal vessels
4. Leakage
Each angiogram should have one fundus photo

with the filters on and before fluorescein is
injected. This is called the control or pre-injection
fluorescein photograph. Normally it is completely dark.
Autofluorescence: It is the emission of
fluorescent light from ocular structures in the
absence of sodium fluorescein. It occurs with
optic disk drusen (Fig. 12.14) and astrocytic
hamartoma.
Pseudofluorescence: It occurs when the blue
exciter and green barrier filters overlap. The green
filter usually allows the passage of green light
and the blue filter allows the passage of blue
Figs 12.14A to C: A Optic nerve head drusen, B Autofluorescence of the drusen is seen
in the pre-injection phase of the angiogram, C FFA shows normal optic nerve head
Figs 12.15.A and B: Pigment epithelium defect (PED). A Fundus photograph showing PED (white arrow) and a
foci of RPE atrophy (black arrow), B Late phase of the angiogram showing the corresponding well-defined hyperfluorescent
lesions
light only. This light reflected off highly reflective

surfaces passes through these mismatched filters
and stimulates the film. Any light colored or
white fundus structure like sclera, exudate, scar
tissue, myelinated nerve fibers, foreign body can
thus cause pseudofluorescence.
2.
3.
4.
5.
6.
Transmitted Fluorescence (Pigment

epithelial window defect)
Abnormal choroidal vessels

It can occur with subretinal neovascularization
and vessels within a choroidal tumor. In
subretinal neovascularization early phases show
a lacy, irregular and nodular hyperfluorescence.
With a choroidal tumor it is also early vascular
type fluorescence although it may increase in
the later phases.4
It occurs because of the absence of pigment in

the pigment epithelium leading to accentuation
of the visibility of the normal choroidal
fluorescence. (Fig. 12.15). It has the following
characteristics:1
1. Appears early along with choroidal filling
2. Increases in intensity as dye concentration
increases in the choroid
3. Does not increase during the later phases
of angiography
4. Tends to fade as the choroid empties the dye
at the end of angiography.
Abnormal Vessels
Abnormal retinal and disk vessels
They can be divided into following categories:
1. Tortuosity and dilatation
Anastomosis
Neovascularization (Fig. 12.16)
Aneurysms
Telangiectatic vessels
Tumor vessels.
All these changes can be viewed in the early
phases and usually appear as hyperfluorescence.
Leak
The fluorescence of the retinal and choroidal
vessels diminishes about 40 to 60 seconds after
injection and empties almost completely about
15 minutes after injection. Any fluorescence that
remains after the retinal and choroidal vessels
have emptied is leakage.
Certain forms of leakage occur in the normal
eye. They are:
1. Fluorescence of the disk margins from the
surrounding choriocapillaris
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196
Figs 12.16A to C: Proliferative diabetic retinopathy (PDR). A Fundus photograph showing NVD, B Late AV phase
of the angiogram showing hyperfluorescence of the disk (black arrow), C Late venous phase showing increased
disk hyperfluorescence (Leakblack arrow)
2. Fluorescence of the lamina cribrosa

3. Fluorescence of the sclera at the disk margin
if the retinal pigment epithelium terminates
away from the disk
4. Fluorescence of the sclera when the pigment
epithelium is lightly pigmented.1
Vitreous leak
Vitreous leak is caused by:
1. Neovascularization growing from the retinal
vessels onto the surface of the retina or disk
or vitreous cavity
2. Intraocular inflammation
3. Intraocular tumors.
The vitreous leak due to neovascularization
is usually localized and appears as a cotton ball
type of fluorescence, and following inflammation,
the leak is usually generalized. If secondary to

tumors it is most often localized over the tumor.1
Disk edema
In the early phases, dilation of the capillaries
on the optic nerve head may be seen and in the
late phases, the dilated vessel leak resulting in
fuzzy fluorescence of the disk margin.
Retinal leak
When the leakage is severe, the extracellular
fluid may flow into cystic pockets and the
angiogram shows fluorescence of the cystic
spaces. Cystoid retinal edema is apparent as the
fluorescein pools in small loculated pockets (Fig.
12.17). In the fovea it takes on a stellate
appearance, elsewhere it has a honeycombed
appearance. Fluorescent staining of non-cystoid
Figs 12.17A and B: A A case of ruptured macroaneurysm with a ring of hard exudates and edema (white
arrow), B FFA- late AV phase showing macroaneurysm (black arrow) and edema as a diffuse hyperfluorescence
(white arrow)
Figs 12.18A and B: Central serous retinopathy. A Fundus photograph shows the serous collection involving
the macula, B Late phase of the angiogram shows the site of leak, smoke stack appearance and pooling
of the dye (white arrow)
edema is diffuse, irregular and not confined to

well demarcate spaces. Sometimes the large
retinal vessels can also leak. This is called perivascular staining and is seen in inflammation,
traction and occlusion.1
Choroidal leak
It can appear as pooling or staining. Pooling
is leakage of fluorescein into a distinct anatomic
space, staining is leakage of fluorescein diffused
into tissue. There are specific differences between
the fluorescent pooling patterns of sensory and
pigment epithelial detachment. In a sensory
retinal detachment the pooling tends to fade away

gradually toward the site where the sensory retina
is attached (Fig. 12.18). In contrast in a pigment
epithelial detachment the pooling extends to the
edges making the entire detachment and its
margins hyperfluorescent.3
Staining refers to leakage of fluorescein into
a tissue or material. The most common form of
staining occurs with drusen. Drusens hyperfluoresce early in the angiogram since choroidal
fluorescence is transmitted through defects in
the pigment epithelium overlying them. However,
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198
Figs 12.19A and B: Disciform scar of Age-related macular degeneration (AMD). A Fundus photograph showing
the macular scar with pigmentation (white arrow), B Late phase of the angiogram showing staining of the scar
tissue (white arrow)
some of the drusens remain hyperfluorent even

in the late phases of angiogram due to staining.
Scars also demonstrate staining- hyperfluorescence (Fig. 12.19). Sclera usually exhibits late
hyperfluorescent staining1.
collarette. In abnormal conditions such as

rubeosis, leakage of fluorescein dye from the
abnormal vessels is extensive. This leakage
occurs early in the angiogram.2
Iris Neovascularization
Iris Fluorescein Angiography

The vasculature of the iris can be examined by
focusing a retinal fundus camera directly on the
iris. This technique is useful in patients with
suspected neovascularization (rubeosis iridis),
iris ischemia or iris and ciliary body tumors.
Normal iris blood vessels leak fluorescein slightly
and are characteristically straight in configuration, with anastomotic connections between
the vessels near the iris root and those at the
In rubeosis iridis an abnormal growth of new

blood vessels occurs on the surface of the iris.
Only vessels on the anterior surface are clearly
detected. However, if leakage of fluorescein dye
from behind the iris is considerable, posterior
surface vessels should be suspected.
Abnormal new vessels have an irregular
distribution across the iris surface, with a
tendency to concentrate at the pupillary border
and at the chamber angle. Normal iris vessels
follow a fairly straight pattern from the iris root
to the pupillary border. Some anastomotic
connections exist between the vessels at the iris
root and the vessels at the collarette. Leakage
of fluorescein occurs from the abnormal vessels
in the early phase of the angiogram.2
References
1. Ryan SJ, Schachat AP (Eds). Retina. St Louis,
Mosby-Year Book Inc, 2001;875-942.
2. Joseph WB, Robert WF, David HO, James SK.
Fluorescein and indocyanine green angiography
Technique and interpretation. American Academy
of Ophthalmology, San Francisco, 1997.
3. Stein MR, Parker CW. Reactions following
intravenous fluorescein. Am J Ophthalmol 1971;
72: 861-68.
4. Yannuzzi LA, Rohrer MA, Tindel LJ, et al.
Fluorescein angiography complication survey.
5. Rabb MF, Burton TC, Schatz H, Yannuzzi LA.

Fluorescein angiography of the fundus: a
systematic approach to interpretation. Surv
Ophthalmol 1978;22:387-403.
6. Schatz H. Flow chart for the interpretation of
fluorescein angiograms. Arch Ophthalmol
1978;10:625.
7. Schatz H. Essential fluorescein angiography
A compendium of 100 classic cases. San Ansalmo,
Pacific Medical Press, 1985.
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200
VASUMATHY VEDANTHAM
13
Indocyanine Green
Angiography
Indocyanine green (ICG) angiography (ICGA) is

fast emerging as a popular and useful adjunct
to the traditional fundus fluorescein angiography
(FFA) in the diagnosis of macular, choroidal and
outer retinal disorders. This technique was
introduced in ophthalmology in 1973 by Flower
and Hochheimer.1 FDA approved the ophthalmic
use of ICG dye in 1975. Yet, for the next twenty
years the ICGA remained largely unpopular
owing mainly to technical difficulties. With the
advent of videoangiogram recordings and the
recognition of its potential in delineating occult
choroidal neovascular membranes, the clinical
use of ICGA has increased tremendously.
Indocyanine Green Angiography vs

The visualization of the choroidal circulation
is better with ICGA due to two reasons. Firstly,
the ICG molecules are not as rapidly extravasated
from the choroidal circulation as those of fluorescein. Secondly, the near-infrared wavelengths of
light that excite and are emitted by ICG dye
penetrate the pigmented ocular structures, hazy
media and small pupils much more readily than
the light of visible wavelengths associated with
fluorescein dye. The excitation and fluorescence

of the blue-green wavelengths of FFA are
absorbed and scattered by the pigments in the
fundus including macular xanthophyll. These
factors result in a much better visualization of
the choroidal circulation and its dynamics with
ICGA than FFA. However, adequate mydriasis
is essential as, its fluorescence efficiency is quite
poor in comparison to fluorescein which requires
a larger quantity of light to be transmitted for
adequate resolution.
Indocyanine Green
The indocyanine green (ICG) is a tricarbocyanine
dye that comes packaged as a sterile lyophilized
powder and is supplied with an aqueous solvent.
It was first used in 1957 to measure cardiac
output. It is an anhydrous 3,3,3,3-tetramethyl1,1-di-(4-sulfobutyl)-4,5,4,5-dibenzoindotricarbocyanine hydroxide sodium salt. Its
empirical formula is C43H47N2O6S2Na. It contains
less than 5% sodium iodide (in order to increase
its solubility). It has a pH of 5.5 to 6.5 in the
dissolved state, and also has limited stability,
and hence must be used within 10 hours
after reconstitution. Ninety eight percent of the
injected dye is bound to plasma proteins, with

80% being bound to globulins, especially alpha1 lipoproteins.2 The dye is secreted unchanged
by the liver into the bile.3 There is no renal
excretion of the dye and it does not cross the
placenta. The dye also has a high affinity for
vascular endothelium, and hence persists in the
large choroidal veins, long after injection.
ICG absorbs as well as emits (fluoresces) light
in the near-infrared region of the spectrum. The
peak absorption after injection is at around 805
nm and peak emission is around 835 nm. It also
exhibits a phenomenon referred to as concentration quenching. After a period of increasing
fluorescence with increasing serum concentration, that results in peak fluorescence, further
increase in concentration, paradoxically leads
to decreased fluorescence. This is referred to as
quenching and is thought to result from dimer
formation.
Adverse Reactions
The rate of mild, moderate and severe reactions
to ICG dye is 0.15%, 0.2% and 0.05%,
respectively.4 The reported death rate following
ICGA is 1 in 333,333 (in contrast to 1 in 222,000
following FFA).5 Owing to its iodine content, it
has to be used cautiously in patients with known
allergy to iodine containing substances such as
shell fish. ICGA is contraindicated in patients
with history of severe allergies, uremia and liver
disease. In fact, persistence of the ICG dye in
the retino-choroidal circulation of the eye for more
than 30 minutes in the late phase of the angiogram
should prompt the search for hepatic dysfunction.
The ICG should also be avoided in pregnancy
due to lack of human toxicity data in this area.
No more than 5 mg per Kg of body weight of
ICG dye should be used for safety purposes.
Extravasation of the dye causes a painless
greenish-blue stain that migrates from the
injection-site to the elbow, which often disappears
in a week. Removal of the injection needle before
all the dye has been injected will produce a

transient dye-stained needle track.
Low- and High-speed Angiography

Two types of fundus camera systems are used
for ICGA. The first type is based on the imaging
optics of the Zeiss fundus camera, but utilizes
a digital charge coupled device (CCD) or a vidicon
video camera for recording of images. The high
resolution CCD camera contains light sensitive
elements (pixels) that are analog to the silver
base of the photographic film of a traditional
camera. Opening of a built-in electromechanical
shutter exposes these pixels to light. The camera
then converts this analogous signal into a digital
one and sends it to the computer for storage or
immediate viewing. The camera employs filtered
light from either a xenon flash lamp or quartz
halogen lamps. As is true for most of the fundus
cameras, the optics are optimized for a field of
50 degrees, which allows maximum field,
maximum light entry with minimum of noise
which in turn increases the image contrast.
Despite a very good spatial resolution, the
temporal resolution is only several images per
second (low-speed angiography). Hence the late
phases are captured in good detail. The early
choroidal arterial filing, especially in younger
subjects with fast blood flow, can be completely
missed using such systems. Another disadvantage associated with CCD systems is the image
blooming or blow-out which is a CCD camera
photographic artifact. It results when the amount
of imaging light exceeds a systems capacity
resulting in saturation of the CCDs pixels, which
in turn overflows to the surrounding pixels. This
appears as overexposure of the hyperreflective
surfaces such as optic nerve head, drusen, and
exudates. Large overlapping vessels, large scars,
melanomas, etc. may be associated with
blooming. It can be corrected by reducing the
flash intensity.
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202

The second type is based on the optics of
the scanning laser ophthalmoscope (SLO). It
employs light from continuous, low-power laser
diodes. Since only a lower amount of peak retinal
irradiance can be delivered safely using
continuous light sources, SLO systems are less
sensitive to small amounts of ICG dye and,
therefore, for the imaging of the late fluorescence
when compared to CCD systems. Their resolution
is of the order of 512 pixels, in contrast to the
1024 pixels of the traditional systems. Their
temporal resolution, however, is of the order of
20 to 30 images per second (high-speed
angiography). Hence SLO systems record
choroidal dye transit better than CCD based
systems. The images also have a greater contrast
owing to the confocal imaging system in which
scattered light is eliminated from the optical
pathway. This is also the reason why the unfilled
retinal vessels are easily seen as dark images
silhouetted against the background fluorescence.
These systems are also more comfortable to the
patient since less stimulating light required to
acquire images. The newer versions also allow
for simultaneous FFA and ICGA. Disadvantages
of the SLO system are their limited field of view
(only 30 degrees), hence imaging of peripheral
pathology is difficult and there is also a reduction
in the landmarks available for image overlay
and laser treatment.
Procedure of Indocyanine
Angiography
The patient is seated comfortably in front of the
fundus camera, with an extended forearm for
dye injection. Red-free and near-infrared reflected
light images (with ICG excitation light on and
barrier filter removed) are obtained prior to
injection. The former image demonstrates the
landmark retinal vessels well. The latter image
demonstrates the light-transmission irregularities in the retinal and choroidal tissues and
helps to differentiate between hypo- and

hyperfluorescent areas due to irregularities in
blood flow. This technique of Red (green-free)
photography is referred to as poor mans ICG
and is tried when there is a contraindication
to ICG. This is achieved using a band pass filter
centered at 640 nm. Pseudofluorescence is also
checked for prior to injection, with the excitator
and barrier filters in place. Areas such as
dehemoglobinized blood that reflect the incident
light are associated with pseudofluorescence. In
the late stages of ICGA study, where the camera
gain and flash are at the maximum, such areas
would appear highly hyperfluorescent.
As the dye is diluted 600 times in the systemic
circulation before entering the choroidal
circulation, a dye concentration of 0.03 mg/ml
is required for maximal fluorescence. The total
amount of dye injected varies from 25 to 50 mg
in 2 to 4 ml of aqueous solvent, with smallervolume higher concentrations (1 ml bolus of 15
to 20 mg/ml injection, followed by a 5-ml saline
flush) being used for high-speed angiography.5
For patients with poor dilatation or dark fundi,
50 mg in 3 ml of aqueous solvent would be
optimal.
The timing of photography is determined by
arm to retina time (approximately 10 in young
and 12-18 seconds in older patients) since the
fundus cannot be observed. 6 The flash and gain
are set at the maximum, at 300 watt seconds
and +24dB respectively. To capture the earliest
phases, photographs should be taken even before
fluorescence is evident on the alignment monitor.
When the first images of the choroidal or retinal
filling phases are seen clearly, the gain should
be progressively lowered with each subsequent
photograph. Images are obtained at intervals of
several seconds in low-speed angiography
systems until maximum hyperfluorescence of the
retinal and choroidal circulations are reached
after which images are taken at 30 to 60 second
intervals for the first few minutes, for the early

phase. Later images are taken between 8 and
12 minutes for the middle phase and between
18 and 25 minutes for the late phase. Occasionally,
images obtained 30 to 40 minutes into the study
are helpful.
Advantages of ICGA over FFA

1. ICGA can be used even when the ocular media
are too hazy for FFA. This is due to the
phenomenon of Rayleigh scatter that occurs
when the scattering particles are small with
respect to incident-light wavelengths, with
the scatter intensity being greater for shorter
wavelengths and hence more troublesome
during FFA than ICGA.
2. ICG fluorescence can be imaged even in the
presence of considerable blood, due to the
phenomenon of Mie or forward scatter. It
occurs when the dimension of the scattering
particles is nearly similar to that of the
wavelength of the incident light. Due to this
effect, the 800 nm light used in ICGA allows
the visualization of large blood vessels hidden
behind hemorrhages.
3. The peak absorption of ICG coincides with
the emission spectrum of diode laser, which
allows the selective ablation of chorioretinal
lesions using ICG dye-enhanced laser photocoagulation wherein a target tissue containing ICG is exposed to the diode laser beam.
4. Infrared light appears as barely visible red
light to the patients, and, therefore,
photophobic patients tolerate ICGA better
than FFA.
5. ICGA accurately measures the size of an occult
choroidal neovascular membrane (CNVM)
when compared to FFA that might over or
underestimate it. On FFA, the occult CNVM
may appear larger due to leakage into pigment
epithelial or neurosensory detachments or
artificially smaller due to blocked fluorescence
from adjacent exudates or blood.
Limitations of ICGA
1. The choriocapillaris cannot be imaged
separately with ICGA since their average
cross-sectional diameter (21 m) is much
smaller than that of their feeding and draining
vessels, and hence the fluorescence of the
former cannot be differentiated from that
arising from the latter. The edge of one
capillary vessel too, cannot be distinguished
from that of an adjacent one since the
intercapillary spaces are on an average only
5 to 7 m, which is below the limit of
resolution of ICGA.
2. The phenomenon of Mie scatter also masks
the unfilled retinal vessels that cannot be
visualized well in low speed angiography
systems.
3. Bright areas do not necessarily signify dye
leakage due to the phenomenon of additive
fluorescence which the fluorescence increases
linearly with increase in vascular thickness
until an aggregate thickness of 50 m is
reached, when a plateau is reached and no
further increase in brightness occurs. Mie
scatter contributes to this additive fluorescence by making the bright area fuzzy and
apparently larger.
4. ICGA is poorer than FFA in the imaging of
classic CNVM since the early hyperfluorescence of the CNVM is overwhelmed by the
intense background choroidal filling.
Moreover, since the affinity of the ICG dye
to the serum proteins is considerably greater
than fluorescein, the leakage of the former
from the classic CNVM is lesser than that
of the latter even in the late phases.
5. Although superior to FFA in the imaging of
occult CNVM, ICGA may underestimate the
size of the CNVM, when there is little dye
leakage. It is, therefore, imperative to view
the films as late as 30 to 40 minutes after
injection.
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204

Normal Phases of ICGA
Depending on time the ICG filling of the posterior
pole choroid follows the following phases:7
During First 2 Seconds (Prearterial

and Arterial Phases)
1. Choroidal arteries fill rapidly, usually in the
peripapillary area (nasal to the fovea, since
this region is the area of highest blood
perfusion pressure in the eye) first and then
radiate to the periphery (prearterial phase).
The entire posterior pole appears as a uniform
network of arterial vessels. Distinct areas of
delayed filling can be seen at times corresponding to the watershed zones described
by Hayreh.8 The period beginning with the
dye injection to the first appearance of the
dye in the choroidal arteries is referred to as
the prearterial phase. Interarterial anastomoses, although common cannot be imaged
by ICGA.
2. Rapid filling of the choriocapillaris occurs
and is complete within 2 seconds after entry
of the ICG dye into the eye. The choriocapillaris filling pattern produces faint and diffuse
fluorescence that prevents the visualization
of the deeper choroidal layers.
3. Concomitant with choriocapillaris filling, the
choroidal veins begin to fill. The arterial phase
refers to the period from early filling of the
choroidal arteries to the first appearance of
the dye in the choroidal veins. The mean time
taken for this is 1.8 seconds.
4. In SLO angiograms, the major retinal vessels
remain dark, blocking the underlying
choroidal fluorescence.
Between 2 and 5 Seconds

(Arteriovenous phases)
1. The fluorescence from the choroidal arteries
begins to fade, while that of the choroidal
veins increases, making them more

prominent. Arteriovenous phase refers to the
period from the late arterial phase to the point
when the veins are beginning to fill.
2. The areas of delayed filling get filled up.
3. The retinal arteries begin to fill up.
Between 5 Seconds and Several Minutes

There is diminishing fluorescence from the
choroidal veins and overall the choroidal
vascular features become less distinct. The period
from the early filling of the choroidal veins to
their emptying is also referred to as venous phase
of ICG. The choroidal veins run parallel to the
periphery and eventually form the vortex veins.
Venous anastomoses occur between large vessels.
Laminar flow (the layered blood-flow pattern in
veins caused by the slower, nonturbulent
movement of blood along the vessel wall), is
sometimes seen in large choroidal veins of
myopic eyes in ICGA.
Beyond Several Minutes

1. The optik disk becomes dark.
2. There is a uniform, faint dimly fluorescent
background against which the major
choroidal and retinal vessels are seen as dark
structures.
The period after the venous phase when there
is leakage or retention of dye in the choroidal
or retinal tissue is referred to as the late phase
of ICGA. This phase demonstrates choroidal
neovascularization best.
Images using low speed angiography with
standard 1024-line digital systems (non-SLO
systems) do not allow imaging of the earliest
phases and hence for these systems, three phases
have been described:
1. Early phase (0-3 minutes): This encompasses
the period from the first appearance of the
dye in the choroidal arterial circulation till

maximal ICG choroidal fluorescence is
achieved (normally within one minute after
dye injection). The medium sized choroidal
arteries and veins are well imaged along with
hyperfluorescent retinal vessels (Fig. 13.1A).
In this phase, choroidal fluorescence
predominates over retinal circulation since
these vessels are larger, more numerous and
layered in three dimensions.
2. Middle phase (5-15 minutes): This is seen 6
to 15 minutes after injection of the dye, wherein the hyperfluorescence of the choroidal veins
and retinal vessels diminishes (gradual dye
washout) to be replaced by a homogenous
diffuse background choroidal fluorescence,
due to perfusion of the choriocapillaris (Fig.
13.1B).
3. Late phase (30 to 40 minutes): This is seen
beyond 18 to 22 minutes after injection,
wherein the choroidal vessels stand out in
relief (silhouettes) as relatively hypofluorescent structures against the hyperfluorescent
background, with a dark optic nerve head.
The leakage of the dye from the choriocapillaris into the choroidal stroma accounts
for the background fluorescence that persists
for hours or days after a single injection of
ICG dye (Fig. 13. 1C). Since there is maximal
contrast at this stage with hyperfluorescent
lesions, this stage identifies CNVMs best by
their late staining and fuzzy margins.
Applications of Indocyanine Green

Angiography
Age-related Macular Degeneration (AMD)
The occult choroidal neovascular membrane
(CNVM) that occurs in AMD is better imaged
by ICGA than FFA. In fact, ICGA can convert
occult CNVM (as per FFA) into well-defined
classic CNVM eligible for ICG-guided laser
treatment in 30% of cases. This is because the
Figs 13.1A to C: Show the various phases of a normal

ICG angiogram (ICGA). A Early phase of ICGA of the
left eye of a patient (1 minute after injection) showing
well-delineated choroidal and retinal vessels. Note that
the hyperfluorescence of the choroidal vessels is superior
to that of the retinal vessels in this phase. B Mid phase
of ICGA of the left eye of a patient (7 minutes after injection)
showing decreased hyperfluorescence of the choroidal
and retinal vessels (dye washout) with homogenous
background fluorescence. C Late phase of ICGA of the
left eye of a patient (30 minutes after injection) showing
a dark optic disk and ill-defined late background choroidal
hyperfluorescence. Note that the choroidal vessels stand
out in relief (silhouettes) as relatively hypofluorescent
structures against the hyperfluorescent background
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leakage of the ICG dye from the CNVM to the
subretinal space is slower and of a lesser
magnitude than fluorescein that delineates the
borders of the CNVM better.9 ICGA might thus
potentially double the number of patients treated
by laser photocoagulation. The CNVMs obscured
by blood are also better imaged due to Mie scatter
by ICGA. The CNVMs that have recurred on the
edge of areas treated by laser are also better
delineated and differentiated from the scar tissue
by ICGA due to better contrast. This is because
the chorioretinal scars are hypofluorescent due
to less ICG extravasation and relative lack of
choroidal vessels, with selective hyperfluorescence of the CNVM. In contrast, the scars would
stain in FFA leading to confusion between the
same and the leak from the adjacent CNVM.
Yannuzzi et al have shown that the finding

of a hyperfluorescent spot on the late ICG
angiogram (hot spot) can separate the neovascularized portion from the serous portion of a
pigment epithelial detachment (PED).10 The same
authors have recognized three morphologic types
of CNVM, namely, focal spots (comprising 29%
of cases), plaques (well and ill defined, comprising
27% and 34% of cases respectively), and
combination lesions (with both focal spots and
plaques, comprising 8% of cases).11 Focal spots
are less than 1 disk diameter in size (Figs 13.2A
to F) and are located outside the foveal vascular
zone (hence they are amenable to ICG-guided
laser photocoagulation); while plaques are larger
lesions (usually more than one disk diameter
in size). The plaque-like lesions are the
Figs 13.2A to F: Hot spot. A Color fundus photograph of the left eye of a patient showing a hemorrhagic detachment
of the posterior pole. B Arteriovenous (AV) phase of fundus fluorescein angiogram (FFA) of the left eye showing
an area of blocked fluorescence corresponding to the hemorrhagic detachment. Also seen are multiple hyperfluorescent
areas suggestive of pigment epithelial detachments (PEDs). There is no hyperfluorescence that could point towards
the underlying choroidal neovascular membrane (CNVM). C Early phase of ICGA of the left eye showing a small
spot of intense hyperfluorescence suggestive of a hot spot (white arrowhead). D Early phase of ICGA of the left
eye showing the increasing hyperfluorescence of the hot spot (white arrowhead). E Mid phase of ICGA of the
left eye showing the increasing hyperfluorescence of the hot spot suggestive of leakage (white arrowhead). F Mid
phase of ICGA of the left eye showing the progressively increasing hyperfluorescence of the hot spot (white arrowhead).
The area of blocked fluorescence corresponding to the hemorrhagic detachment is also obvious
Figs 13.3A to D: Plaque. A Color fundus photograph of the left eye of a patient showing a hemorrhagic PED
with a notch (black arrowhead). Also seen are hard exudates with retinal pigment epithelial (RPE) degeneration
at the fovea. B Venous phase of the FFA of the left eye showing blocked fluorescence corresponding to the hemorrhagic
PED (black arrowhead). There is an ill-defined hyperfluorescence in the area of the notch (white arrow). C Mid
phase of ICGA of the left eye showing blocked fluorescence corresponding to the hemorrhagic PED (black arrowhead).
D Late phase of ICGA of the left eye showing a well defined plaque of hyperfluorescence suggestive of CNVM
(white arrowhead) along with an adjacent area of blocked fluorescence of the hemorrhagic PED (black arrowhead)
commonest type of occult CNVMs and they

correspond to the thick subretinal pigment
epithelial membranes (Figs 13. 3A to D). They
are usually subfoveal in locations and hence
ICG-guided laser photocoagulation is not advisable and either transpupillary thermotherapy
(TTT) or photodynamic therapy (PDT) may be
tried. Combination lesions can further be divided
into marginal spots, focal spots at the edge of
a plaque in 3% of cases (Figs 13.4A to D),
overlying spots, hot spots overlying plaques in

4% of cases (Figs 13.4A to D) or remote spots
(focal spots remote from a plaque of neovascularization seen in 1% of cases). Interestingly, the
patients are often found to develop the same
morphologic type of CNVM in the other eye as
well.12
ICGA also reveals the retinochoroidal
anastomosis (RCA) in eyes with occult CNVM
along with a vascularized pigment epithelial
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208
Figs 13.4A to D: Marginal and overlying hot spots. A Color fundus photograph of the right eye of a patient showing
an occult CNVM with subretinal blood seen superiorly and sub-RPE blood inferiorly and overlying the fovea.
B Mid phase ICGA of the right eye showing the blocked fluorescence due to subretinal and sub-RPE blood with
a vague central hyperfluorescence. C Late phase ICGA of the right eye showing blocked fluorescence (black arrow)
and central hyperfluorescence (white arrowhead). D Late phase ICGA of the right eye showing a well-defined plaque
(white arrowhead) along with two hyperfluorescent hot spots (white arrows). The vertical arrow denotes the overlying
hot spot while the horizontal arrow denotes the marginal hot spot
detachment (PED). This is a variant of CNVM

that is fed by both a choroidal and retinal vascular
component.13 RCA is the stage III of a retinal
angiomatous proliferation (RAP) which
originates in the inner retinal layers, progresses
into the subretinal space and becomes eventually
associated with new vessel growth from the
choroid. Associated features in this type of CNVM
include pre- or intraretinal hemorrhages at the
lesion site, dilated tortuous retinal vessels,
sudden termination of a retinal vessel and cystoid
macular edema. Of these, intraretinal hemorrhage

is considered pathognomonic of RAP. This entity
has to be distinguished from small branch retinal
vein occlusions. RAP responds poorly to
treatment. These lesions are difficult to be detected
on early phase of ICGA and are better imaged
on the mid-late phases when there is progressive
intraretinal dye leakage (Figs 13.5A to H). They
are best identified when they overlie a serous
PED that produces a homogenous background
of relative hypofluorescence. FFA is poorer to
Figs 13.5A to H: Retinochoroidal anastomosis (RCA). A Color fundus photograph of the right eye of a patient
showing an occult CNVM with an inverted C-shaped subretinal hemorrhage (SRH). B Arterial phase of the FFA
of the right eye showing blocked fluorescence corresponding to the SRH. The white arrow points to the two hyper
fluorescent spots (choroidal in origin) connected to the vasculature arising from the inferior temporal artery. C Arteriovenous
phase of the FFA of the right eye showing the spots to progressively increase in hyperfluorescence (white arrow).
Also seen are a few hyperfluorescent spots representing RPE window defects in the papillomacular bundle. D Venous
phase of the FFA of the right eye showing progressive increase in hyperfluorescence of the spots (white arrow).
E Late venous phase of the FFA of the right eye showing increased hyperfluorescence of the spots suggestive
of leakage (white arrow). F Early phase of the ICGA of the right eye showing a small area of hyperfluorescence
at the choroidal level suggestive of a new vessel (white arrow). G Mid phase of the ICGA of the right eye showing
the communication of the choroidal vessel to the retinal vasculature (arising from the inferior temporal artery) (white
arrow). H Mid phase of the ICGA of the right eye showing the communication of the choroidal vessel to the retinal
vasculature (arising from the inferior temporal artery) with progressively increasing hyperfluorescence (white arrow)
ICGA in the detection of RAP lesions due to

obscuration of the lesion due to progressive dye
leakage both intra and subretinally. In contrast,
the RAP lesions in ICGA remain localizable to
a small spot of hyperfluorescence due to lesser
dye leakage till late into the study.
Polypoidal choroidal vasculopathy (PCV) that
is considered to be a variant of AMD in recent
years has a characteristic appearance on ICGA.
The characteristic lesion is a vascular bulge from

the surface layer of the choroidal vessels, visible
as a spheroidal orange-red polyp-like structure.
These lesions have a predilection to the
peripapillary areas but isolated lesions in the
macula or the periphery can also occur and are
associated with serosanguineous detachments
of the neurosensory retina and the retinal
pigmentary epithelium. When the leakage is
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210
Figs 13.6A to D: Polypoidal choroidal vasculopathy (PCV). A Color fundus photograph of the right eye of a patient
showing the characteristic orange lesions of PCV (white arrowheads). Also seen is an area of subretinal hemorrhage
(SRH) superior to the disk. B Venous phase of FFA of the right eye showing the blocked fluorescence corresponding
to SRH superior to disk. Also seen are mottled hyperfluorescent areas over the macula. C Mid phase of ICGA
of the right eye (10 minutes) showing multiple polyps in relation to large choroidal vessels (white arrowheads).
D Mid phase of ICGA of the right eye (20 minutes) shows that the polyps (white arrowheads) are not leaking
predominantly serous from the polpys the entity

might be mistaken for central serous
chorioretinopathy (CSCR). In the early frames,
larger choroidal vessels of the PCV network are
easily identifiable, with the area around and
within the network remaining relatively
hypofluorescent. Shortly thereafter, small
hyperfluorescent polyps, corresponding to the
reddish-orange choroidal excrescences seen
clinically, become visible (Figs 13.6A to D).14 The
late phases of ICGA first show a reversal of the
fluorescence pattern (hypofluorescent core and

a hyperfluorescent surrounding casement of the
polpys); and later show usually a uniform
disappearance of the dye (washout) from the
polyps (except when they are actively leaking),
with no late staining characteristic of classic or
occult CNVM. The ring of ICG staining due to
reversal of fluorescence has also been noted in
retinal arterial macroaneurysms and serous
pigment epithelial detachments (PEDs). The
central core of polyps less than 0.5 disk diameters

in size appear to have uniform intense fluorescence while the internal details are generally
visible in larger polyps, suggestive of the presence
of an internal architecture. Recently, both PCV
and retinal angiomatous proliferation (RAP) are
classified as types of hot spots by Yannuzzi.
The CNVM that is imaged as a hot spot which
does not fall into either category is referred to
as focal occult CNVM.
In geographic atrophy (GA), in the early
phase, there is hyperfluorescence due to
transmitted fluorescence from the large choroidal
vessels that are imaged better due to the absence
of the attenuating influence of the RPE. In the

mid phases, this hyperfluorescence decreases as
the ICG dye washes out of the choroidal
circulation. In the late phases of the angiogram,
hypofluorescence is observed due to absence of
the choriocapillaris (which is the source of late
background fluorescence) in the area of GA.
Central Serous Chorioretinopathy (CSCR)

In the early to the mid phases of ICGA in CSCR,
diffuse or multifocal areas of choroidal hyperpermeability,15 not associated with abnormalities
Figs 13.7A to D: Central serous chorioretinopathy (CSCR). A Color fundus photograph of the left eye of a patient
showing a central blister of subretinal fluid with subretinal fibrin. B Early phase of ICGA of the left eye showing
widespread choroidal hyperpermeability with no clear cut vasculature. C Mid phase of ICGA of the left eye is similar
to the early phase, showing multiple islands of choroidal hyperpermeability. D Late phase of ICGA of the left eye
showing multiple hyperfluorescent spots representing PEDs (black arrowheads). The central hyperfluorescent streak
represents a leaking PED
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212

detected both clinically and by FFA, are seen
in both the involved and the uninvolved eye
(Figs 13.7A to D). In the late phase, there is
dispersion of the fluorescence and a distinct
silhouetting of the larger choroidal vessels.
Additionally, multiple occult presumed PEDs
with a typical staining pattern of early
hyperfluorescence and late hypofluorescence
may also be imaged. In elderly patients with
atypical hyperfluorescence on FFA that does not
rule out CNVM, the ICGA demonstration of
bilateral choroidal hyperpermeability helps to
rule out neovascular AMD. In contrast to
fluorescein dye, the pooling of ICG dye into the
sub-RPE and sub-neurosensory retinal space
does not occur, due to the higher protein binding
of the latter. However, when seen, it is thought
to represent a blow-out of the PED and the Bruchs
membrane which allows the protein-dye
conjugate to leak through into the spaces.
Diabetic Retinopathy (DR)

FFA remains the gold standard in the management of DR. ICGA, however, has demonstrated
irregular and delayed choroidal filling in most
of the proliferative DR cases and in up to 50%
of background DR cases.6
Choroidal Inflammatory Conditions

Digital ICGA is invaluable in the diagnosis and
follow-up of patients with choroidal inflammatory disorders. In eyes with choroiditis, areas
with active inflammation block the choroidal
fluorescence and are imaged as hypofluorescent
areas that might resolve with treatment, as in
serpiginous choroiditis.16 Late hyperfluorescence
is seen at sites if a CNVM has evolved. In fact,
ICGA is superior to FFA in bird shot choroiditis,
in defining the typical patches. Multiple hypofluorescent lesions radiating to the periphery,
corresponding to the areas of choriocapillaris
drop-out, are observed between the choroidal

veins in this condition, by ICGA. Eyes with
enlarged blind spots on visual field testing can
show confluent hypofluorescence around the
optic nerve. Acute posterior multifocal placoid
pigment epitheliopathy (APMPPE) lesions
remain hypofluorescent both in the initial and
late phases of ICGA, and these recover with
resolution, in contrast to the initial hypofluorescence and late hyperfluorescence in FFA. This
hypofluorescence might be due to a partial
choroidal vascular occlusion secondary to
occlusive vasculitis. 17 The hypofluorescent
lesions are also seen beyond the areas of clinically
observed yellow lesions, implying that they are
not due to masking of the choriocapillaris by
abnormal RPE (Figs 13. 8A to D). Additionally,
the larger choroidal vessels are visualized within
the hypofluorescent areas pointing towards the
non-perfusion of the overlying choriocapillaris.
The ICGA findings have thus lent credence to
the theory of primary choriocapillaris rather than
RPE involvement in APMPPE. In resolved
APMPPE, the hypofluorescent areas are seen to
be decreased in size or completely resolved
representing areas of RPE hyperpigmentation
(the hyperpigmented RPE remains transparent
to the infrared wavelengths of ICGA). However,
a few persistent hypofluorescent areas might
remain corresponding to RPE hypopigmentation,
suggestive of persistent hypoperfusion due to
choriocapillaris damage.
In eyes with multiple evanescent white dot
syndrome (MEWDS), ICGA shows a pattern of
hypofluorescent spots seen in the mid-phase,
approximately 10 minutes after injection,
throughout the posterior pole and the peripheral
retina. These spots persist throughout the
remainder of the study. These spots appear larger
than the white spots seen clinically and more
in number on ICGA.18A ring of peripapillary
hypofluorescence corresponding to the enlarged
blind spot is also seen. The hypofluorescent
Figs 13.8A to D: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE). A Color fundus photograph
of the left eye of a patient showing yellowish white plaque like peripapillary lesions. Also seen are peripapillary concentric
lines suggestive of subretinal fluid. B Venous phase of FFA of the left eye showing hyperfluorescent and hypofluorescent
spots. The former are seen in the peripapillary area. C Mid phase of ICGA of the left eye (10 minutes) showing
peripapillary hypofluorescent spots (white arrowheads). D Mid phase of ICGA of the left eye (20 minutes) is similar
showing persistence of the hypofluorescence of the peripapillary spots (white arrowheads)
lesions and the peripapillary hypofluorescence

disappear with clinical resolution.
Choroidal Tumors
Heavily pigmented tumors such as choroidal
melanomas absorb the near-infrared light and
block ICG fluorescence. However, the tumor
borders are better delineated by ICGA than FFA,
which is essential in the assessment of tumor
size in response to treatment as well as in follow-
up.6 Choroidal hemangiomas, due to their

vascular channels demonstrate progressively
increasing hyperfluorescence on ICGA, with very
intense late hyperfluorescence.19 Choroidal
metastasis show variable characteristics on ICGA
depending on their vascularity and pigmentation. For instance, while metastasis of thyroid
carcinoma and metastatic bronchial carcinoid
tumors are hyperfluorescent, metastasis of breast
carcinoma blocks the choroidal fluorescence of
ICGA.19
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214

Miscellaneous Conditions
Reduced choriocapillaris filling has been noted
in myopia with ICGA.6 ICGA is superior to FFA
in the detection of lacquer cracks in the macular
area, especially those obscured by the overlying
subretinal hemorrhage. These appear as
hypofluorescent streaks first discernable in the
mid and more evident in the late phases. In
contrast, lacquer cracks appear hyperfluorescent
on FFA. For the same reason, ICGA is also
superior to FFA in detecting CNVMs close to
lacquer cracks and atrophic areas as only the
former are hyperfluorescent on ICGA.
ICGA can also be useful in patients with mild
vitreous hemorrhage, where FFA might not be
very useful due to Rayleigh scatter, identification
of vortex vein ampulla (by the dynamic pooling
of the dye with gaze shift).6 Finally, ICGA can
be used to study the velocity of choroidal
circulation and the ocular hemodynamics with
a certain success but there is no definite clinical
application of this as yet.19
Recent Advances in Indocyanine

Green Angiography
1. Wide-angle angiography: This is carried out
by performing ICGA with the aid of wideangle contact lenses, such as Volk SuperQuad
and a traditional Topcon fundus camera. The
diopter compensation knob of the camera
should be set to the (+) setting to compensate
for the image plane of the contact lens. This
allows real-time imaging of a wide field of
the choroidal circulation up to 160 degrees
of field of view.
2. Overlay technique: This technique allows
lesion on one image to be traced on to another
color or red-free image. This would allow
precise localization of the lesion for thermal
laser treatment and assessment of the
adequacy of treatment.
3. Digital stereo imaging: As with FFA images,

ICGA images too can be viewed by stereo
imaging. Elevated lesions such as PEDs can
be better imaged in this way.
4. ICG as a photo sensitizer: It is considered
to be a cheaper alternative to vertoporfin in
photodynamic therapy of neovascular AMD
and other disorders. The advantage of ICG
is that it can be imaged and hence proper
timing of dye activation (theoretically the
ideal timing is when the ratio of ICG
fluorescence of the CNVM to that of the normal
tissue is greatest) and precise localization for
treatment are possible. The need for a separate
angiogram prior to treatment is also
eliminated. However, this technique is still
in its infancy and several investigators are
working on it.
5. Digital subtraction ICGA: It uses digital
subtraction of sequentially acquired ICG
images along with pseudocolor imaging. It
shows occult CNVM in greater detail and
within a shorter time than conventional
ICGA.
The Future Applications of

In the future, ICGA is expected to play a more
important and wider role especially in the
management of macular disorders.
1. Identifying subclinical neovascular lesions
in the other eye of patients with AMD. There
are several reports that mention that 10% of
such eyes with no clinical or fluorescein
angiographic evidence of an exudative
process harbor plaques of neovascularization
evident on ICGA.
2. ICG-guided feeder vessel photocoagulation:
SLO high-speed ICGA can adequately image
the feeding vessels of the CNVM which are
0.5 to 3 mm in length and are believed to

lie in the Sattlers layer of the choroid. Either
conventional thermal laser or micropulsed
(810 nm diode laser) with ICG-dye enhancement are treatment modalities gaining
popularity. The drawbacks of this technique
is the high cost of the SLO imaging systems,
frequent occurrence of multiple feeder vessels
and a high rate of reperfusion after a single
treatment, both of which necessitate multiple
treatment sessions.
References
1. Flower RW, Hochheimer BF.A clinical technique
and apparatus for simultaneous angiography
of the separate retinal and choroidal circulations.
Invest Ophthalmol 1973;12: 258-61.
2. Cherrick GR, Stein SW, Leevy CM, Davidson
CS. Indocyanine green: observation of its
physical properties, plasma decay and hepatic
excretion. J Clin Invest 1960;39:502-600.
3. Sutoh N, Murakoka K, Takahashi K, et al.
Remodeling of choroidal circulation in carotid
cavernous sinus fistula. Retina 1996;16: 497-504.
4. Hope-Ross M, Yannuzzi LA, Gragoudas ES, et
al. Adverse reactions to indocyanine green.
5. Lutty G. The acute intravenous toxicity of
biological stains, dyes and other fluorescent
substances. Toxicol App Pharmacol 1978;44: 22549.
6. Bischoff PM, Flower RW. Ten years experience
with choroidal angiography using indocyanine
green dye: A new routine examination or an
epilogue? Doc Ophthalmol 1985;60:235.
7. Yannuzzi LA, Flower RW, Slakter JS (Eds).
Indocyanine Green Angiography. St. Louis, Mosby,
1997.
8. Hayreh SS. In vivo choroidal circulation and
its watershed zones. Eye 1990;4:273-89.
9. Hayashi K, Hasegawa Y, Tazawa Y, et al. Clinical
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
application of indocyanine angiography to

choroidal neovascularization. Jpn J Ophthalmol
1989;33:57.
Yannuzzi LA, Slakter JS, Sorenson J, et al. Digital
indocyanine green videoangiography and
choroidal neovascularization. Retina 1992;12:
191.
Guyer DR, Yannuzzi LA, Slakter JS, et al.
Classification of choroidal neovascularization
by digital indocyanine green videoangiography. Ophthalmology 1996;103:2054.
Chang B, Yannuzzi LA, Ladas ID, et al. Choroidal
neovascularization in second eyes of patients
with unilateral exudative age-related macular
degeneration. Ophthalmology 1995;102:1380.
Kuhn D, Meunier I, Soubrane G, Coca G. Imaging
of chorioretinal anastomoses in vascularized
retinal pigment epithelial detachments. Arch
Ophthlamol 1995; 113:1392.
Yannuzzi LA, Ciardella AP, Spaide RF, et al.
The expanding clinical spectrum of idiopathic
polypoidal choroidal vasculopathy. Arch
Guyer DR, Yannuzzi LA, Slakter JS, et al. Digital
indocyanine green videoangiography of central
serous chorioretinopathy. Arch Ophthalmol 1994;
112:1057.
Krupsky S, Friedman E, Foster CS, et al.
Indocyanine green angiography in choroidal
diseases. Invest Ophthalmol Vis Sci 1992;33:723.
Howe LJ, Woon H, Graham EM, et al. Choroidal
hypoperfusion in acute multifocal posterior
placoid pigment epitheliopathy. An indocyanine
green angiography study. Ophthalmology
1995;102:790.
Ie D, Glaser BM, Murphy RP, et al. Indocyanine
green angiography in multiple evanescent white
dot syndrome. Am J Ophthalmol 1994;117:7.
Mones J, Guyer DR, Krupsky S, Freidman E,
Gragoudas ES, Ciardella AP. Indocyanine green
Videoangiography (2nd edn). In Principles and
Practice of Ophthalmology. Albert DM, Jakobiec
FA, Azar DT, Gragoudas ES (Eds). Philadelphia,
WB Saunders, 2000.
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RAJIV NATH, TINKU BALI, MONICA SAHA
14
A-scan
Ultrasonography
Ophthalmic ultrasonography is a non-invasive,

efficient and inexpensive diagnostic tool to detect
and differentiate various ocular and orbital
pathologies. It is an indispensable tool for the
calculation of intraocular lens (IOL) power, the
evaluation of the posterior segment behind dense
cataract or vitreous hemorrhage, the diagnosis
of complex vitreoretinal conditions and the
differentiation of ocular masses. Ultrasound,
unlike other imaging modalities, is examinerdependent and needs a high level of skill and
expertise. It is a dynamic test where diagnosis
is best reached during examination and not from
still pictures. However, a correlation with
clinical findings is essential to make a precise
diagnosis.
History
Ultrasound was first used in ocular diagnosis
in 1956 by Mundt and Hughes who employed
the A-scan technique. Oksala and Lehtinen of
Finland further refined this technique in the early
1960s. Baum and Greenwood developed the Bscan using the immersion method in late 1950s.
The quality of these B-mode images was quite
poor and, therefore, almost all the ultrasono-
graphy of the eye was initially performed

using the A-mode. Later on the biometric
precision of A-scan was increased by
increasing transducer frequencies and using
more advanced time measurement techniques to
replace the ruler measurement of photographed
A-mode displays. In 1967, Giglo and Ludlam
developed the system, using 20 mHz focused
transducer with a multitrace oscilloscope display.
In the 1970s the interpretation of A-mode patterns
became more precise and standardized due to
the efforts of Ossoinig of Vienna. However, its
acceptance was limited because the multiple
peaks of an A-scan were bewildering for the
uninitiated. Standardized echography is a widely
used ultrasonic method in ophthalmology
conceptualized by Ossoinig, which combines
diagnostic A-scan, diagnostic B-scan, biometric
A-scan and at times Doppler evaluation.
Ultrasonograhy has thus become a reliable
and simple procedure with increasing
indications.
The advent of high resolution, high frequency
probes has improved B-mode studies for
intraocular and orbital imaging thus pushing
A-scan into the backdrop. However, A-scan still
remains the best modality for biometry.
A-scan Ultrasonography
Physics of Ultrasound
Ultrasonography is based on the propagation,
reflection and attenuation of sound waves.
Ultrasound consists of high frequency sound
waves of greater than 20 kilohertz (20 kHz). Those
used for diagnostic ophthalmic ultrasound have
a frequency of 7.5 to 12 megahertz (1 MHz =
106 Hz). These high frequency waves have a small
penetration (approximately 6 cm at 7.5 MHz)
but provide good resolution of minute structures
in the eye and orbit.
The speed of the ultrasound depends on the
medium through which it passes. As the
ultrasound passes through tissues, part of the
wave may be reflected back towards the probe;
this reflected wave is referred to as an echo. Echoes
are produced by acoustic interfaces that are
created at the junction of media with different
sound velocities. The greater the difference in
sound velocities of the media at the interface,
the stronger is the echo. For example, the lens
(velocity = 1641 m/s) produces a stronger echo
when adjacent to aqueous (velocity = 1532 m/s) as
opposed to blood (velocity = 1550 m/s), such
as in hyphema.
The returning echoes are affected by many
factors, including the size and shape of acoustic
interfaces, the angle of incidence of sound beam,
absorption, scattering and refraction. The
detected echo is highest when the beam is
incident perpendicular to the interface.
Instrumentation
An ultrasound unit is composed of four basic
elements : pulser, receiver, and display screen, all
contained within the same unit and connected
to the transducer located at the tip of the probe,
which acts as sending and the receiving device
(Figs 14.1A and B).
Fig. 14.1: (A) A-scan biometer, (B) Basic

components of A-scan
The pulser produces electric pulses that excite

the piezo-electric quartz of the transducer probe
generating sound waves. The returning echoes
are received by the transducer and transformed
into electric signals, which are processed in the
receiver and then displayed on the screen as
echograms. The examiner can adjust the
amplitude of the echo signal displayed by
changing the gain or sensitivity of the instrument.
The display may be in one of the two modes:
A-scan or B-scan.
A-mode (Amplitude Modulation)

A-scan (A stands for amplitude) is a onedimensional display in which echoes are
represented as vertical spikes from a baseline.
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is narrower, with less penetration, and the spike
amplitude is decreased. This eliminates the
weaker signals but improves resolution (ability
to display two interfaces as separate spikes).
The A-scan probe of a frequency of 7.5 to
8 MHz is used for the orbit and 10 MHz for
the globe. A non-focused beam is used, which
has parallel borders allowing pattern recognition
at different distances from the ultrasound probe
(Fig. 14.3A).
B-Mode (Brightness Modulation)
Fig. 14.2: Schematic representation of A-scan in

orbita mode of examination
These spikes represent reflectivity, location and

size of the anatomic structure (Fig. 14.2).
The A-mode display is a time-amplitude
display. The X-axis represents time elapsed,
which is a function of tissue depth. Knowing
the speed of ultrasound in soft tissues the
distance between two spikes can be derived. The
horizontal expansion can be modified according
to type of examination for which three modes
orbita, bulbus and varia have been provided. The
orbita mode is used for orbital examination, each
microsecond measures approximately 1 mm on
screen. In the bulbus mode examination (in
intraocular examination) each microsecond
measures approximately 2 mm of horizontal
expansion on the screen. The varia mode is used
for axial length measurement. The reflectivity is
measured in decibels on the Y-axis and is directly
related to the height of the spike above the baseline.
When on highest gain, the sound beam is widest,
the penetration highest and the spike amplitude
maximum, enabling visualization of the weak
signals. When gain is lowered, the sound beam
B-scan (B stands for brightness) differs from Ascan in that it produces a two dimensional
acoustic section. An echo is represented as a
dot on the screen rather than a spike. The strength
of the echo is depicted by the brightness of
the dot and coalescence of multiple dots on the
screen forms a two dimensional picture of the
reflecting tissue. A focused beam is used, as the
examination takes place in a focal zone (Figs
14.3B and 14.4).
Figs 14.3A and B: A Nonfocused beam of A-scan,

B Focused beam of B-scan
Fig. 14.4: Schematic representation of B-scan
patient reclining or sitting, after anesthetic drops

are instilled in both eyes. No other coupling agent
is needed. The echographer sits on an adjustable
examining stool on one side of patient.
The ultrasound probe is first applied at 6
oclock limbus (Fig. 14.6), aiming at the center
of the globe. It examines the opposite
chorioretinal layers at the 12 oclock meridian.
The patient is instructed to look away from probe
to avoid scanning through the lens. The probe
is shifted from limbus to fornix (Fig. 14.7) still
aiming it towards the center of the globe, thus
screening a particular meridian from the
posterior pole to the ora serrata. The ultrasound
beam is always kept perpendicular to the
opposite retina (Fig. 14.8). The same procedure
is repeated in eight o'clock meridians, moving
the probe temporally around the globe (Fig. 14.9).
Fig. 14.5: Simultaneous display of A and B modes (Note:

White arrow is pointing at A-scan spikes corresponding
to the B-scan display above it)
Vector A-scan Display

A-scan display is provided with some B-scan
units, which allows a simultaneous display of
both modes (Fig. 14.5). The A-scan pattern
corresponds to the vectors direction.
Fig. 14.6: Ultrasound probe applied at 6 oclock limbus
Procedure
To perform a successful ultrasound examination,
two key components need to be mastered viz.
the acquisition of images, and the interpretation
of images.
Basic Screening Examination

The screening examination is used to detect a
lesion. The examination is performed with the
Fig. 14.7: Ultrasound probe is placed at fornix
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Further examinations are performed at higher
system sensitivity (gain) allowing the detection
of any vitreous opacity missed during the
examination at tissue sensitivity. However,
examination at lower system sensitivity allows
detection of flat fundus lesions.
Anterior Segment Evaluation

Immersion Technique
Fig. 14.8: Ultrasound probe is kept perpendicular to
the opposite retina
Indications for anterior segment evaluation are

limited. However, A-scan may be performed by
using a simple immersion technique.
A scleral shell filled with methylcellulose is
inserted between the lids and the probe placed
on it. Using this technique the cornea, anterior
chamber, iris, lens and retrolental space can be
evaluated and axial length of the eye can be
measured.
Special Examination Techniques

If a lesion is detected on screening examination
then special techniques are employed to
differentiate lesions through the analysis of
specific acoustic characteristics. The special
examination techniques include:
1. Topographic echography
2. Quantitative echography, and
3. Kinetic echography.
Topographic Echography
Fig. 14.9: Screening-probe position for scanning in
eight meridians
The printout is labeled according to the meridian

that has been screened, and the segment of the
meridian that has been examined, using P for
posterior, E for equator and A for anterior. For
example, when the probe is placed at 6 oclock
limbus for examining the posterior pole at the
12 oclock meridian, the picture is labeled as
12P.
It entails the assessment of shape, location and

elevation of lesions. The following maneuvers
are used:
a. The probe is placed at the limbus of the
meridian opposite to the center of the lesion
and then moved from limbus to fornix to
assess the lesion anteroposteriorly
(radially).
b. The probe is shifted from side-to-side (parallel
to limbus) to evaluate the lesion laterally.
TABLE 14.1: TOPOGRAPHIC DIFFERENTIATION OF LESIONS ON A-SCAN
Category
Point-like
Membrane-like
Space-occupying
Echogram
Differential diagnosis
Single spike
Foreign body
Vitreous opacities
Single spike or chain of spikes

Retinal detachment
Choroidal detachment
Vitreous membranes
Tumor surfaces
Chain of spikes
Melanoma
Retinoblastoma
Hemangioma
Vitreous hemorrhage
c. The probe is placed in positions that are 90

apart, to examine the lesion from different
beam directions.
The pathological findings are classified into
one of the three categories point-like, membranelike and space occupying (Table 14.1).
Quantitative Echography
Once the topographic findings have been ascertained, quantitative echography is performed
with A-scan to determine the reflectivity (i.e. spike
amplitude) of a lesion, after directing the sound
beam perpendicular to it. The resultant spike
height is expressed as a percentage of the maximum height that can be displayed on the screen
and the lesion can be categorized (Table 14.2).
The determination of reflectivity is necessary
for evaluation of the internal structure and sound
attenuation of a mass lesion. Internal structure
refers to the histological configuration (size and
arrangement of interfaces) of mass lesions.
An internal acoustic structure of a lesion is
classified as regular when the echo spikes are
uniform. The spikes are uniformly low in
melanoma and uniformly high in hemangioma.
The acoustic structure is irregular (heterogenous)

if the echo spikes show marked variation in
amplitude as seen in a metastatic carcinoma.
Sound attenuation occurs when incident
sound energy is scattered, reflected or absorbed
by a given medium. It is indicated by decreasing
spike height within, or posterior to a lesion
(occurring from left to right). This spike
decrease called angle kappa is determined by
drawing an imaginary line through the peaks
of the lesion spikes and estimating the angle
then formed with the vitreous base line (Fig.
14.10). The steeper the angle, the greater is the
Fig. 14.10: Sound attenuation showing large angle

kappa K
TABLE 14.2: CATEGORIZATION OF LESIONS ON SPIKE HEIGHT

PERCENTAGE
1.
2.
3.
4.
5.
Spike height
Lesions
Low (2-20%)
Low medium (10-60%)
Medium (20-80%)
High (80-100%)
Very high (100%)
Senile vitreous floaters

Choroidal melanoma
Vitreous membrane
Asteroid hyalosis, metastatic carcinoma
Retinal detachment, organized vitreous
hemorrhage or foreign body
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sound attenuation. Bone, calcium and most
foreign bodies produce strong sound attenuation.
This results in a marked decrease of scleral or
orbital spikes.
Kinetic Echography
The purpose of this examination is to detect
spontaneous movements and after movements.
It is done at a low gain.
Spontaneous movements indicate a vascular
lesion as evidenced by multiple, very quick, small
amplitude, vertical oscillations in the echo spike
pattern. This is assessed with the probe stationary
and the eye fixing steadily on a target.
After movements indicate mobility and are
seen as a vertical motion of the echo spikes
following cessation of eye movements. Non-solid
lesions like PVD or retinal detachment display
after movements, whereas solid lesions like
tumors do not.
Indications of A-scan
A-scan ultrasonography is indicated for
evaluation of the posterior segment of the eye
in the presence of complete or partial opacification
of the anterior or posterior segments. It is also
used to localize and measure and differentiate
tumors and evaluate growth during follow-up
of patients as well as to detect intraocular foreign
bodies and assess extent of intraocular damage
in case of trauma.
Biometry is another important indication of
A-scan for accurate axial length measurements
required in IOL power calculation. Measurement
of the axial length of globe, is also important
in evaluating congenital glaucoma, microphthalmos, nanophthalmos, myopia, PHPV and
phthisis bulbi.
Morphological characteristics of the eyeball
and its contents, like corneal thickness, lens
thickness, anterior chamber depth and relative

lens position in the anterior segment, have been
extensively studied in various conditions such
as narrow-angle glaucoma and refractive errors,
with the help of A-scan ultrasonography (Table
14.3). Ultrasonic pachometry which uses the
principle of A-scan is now the standard for
measurement of corneal thickness.
TABLE 14.3: INDICATIONS OF A-SCAN
ULTRASONOGRAPHY
Anterior Segment
Corneal opacification
Anterior chamber hyphema or hypopyon
Miosis
Pupillary membrane
Cataract
Posterior Segment
Vitreous hemorrhage
Endophthalmitis
Clear Ocular Media
Tumors and masses detection, differentiation
and follow-up
Vitreous pathologies
Choroidal detachment
Retinal detachment rhegmatogenous and
exudative
Biometry
Axial length of eyeball
Anterior chamber depth
Lens thickness
Tumor measurements
Ultrasonic pachometry
Corneal thickness
Interpretation of Normal A-scan

Examination of a normal globe displays the
following echo spikes from left to right (Fig.
14.11).
1. The initial spike (I) represents reverberations
at the probe tip and has no clinical
significance.
2. The baseline (B) represents the vitreous cavity
which is characterized by absence of echo
spikes in normal conditions. The presence
of any blip on the horizontal line needs
evaluation to rule out a pathological condition.
Fig. 14.11: Normal A-scan

with sound beam bypassing
lens; I: Initial spike, B: baseline
representing
echo-free
vitreous, R: retina, S: sclera,
O: orbital soft tissues, E:
electronic scale
3. The retinal spike (R) is a straight, high rising

echo spike perpendicular to the baseline. A
jagged echo spike means that the probe is
not perpendicularly placed.
4. The choroidal spikes are multiple high
reflective spikes, which are seen between the
retinal spike (R) and the scleral spikes (S).
5. The scleral spike (S) is difficult to differentiate
from choroidal spikes.
6. The orbital spikes (O) are multiple spikes
behind the scleral spike. The initial spikes
are high reflective and the reflectivity
decreases rapidly because of sound
attenuation in the orbit.
7. An electronic scale (E) is displayed on the
lower part of the screen. Examination at low
system sensitivity (low gain) clearly identifies
the retinal and scleral spikes.
Fig. 14.12: A-scan

pattern of a vitreous
floater (arrows)
A-scan in Common Ocular

Pathologies
Vitreous
Vitreous Floaters
They are found due to condensation of vitreous
sheets in an aging eye. Very low reflective
(2-20%) spikes are displayed as small blips along
the baseline, which are better displayed at a
higher gain (Fig. 14.12).
Asteroid Hyalosis
Multiple echo spikes with medium to high
reflectivity (50100%) are displayed along the
baseline. The high reflectivity results due to
presence of calcium within the asteroid bodies.
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Fig. 14.13: A-scan of organized

vitreous hemorrhage
Vitreous Hemorrhage
Posterior Vitreous Detachment
In fresh, mild vitreous hemorrhage with

dispersed red blood cells, a chain of low
amplitude spikes is found on A-scan. These are
often limited posteriorly by a higher reflective
spike representing a posterior vitreous
detachment. Denser the hemorrhage, the higher
is the reflectivity of the echo spikes. If the blood
organizes larger interfaces are found, which may
present even 60-100% reflectivity (Fig. 14.13).
A single lesion spike is present along the baseline.

The reflectivity is low (510%) if the posterior
vitreous layer is thin. The reflectivity is high (8090%) if the posterior vitreous layer is thick or
lined by red blood cells (Fig. 14.15).
Endophthalmitis
In endophthalmitis diffuse inflammatory cells are
present in the vitreous, which are displayed as
multiple echo spikes with low to medium reflectivity (1060%). With organization and membrane
formation, the reflectivity increases (Fig. 14.14).
Daily follow-up examinations are required.
Retina
Retinal Detachment
Retinal detachment is characterized by a single,
steeply rising, extremely high (100%) and
moderately thick retinal spike when the sound
beam is perpendicular to the retinal surfaces (Fig.
14.16). Other directions cause a change in pattern
an oblique beam gives lower and wider spikes
with two or more peaks and tangential beams
show a long chain of low to medium high spikes.
Fig. 14.14: A-scan of endophthalmitis,

a week after its occurrence. Spike due
to organized inflammatory membrane
in vitreous (arrow)
Fig. 14.15: A-scan at high

gain: A:medium reflective
spike of PVD, B: low reflective
spike from subvitreal blood
Fig. 14.16: A-scan of retinal

detachment showing 100% tall
single peak spike (R)
The distance between the retinal spikes and the

ocular wall spikes in a given beam direction is
equal to the degree of elevation. The presence
of signals between the retinal and scleral spikes
is indicative of an exudative or hemorrhagic
retinal detachment.
Sometimes it is difficult to differentiate
between a thick vitreous membrane due to
inflammation or trauma, and a retinal

detachment, as both may show a highly reflective
(100%) spike. However, they have different
reflectivities in the periphery. A retinal
detachment is highly reflective both posteriorly
and in the periphery. Vitreous membranes tend
to be highly reflective posteriorly but less in the
periphery (Fig. 14.17).
Fig. 14.17: A-scan technique for

differentiating a dense PVD or
thick vitreous membrane from RD
in the superior portion of eyeball.
On scanning the membrane
posteriorly 100% high spike is
first seen (1). The probe is then
shifted so as to follow the
membrane to its insertion in the
periphery. A PVD shows low
reflective spikes in the periphery,
while the retina remains highly
reflective as seen in (4)
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Retinoschisis
A 100% high spike is produced in retinoschisis
which may demonstrate slight vertical after
movements. Retinoschisis differs from a retinal
detachment by its more focal, smooth and thin
character.
Intraocular Tumors
A-scan helps in the detection, differentiation and
measurement of intraocular tumors.
Extrascleral extension of the melanoma is seen

as jagged scleral echospike with low reflective
spikes immediately behind the sclera. A-scan
can also be used for follow-up of tumor growth
and to assess effectiveness of therapy. Typically,
a treated melanoma becomes highly irregular
and more highly reflective due to tumor necrosis,
with decreased elevation and loss of vascularity.
A-scan can help in differential diagnosis of
choroidal tumors (Table 14.4 and Fig. 14.18).
Metastatic Carcinoma
Choroidal Melanoma
Most malignant melanomas can be diagnosed
or suspected from their characteristic ophthalmoscopic appearance. Ultrasound provides
confirmation of the diagnosis especially in eyes
with opaque ocular media; provided the lesion
is elevated by at least 0.75 mm from the inner
scleral wall.
The key acoustic criteria of a choroidal
melanoma are regular acoustic structure and a
low to medium internal reflectivity due to a
homogeneous cellular architecture. Vascularity
is present, with fast spontaneous vertical spike
movements seen during examination; and a solid
consistency, with no after movements of spikes
following ocular movements. Larger tumors may
have a more irregular internal structure due to
tumor necrosis and large blood vessels. They
also show a moderately steep angle kappa due
to strong sound attenuation within the tumor.
The acoustic structure of metastatic carcinoma

is irregular with a high internal reflectivity (6080%) and absence of vascularity. Measurements
of tumor height on follow-up show slow growth
or no growth.
Choroidal Hemangioma
The acoustic structure of choroidal hemangioma
is regular with a very high internal reflectivity
due to multiple blood filled channels. Vascularity
is present and follow-up shows no growth.
Choroidal Hemorrhage
Choroidal hemorrhage may show a reflectivity
similar to that of melanoma but profoundly
differs from it by displaying after movements
during kinetic echography if it is sufficiently
elevated.
TABLE 14.4: A-SCAN ULTRASONIC DIFFERENTIATION OF CHOROIDAL TUMORS

Criteria
Choroidal melanoma
Metastatic carcinoma
Choroidal hemorrhage
Regular
Low to medium (10-60%)
Irregular
High (80-100%)
Regular
High (100%)
Spontaneous
movements (vascularity)
Fast, vertical
Minimal or no
movements
Fast, vertical
Growth during follow-up
Significant
Slow
None
Internal structure
Reflectivity
Fig. 14.19: A-scan of retinoblastoma. Very high reflective

tumor spikes (T) are seen with decreased reflectivity
behind them due to shadowing of sclera and orbital tissues.
Vitreous seeding is seen as a low reflective echo spike
(V)
Figs 14.18A to C: Differential diagnosis of choroidal

tumors: A Choroidal melanoma, low internal reflective,
B Choroidal hemangioma, uniform high reflectivity, C
Metastatic carcinoma, variable reflectivity, Arrow internal
tumor spikes, T: tumor surface, S: sclera
Retinoblastoma
Retinoblastoma is best diagnosed by indirect
ophthalmoscopy. A-scan offers additional diagnostic information through the quantitation of
sound attenuation by the lesion. The measurement of axial length helps in differentiating it
from other causes of leukocoria. The status of
the lesion and the effect of treatment can also

be assessed by A-scan.
On A-scan, a retinoblastoma shows an
irregular acoustic structure with high internal
reflectivity (70-100%) (Fig. 14.19). Tumor cell
arrangement, large vessels and particularly
calcifications are responsible for the high
reflectivity. Vascularity is present as evidenced
by spontaneous movements of the lesion spikes.
The axial length may be normal or increased.
The A-scan pattern may vary depending upon
size of tumor and degree of tumor calcification
and necrosis. A small retinoblastoma without
calcification will not produce a high reflectivity.
Other conditions that can cause leukocoria
but can be differentiated from a retinoblastoma
by ultrasonography include, persistent hyperplastic primary vitreous (PHPV), retinopathy of
prematurity, and Coats disease (Flow Charts
14.1A to D). In PHPV, an A-scan examination
confirms the absence of a retinal pathology, as
normal retinal echo spikes are seen. The axial
length of the affected eye is shorter than the fellow
eye. In retinopathy of prematurity, the A-scan
shows absence of a mass lesion and the presence
of a large echo spike representing the detached
retina with normal axial length. Coats disease
consists of retinal detachment with subretinal
exudates. A-scan shows a high reflective echo
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Flow chart 14.1A: Differential diagnosis of intraocular lesions on A-scan.
Point-like lesions on topographic echography
Flow Chart 14.1B: Membrane-like lesions on topographic echography
Flow chart 14.1C: Diffuse mass lesions on topographic echography
Flow chart 14.1D: Well-defined mass lesions on topographic echography
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230

spike of detached retina followed by low reflective
echo spikes representing red blood cells and
cholesterol in the subretinal exudates.
Choroid
Choroidal Thickening
A low gain should be used to detect choroidal
peaks as it improves the resolution of the closely
spaced posterior layers. The choroidal thickening
may be diffuse or focal, and its reflectivity may
be high or low depending on its etiology. High
reflective thickening is seen in macular edema,
endophthalmitis and uveitis while low reflective
thickening in VKH syndrome and sympathetic
ophthalmitis. Certain tumors may also appear
as thickened choroid.
Choroidal Detachment
A thick steeply rising 100% high spike is
produced by choroidal detachment on A-scan.
On lowering the gain the spike is observed to
be double peaked. If choroidal hemorrhage is
present, low to medium spikes are seen in the
subchoroidal space. If choroidal effusion is
present the space is echo-free.
Ocular Trauma
In a traumatized eye, the fundus visualization
may be obscured by a hyphema, a cataract or
a vitreous hemorrhage. A-scan examination of
the eye in such cases is used to detect any
intraocular damage and the presence of an
intraocular foreign body (IOFB).
It is advisable to repair an open wound before
ultrasonic examination. However, if intraocular
assessment is imperative before closure, the Ascan probe should be placed on the conjunctiva
in an area away from the wound. Marked lid
swelling or severe pain may prevent placement
of probe directly on the globe in such case it

may be placed on the closed lids with methylcellulose applied for better sound penetration.
It is important to use a very high gain when
examining through the closed lids.
Foreign Body Detection and

Localization
A foreign body in the eye can be easily recognized
by the characteristic steeply rising overloaded
echo spike with extremely high reflectivity (100%).
It may show a great width at lower gain. Because
of the small size of the IOFB, the high reflective
single echo spike is seen whenever the foreign
body is centered in the path of the sound beam,
irrespective of the beams direction. A foreign
body produces strong sound attenuation and
the ocular wall spikes behind it are significantly
lower due to shadowing.
A-scan complements radiologic evaluation
and can detect radiolucent foreign bodies missed
on X-ray. A small spherical foreign body, like
a pellet, shows a high echo spike followed by
a long chain of echo spikes with decreasing
height. These multiple echoes are caused by
multiple reverberations of sound between the
anterior and posterior surfaces of the spherical
foreign body. A larger foreign body has anterior
and posterior echo spike and its thickness may
be measured between these surface spikes.
Preretinal Foreign Bodies

When a foreign body is lying within 2 mm of
the sclera or in the coats of the eye, it becomes
difficult to decide on A-scan whether the foreign
body is intraocular or extraocular. In such
situation, it is important to know that the sclera
yields a high reflective echo spike only when
the sound beam is perpendicular to it, while a
high reflective foreign body signal can be
Fig. 14.20: A-scan of traumatic

retinal detachment: R: 100% tall
spike from retinal detachment, H:
low reflective echo spike from
subretinal hemorrhage
displayed if it is centered within the sound beam

at any angle.
Therefore, the sound beam is aimed towards
the foreign body at an angle oblique to the sclera,
thus decreasing its reflectivity. High reflective
foreign body spikes are then displayed in front
of the lower reflective ocular wall spikes if the
foreign body is intraocular.
Traumatic Retinal Detachment

The high reflective echo spike of retinal detachment
is followed by low reflective echo spikes between
the retinal spike and ocular wall spikes. These
represent a subretinal hemorrhage (Fig. 14.20).
Dislocated Lens in Vitreous

A dislocated lens in the vitreous shows two smooth
and high reflective surface spikes, displayed in
front of the ocular spikes. There may be lower
Fig. 14.21: A-scan of dislocated

lens in vitreous: A: anterior lens
spike, P: posterior lens spike
seen in vitreous cavity
reflective spikes representing the lens nucleus,

separating the surface spikes (Fig. 14.21).
Phthisis Bulbi
In phthisis bulbi the globe is atrophic and
shrunken, the intraocular contents are
disorganized and intraocular calcification may
be present. The A-scan represents these changes
as an irregular pattern of high and low reflective
echo spikes which fill the globe. High reflective
echo spikes may be present due to ossification
and the normally high orbital echo spikes are
absent. The axial length of the eyeball is shorter
than normal.
Biometry
The most commonly used function of the A-scan
is for measurements in the eye, i.e. biometry. This
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includes measurement of axial length of the eye
for IOL calculations, for monitoring eyes with
congenital glaucoma, myopia and nanophthalmos and measuring intraocular parameters like
anterior chamber depth and lens thickness.
Method
The A-scan biometer probe is a 10 MHz solid
probe with an inbuilt fixation light. The probe
has to be aligned with the optical axis of the
eye for accurate axial length measurement. This
can be done by the immersion or the contact
technique.
Immersion Technique
The patient is placed in a supine position or
in a reclining examination chair and local
anesthesia is instilled. A scleral shell is applied
to the eye, the most commonly used being Hansen
or Prager shell, which is available in different
diameter sizes. The scleral shell is filled with
1% or 2% methylcellulose, which should be free
of air bubbles; the presence of air bubbles causes
Fig. 14.22: A: scan display of phakic eye measured with

Immersion technique. IS: Initial spike produced at the tip
of the probe. C: The corneal spike C is double peaked
representing the anterior C1 and posterior surfaces C2
of the cornea. L1: The anterior lens spike generated from
anterior surface of lens. L2: The posterior lens spike
generated from posterior surface of lens and is usually
smaller than L1. R: The retinal spike, from anterior surface
of retina. It is straight, highly reflective and tall whenever
the ultrasound beam is perpendicular to the retina. S:
Scleral spike. O: The orbital spikes are low reflective
behind the scleral spike
variations in the speed of sound and is

responsible for noise formation, within the
ultrasound pattern. The ultrasound probe is
immersed in the solution keeping it 5-10 mm
away from cornea. Since the probe does not touch
the cornea, corneal compression is avoided. The
patient is asked to look with the other eye, at
a fixation point placed at the ceiling. The probe
is gently moved until it is properly aligned with
the optical axis of eye and the echo spikes
displayed as shown in Figure 14.22.
Contact Technique
The contact technique for axial length
measurement is an alternative to immersion
biometry. It does not use scleral shell. Instead
the probe comes in contact with the cornea,
which can be done in two ways: either hand
held by examiner or attaching the probe to slitlamp biomicroscope or applanation tonometer
holder (Fig. 14.23).
The patient is examined in the seated position
after instilling local anesthetic drops. The patient
is asked to fixate a target straight ahead with
the non-testing eye or to look directly at the
probes fixation light with the tested eye. The
probe is brought forward to touch the cornea
Fig. 14.23: A-scan probe fit into the applanation

tonometer holder
Fig. 14.24: A-scan display of a phakic

eye measure with contact A-scan
biometry. Since the probe is in contact
with the eye, the initial spike and the
anterior corneal spike become one:
C: cornea/probe, A: anterior lens
surface, P: posterior lens surface,
R: retina, S: sclera
without indenting it. It is properly aligned along

the visual axis to optimize the five high amplitude
spikes on the screen. The five spikes in a phakic
patient represent from left to right: (1) anterior
surface of cornea, (2) anterior surface of lens,
(3) posterior surface of lens, (4) anterior surface
of retina, (5) sclera (Fig. 14.24). An aphakic eye
will not show the lens spikes (Fig. 14.25) though
sometimes a spike of intact posterior capsule,
if present, may be seen.
The leading edge of each echo spike should be
perpendicular to the horizontal baseline. The
gain is kept at the minimum level that allows proper
resolution of these spikes. The density of the
cataract determines the need for changing the gain
setting due to absorption of sound. Dense cataract
requires higher gain to achieve good resolution.
The anterior chamber depth which appears on the
screen should also be monitored to detect corneal
compression during contact biometry.
The biometer has an automatic as well as
manual mode. Use of the automatic mode
Fig. 14.25: A-scan of an aphakic

eye with probe on cornea. Note the
striking absence of the lens spikes:
C: cornea/probe: R: retina, S: sclera
increases the risk of error as the biometer may

capture poor quality scans. Biometers are
programed to capture any scans with spikes that
are of high amplitude within their given
appropriate area. However, they cannot determine
if the spike arose steeply from the baseline or if a
step or hump was present in the spike origin.
Manual mode is preferable, in which the examiner
presses a foot switch to capture the scan when it
is seen to be of high quality. The axial length of the
eyeball is measured from corneal surface to retinal
surface and an electronic readout is obtained.
A comparison between contact and immersion
techniques of biometry is given in Table 14.5.
Biometry in Ocular Pathologies

Congenital Glaucoma
Axial length measurement in congenital
glaucoma allows confirmation of the clinical
diagnosis, and differentiates congenital
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TABLE 14.5: COMPARISON BETWEEN CONTACT TECHNIQUE AND IMMERSION TECHNIQUE OF BIOMETRY
Contact technique
Immersion technique
Patient is in a more comfortable position, sitting
Patient is in a supine or reclining position
Variability from one test to next is present due

to inconsistent corneal compression
No variability since probe does not come in contact with

cornea
Axial length measured is shorter by an average

of 0.24 mm
Axial length measured is closer to the true value
glaucoma from megalocornea in which axial

length remains normal. It can also monitors
efficacy of glaucoma therapy. The immersion
technique is preferable as it can detect minute
changes in axial length in small eyes of children.
Nanophthalmos
Myopia
Limitations and Pitfalls of A-scan
Biometry helps differentiating the axial myopia

from the lenticular myopia. A posterior
staphyloma in highly myopic eyes causes an
increase in axial length. A comparison with
previous axial length measurement or with that
of the other eye may reveal a difference of more
than 1 mm.
Artifacts
The diagnosis of nanophthalmos is made when

the globe of an adult is smaller than 17 mm with
thickening of retinochoroid and sclera.
Acoustic artifacts result from multiple reflections,

attenuation and variations in propagation speed
in tissues. One must be aware of these artifacts
in order to avoid misdiagnosis.
Multiple Reflection Artifacts

Tumor Height
Tumor height can be obtained by measuring the
distance between tumor spike and scleral spike.
Follow-up measurements are performed to
monitor the height of the lesion. An increase of
0.5 mm suggests tumor growth.
Multiple reflections (reverberations) may occur

between the probe tip and a highly reflective
surface, or between two highly reflective ocular
interfaces. Calcified lens, intraocular implants
(Fig. 14.26), foreign bodies, scleral buckles and
air bubbles are common producers of multiple
Fig. 14.26: A-scan of intraocular lens

implant producing multiple signals:
L: highly reflective spike from IOL, M:
multiple signals (reverberations). PMMA
lens has a longer chain of reverberations
than a silicone lens
signals and may cause error in axial length
measurements. These artifacts can be
distinguished from true echoes by their position
in the echograms as well as by their more
pronounced movements.
Attenuation Artifacts
Silicone oil disperses the ultrasound beam, and
the examination is, therefore, very difficult to
perform. The sound attenuation prevents
resolution of posterior ocular wall and orbital
contents (Fig. 14.27). The velocity of sound in
silicone oil is much less than in vitreous. This
causes the echograms to appear larger than normal.
Low Reflective Spike

Low reflective spikes can occasionally be seen
in front of the retinal spike when examination
is performed at high gain. This occurs due to
the lateral portion of the ultrasound beam reaches
the concave retina earlier than the central portion.
Tumors
A tumor mass less than 0.75 mm will be missed
on A-scan. To detect the acoustic structure the
thickness should at least be 2 mm. A false
negative result may occur in case of a small
retinoblastoma with no calcification, as it will
show low reflective spikes. A diagnosis of
retinoblastoma may be made if a mass shows
high reflectivity. Reflectivity may be due to some

other causes such as intraocular calcification or
bone formation in phthisis bulbi. Axial length
measurement and clinical history should be
helpful in making the correct diagnosis.
Vitreoretinal Diseases
Dispersed vitreous cells or hemorrhage may be
missed initially due to low reflectivity. The gain
should be increased to improve resolution. It is
sometimes difficult to differentiate between a
thick vitreous membrane and retinal detachment
as both show high reflectivity.
Intraocular Foreign Bodies

A foreign body may be missed on A-scan if its
surface is less than 1 mm2 or if it is embedded
in the sclera. A wooden foreign body may initially
be highly reflective but its reflectivity may
decrease making its localization extremely
difficult. Small air bubbles which enter the eye
as a result of penetrating injury may mimic an
intraocular foreign body, but they usually
disappear within a day or two.
Errors in the Axial Length

Measurement by Biometry
In the measurement of axial length by biometry,
a few errors can creep in. They are mentioned
here along with the corrections required.
Fig. 14.27: A-scan of globe filled with

silicone oil: A: spikes from anterior
surface of silicone drop, B: spikes from
posterior surface of silicone drop,
C: markedly attenuated spikes from
ocular wall and orbit
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Immersion vs Contact technique: Corneal
compression in contact technique yields shorter
axial length. The axial length measured by contact
technique is shorter by about 0.24 mm in
comparison to immersion technique. Therefore,
anterior chamber depth must be monitored and
the displays with more shallow depths deleted
even if the spikes appear to be of a high quality.
Posterior staphyloma: Problem should be

suspected if a difference of more than 0.3 mm
is present between the two eyes or a difference
of more than 0.2 mm is found on consecutive
measurements in the same eye. In these instances,
the patients history should be taken to find
reasons for the difference, or probe for a macular
lesion like posterior staphyloma.
Misalignment: Erroneous axial length

measurements occur when the ultrasound beam
is not aligned with the visual axis of the eye
or is not perpendicular to the macula. The retinal
and scleral spikes should be of high amplitude,
with the retinal spike arising steeply from the
baseline. No sloping of the retinal spike should
be present and there should be no jags, humps
or steps on its ascending edge. If the posterior
or the anterior lens spikes are not of high
amplitude, the sound beam is misaligned and
is not in the visual axis. The posterior lens spike
may be slightly shorter than anterior lens spike
because of its greater curvature. However, if the
posterior lens spike is more than 10% shorter
than the anterior one, the sound beam is
misaligned (Fig. 14.28).
Cataract: Extremely dense cataracts can be a

challenge due to absorption of the sound beam
as it passes through the lens. A higher gain setting
may be needed to achieve high amplitude retinal
and scleral spikes. In an extremely dense,
calcified lens, the entire sound beam may be
absorbed with no echoes at all from the posterior
segment. In such case, measurements from the
fellow eye must be used in calculation.
Methylcellulose or thick tear film: Longer axial

length may appear due to presence of a fluid
meniscus between the probe and the cornea,
caused by use of ointment, methylcellulose from
previous eye examination or abnormally thick
tear film. If these are suspected, the eye should
be washed with saline prior to biometry.
Fig. 14.28: Misalignment demonstrated

by the decreased amplitude of the
posterior lens spike (arrow): A: anterior
lens surface, P: posterior lens surface,
R: retina
Difference between the average sound velocity

and the specific sound velocities: The human
eye is mostly composed of aqueous and vitreous
humors, both of which have an ultrasound
velocity of 1532 m/s. Only the cornea and
crystalline lens have different ultrasound
velocities. If the eye is measured at an ultrasound
velocity of 1532 m/s then the true axial length
(TAL) = MAL + 0.32, where MAL is the measured
axial length and 0.32 mm is the addition, which
stands for the correction for underestimation due
to corneal thickness and lens thickness.
Refractive errors: The formula, distance = velocity
X time is programed into the biometer to calculate
the distance between the corneal and retinal
spikes, with the average velocity in a phakic eye
taken as 1550 m/s. However, the velocity of
sound in various ocular media in the same eye
and in same ocular media of different eyes is
not the same, but the machine does not
differentiate it. For example, in a myopic person
who is likely to have a fluid vitreous, sound
waves should be able to travel faster in the vitreous
cavity than in a hyperopic person. Since the
biometer is not capable of recognizing the
difference in velocities it may underestimate the
length of vitreous cavity in myopia. It will be
the reverse in hyperopia, where axial length may
get overestimated. An axial myopia of 29 mm
is best measured at an average velocity of 1550
m/s while an axial hyperope of 20 mm is best
measured at average velocity of 1560 m/s. The
type of eye (phakic, aphakic or pseudophakic)
should also be carefully fed in before biometry
as the average velocities programed for them are
different.
The errors which creep into the estimation
of axial length prevent accurate IOL power
calculation. An error of 1 mm in measuring axial
length affects the postoperative refraction by at
least 2.5 diopters. This causes a large residual
postoperative error of refraction (spherical) in
eyes with high ametropia. Modification in IOL
calculation formulae have been suggested
(Holladay modification), but these are complex,
time consuming and require additional software.
Importance of Clinical Correlation in

Making a Diagnosis
Before beginning the examination, the echographer should be informed of the pertinent
history and clinical findings. Some clinically
disparate conditions may have similar acoustic
properties; for example, it is difficult to differentiate vitreous hemorrhage from endophthalmitis
on A-scan as both show low to medium reflective

echo spikes. A clinical history assists in their
differentiation.
In case of a dense cataract, an ultrasound
examination is warranted when other clinical
features raise the suspicion of a posterior segment
abnormality. Such indications include a rapidly
developing cataract, history of trauma or a
possible IOFB, heterochromia, afferent pupillary
defect, posterior synechiae, acute red eye, acute
rise of IOP and diabetes mellitus.
A-scan versus B-scan

The B-scan covers a considerably larger area than
a single A-mode pattern. By providing a twodimensional topographic documentation, the Bscan is used to define a lesions shape and
position. However, the information obtained
from amplitude, shape and motion of A-scan
spikes is missing. The quantitative reflectivity
of ocular lesions, the most important ultrasonic
differential criterion can be evaluated only on
A-scan. Thus, A- and B-scan displays provide
specific acoustic information which in either of
one display mode is absent or poorly differentiated.
The A-scan has certain unique advantages.
The probe used is smaller and can be angled
to detect peripheral lesions and small vitreous
opacities (which may be missed on B-scan).
Because of the small probe size it is the method
of choice in posttraumatic cases with open globe
wounds. However, orbital lesions are better
delineated by B-scan. The two modes are,
therefore, complimentary to each other and an
optimal echographic examination results from
a combination of both modalities.
Bibliography
1. Atta HR. Ophthalmic Ultrasound: A Practical
Guide. London,Churchill Livingstone, 1996.
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2. Baum G, Greenwood I. The application of ultrasonics locating techniques to ophthalmology.
Theoretic considerations and acoustic properties
of ocular media. I: Refractive properties. Am
J Ophthalmol 1958, 46:319.
3. Binkhorst RD. Biometric A-scan ultrasonography and intraocular lens power calculation.
In: Emery JM (Ed). Current Concepts In Cataract
Surgery: Selected Proceedings of the Fifth
Biennial Cataract Surgical Congress. St. Louis,
Mosby: 1987.
4. Byrne SF. Standardized echography, Part I: Ascan examination procedures. Int Ophthalmol Clin
1979;19:267-81.
5. Baum G. Ultrasonic characteristics of malignant
melanoma. Arch Ophthalmol 1967;78:72-75.
6. Blumenkranz MS, Byrne SF. Standardized echography for the detection and characterization
of retinal detachment. Ophthalmology 1982;89:
821-31.
7. Coleman DJ, Carlin B. A new system for visual
axis measurements in the human eye using
ultrasound. Arch Ophthalmol 1967;77:124-27.
8. Coleman DJ. Ophthalmic biometry using

ultrasound. Int Ophthalmol Clin 1969;9:667-83.
9. Coleman DJ, Lizzi FL, Jack RL. Ultrasonography
of the Eye and Orbit. Philadelphia: Lea and
Febger, 1977.
10. Coleman DJ, Lizzi FL, Silverman RH. A model
for acoustic characterization of intraocular
tumors. Invest Ophthal Vis Sci 1985;26:545-50.
11. Dallow RL. Ultrasonography in ocular and orbital trauma. Int Ophthalmol Clin 1994;14:23-56.
12. Holladay JT. Standardizing constants for ultrasonic biometry, keratometry, and intraocular
lens power calculations. J Cataract Refract Surg
1997;23(9):1356-70.
13. Nhindatz GH Jr, Hughes WB. Ultrasonics in
ocular diseases. Am J Ophthalmol 1956;41: 488-89.
14. Ossoinig KC. Standardized echography: Basic
principles clinical application and results. Int
Ophthalmology Clin 1979;19:127-210.
15. Price PR, Jones TB, Goddard J. Basic concepts
of ultrasonic tissue characteristics. Radiologic
Clinics of North America 1980;18:21-30.
16. Shammas HJ. Atlas of Ophthalmic Ultrasonography and Biometry, St Louis, Mosby, 1984.
B-scan Ultrasonography
TARAPRASAD DAS, VASUMATHY VEDANTHAM, ANJALI HUSSAIN,

SANGMITRA KANUNGO, LS MOHAN RAM
15
B-scan
Ultrasonography
Since the first application in ophthalmology by

Mundt and Huges,1 ultrasonography, in little
over four decades, has emerged as an indispensable tool in the diagnosis and management of
various ocular and orbital abnormalities. The
value of ultrasonography in the diagnosis of
vitreoretinal diseases, and particularly in
preoperative evaluation of the posterior segment
of the eye need not be over emphasized.2
Ultrasonography is mostly indicated in hazy
media when the traditional optical evaluation
is not possible. It is also of immense diagnostic
and therapeutic value in selected situations
despite media clarity such as intraocular space
occupying lesions. This chapter briefly describes
the technique, and evaluation of the posterior
segment eye diseases using B-scan contact
ultrasonography. Care is taken to describe the
ultrasonic features of commonly seen vitreoretinal
diseases with representative illustrations. An
acquaintance with the technique and
interpretation is imperative to appreciate the
technical potential of ocular ultrasound.
kilohertz (kHz). The tissue ultrasound interaction

consists of reflection (and refraction), scattering,
and absorption of the sound energy.
Physics and Basic Technology
Scattering
Ultrasound consists of high frequency sound

waves over 20,000 cycles per second or 20
Scattering of ultrasonic energy occurs both at

rough interfaces between different tissues and
Reflection and Refraction

When the pulse of ultrasound energy meets a
large smooth boundary between two tissues that
differ in physical properties, some of the incident
pulse energy may be reflected between the two
media. This part of the pulse energy is redirected
in a specific direction back into the original tissue
with the same speed with which it approached
the boundary; some energy, however, continues
to be transmitted forward into the tissue beyond
the boundary, with the speed of propagation
determined by the medium. If the incident pulse
strikes the boundary perpendicularly, the
reflected energy will be maximal and the
transmitted pulse will propagate forward with
none or minimal change in direction. If the
boundary is approached obliquely by the incident
pulse, then the reflected pulse will be reduced
and the transmitted pulse will be refracted.
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different homogeneity of density or elasticity
within a tissue. It can be considered to be the
redirection of the incident ultrasound energy into
many directions. There is no particular direction
ascribed to the reflected energy, but a continuum
of directions. In true scattering no energy is lost
from the pulse, but the energy is redirected.
Absorption
In the ocular tissues, an ultrasound pulse loses
energy due to conversion of the vibrational energy
of the pulse to other energy forms such as heat.
The mechanisms of absorption in media are not
properly understood; different tissues exhibit
different frequency dependent absorptions.
Ophthalmic ultrasonography utilizes 8-10 MHz
sound waves. As it travels through the eye, it
is reflected by the intraocular structures, and the
echoes or the signals are returned to the screen.
Ultrasound Unit
An ultrasound unit is composed of four basic
elements: the pulser, the receiver, and the display
unit are all contained within the same chassis
and connected to the transducer, located at the
tip of the probe by an electrically shielded cable.
The pulser produces electric pulse at a rate of
1000 pulses per second. Each pulse excites the
electrodes of the piezo-electric crystal of the
transducer, generating sound waves. The
returning echoes are received by the transducer
and transformed into electric signals. These
signals are processed in the receiver and
demodulator, and then displayed on the screen
of the display unit.
Ophthalmic ultrasonography commonly uses
two modes of displaythe A-scan, and B-scan.
A-scan or amplitude modulation scan provides
one dimensional image of vertical deflections
from a base line. The A-scan provides information
regarding structure (size, distribution),

reflectivity (height of spikes), sound attenuation
(absorption), and vascularity.
B-scan or brightness modulation scan provides
two dimensional images of a series of dots and
lines. B-scan provides the topographic
information of shape, location, extension,
mobility, and gross estimation of thickness of
the tissue. While independently each mode of
ultrasonography do provide a wealth of
information, the combination of both A- and Bscan (Vector A-scan) is invaluable in a variety
of occasions where diagnostic dilemma exists.
In vector display the A-scan pattern corresponds
to the vectors direction. The vector B-scan uses
a focused 10 MHz transducer in contrast to
8 MHz unfocused transducer used in
standardized A-scan.
Three-dimensional ultrasound tomography
of the eye is a new advanced ultrasound
technique and digital computer technology where
ocular pathology can now be viewed in 3D.
The sonographer scans the eye using a regular
B-scan ultrasound probe which is inserted into
the motorized scanner assembly. This in turn
rotates the probe allowing the computer to acquire
over 200 B-scan images in 5 to 10 seconds. Using
digital technology, the 2D images and their global
positions are recorded, reconstructed and
displayed in real time as part of a 3D volume.
Three-dimensional ultrasound tomography
provides the following benefits over the current
one- and two-dimensional evaluations:
1. Improved visualization: Information is
presented in a format that reflects the 3D
nature of the pathology under examination.
The multiple acquired scans in 3D imaging
also reduce the risk of missing a small
pathology that can be overlooked if the probe
is not properly aimed toward it.
2. Volume measurements: The 3D examination
provides volume measurement capabilities
that surpass any of the volume estimation
methods available with conventional 2D
ultrasound techniques. Accurate volume
measurements of intraocular tumors allow
the physician to monitor changes over a
certain period of time, i.e. growth of a small
choroidal tumor, decrease in size of a
disciform macular degeneration, or the
response of a melanoma to radiation, laser
or drug therapy.
3. Profile A-scan analysis: Using an S-shaped
amplifier that allows an evaluation of the
internal echo-spikes an accurate linear
measurement in any chosen direction can be
made.
4. Analysis of the volume-of-interest: With
multidirectional slicing can show a tomographic display of intraocular pathology.
5. Surface rendering with a three-dimensional
view: The surfaces and boundaries of the
ocular pathology can be made under
examination.
Screening Techniques
It is best to begin with a maximum gain (80
decibels) setting on the B-scan, with the patient
lying on his back. The eye is anesthetized with
topical paracaine when the transducer can be
placed on the sclera; alternately, the probe can
be placed on the closed eyelid and in such a
situation the eye need not be anesthetized. The
probe is placed on the globe opposite the area
to be examined. The marker on the probe acts
as the orientation point and corresponds to the
upper portion of the echogram. To evaluate the
superior and inferior fundus the marker is
directed towards the nose (horizontal transverse),
and to evaluate the nasal and temporal fundus,
the marker is directed at 12 oclock meridian
(vertical transverse). The best detail of pathology
is obtained in the central portion of the echogram;
if the pathology is not located in one of the major

meridians (3, 6, 9, 12 oclock) an oblique
transverse scan can be used to evaluate the
pathology. In order to completely scan the eye
it is prudent to first direct the probe face at the
limbus, and then slowly shift to the fornix. Thus
one could evaluate from the posterior pole to
the periphery in each quadrant. Once the crosssectional evaluation is completed, the area of
interest is scanned by longitudinal scan.
Longitudinal scans allow for evaluation of a
single meridian from its most posterior aspect
to the far periphery. This is accomplished by
directing the marker at the corneal limbus
opposite the area to be examined. Axial scan
provides a pleasing, generally understandable
picture; however, it requires placement of the
probe directly on the cornea and thus the risk
of corneal abrasion increases.
A-scan produces a series of deflections from
the base line. The amplitude of the spike is directly
related to the density of the interface, and the
space between the spikes indicates the time it
takes for the sound to encounter an interface
and return as a signal.
Screening Technique with a 3D Unit

To begin scanning with 3D-unit, the operator
either presses a foot switch or may press the
on-screen scan button. The scanner assembly
rotates for several seconds (5, 7.5, or 15 according
to the chosen scan type), and then return to its
starting position. The system emits a beep tone
at the start and end of actual scanning period,
during which fixation must be maintained. After
scanning, the images become static, the recorded
initial scan plane images replace the line B-scan
display. Several buttons appear on the right side
of screen, which allow the operator to review
the recorded images and send to the 3D reviewing
mode.
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3D Scan Review
Evaluation of the Vitreous
Activating the 3D viewing function produces a

screen, where central part of the screen shows
the polyhedron (cube), with its sides positioned
at the extreme borders of the scanned volume.
The view is initially oriented as seen by the
ultrasound probe, i.e. the near field is in front
and the far field is behind. The 3D viewing
software includes many functions.
A maximum high gain should be used for

evaluation of the vitreous humor. The normal
vitreous cavity is devoid of any acoustic signals
and appears black or sonolucent on the B-scan.
On the A-scan the baseline remains flat
throughout the scan. During normal aging the
vitreous begins to degenerate, and varying
amounts of opacities are seen. Also there may
be significant contracture of the vitreous gel
leading to complete separation of the posterior
hyaloid.
The Normal Eye

Examination of a normal globe at high system
sensitivity reveals two echographic areas,
separated by an echo free area. The echographic
area at the beginning of the scan represents
reverberations at the tip of the probe and has no
clinical significance. When the scan resolution is
good, one could see the posterior convex structure
of the crystalline lens. The large echo free area
represents the vitreous cavity. The echogenic area
after the vitreous represents the retina, choroid,
sclera, and the orbital tissue behind it. The retina
is seen as a concave surface proximally. The optic
nerve shadow is seen as a triangular shadow
within the orbital fat (Fig. 15.1).
Asteroid Hyalosis
Asteroid hyalosis, a unilateral condition
characterized by formation of calcium soaps
within the vitreous cavity, appears as bright
round signals on B-scan, and medium amplitude
spikes in A-scan, with an echo free space just
in front of the retina that represents the echofree vitreous gel (Fig. 15.2). This is in contrast
to an eye with emulsified silicone oil, where there
is no echo-free space. Generally, these opacities
exhibit distinct movement on movement of the
eye.
Fig. 15.1: Normal globe: Ultrasonogram shows an echolucent vitreous cavity, concave
retinochoroidal layer and the triangular shadow of the optic nerve
Fig. 15.2: Asteroid hyalosis: Bright round signals seen on B-scan with echo free
space separating them from the retina
Posterior Vitreous Detachment

Posterior vitreous detachment (PVD) appears as
an undulating membrane in front of the
retinochoroidal layer that moves with movement
of the eye. It may separate completely from the
posterior pole or may remain attached to the
optic disk. On A-scan it appears as a tall spike,
but not as tall as the spike of a retinal detachment
(RD) or a retained intraocular foreign body. The
height of the A-scan spike and the brightness
of B-scan of PVD reduce as the gain is reduced;

in contrast the RD maintains its 100% reflectivity
all the time. Kinetic scanning is also useful
where a PVD shows wafting after-movements
(Fig. 15.3). PVD may be complete or incomplete.
It is incomplete in most of the vascular retinopathies associated with vitreous hemorrhage,
particularly proliferative diabetic retinopathy
(PDR). One could also image vitreoschisis that
usually occurs in PDR.
Fig. 15.3: Posterior vitreous detachment (PVD): B-scan shows an undulating membrane in front of the retinochoroidal
layer attached to the optic disk. The configuration of the detached vitreous is changed with the movement
of the eye (right)
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Vitreous Hemorrhage
The ultrasonic pattern of vitreous hemorrhage
depends on the density, location, extent, and
associated fibrous changes. The density of
hemorrhage is best estimated from the A-scan
amplitude and the area of vitreous hemorrhage
from B-scan. Hemorrhage in the vitreous appears
as small white echoes on B-scan and low
amplitude spikes on A-scan. With greater density
of vitreous hemorrhage, usually greater opacities
are seen on the B-scan. A fresh diffuse and
unclotted hemorrhage produces very little or no
echo response so that many time the vitreous
might appear sonolucent. Membranes are easily
differentiated from blood clots by their patterns,
and the height of the echoes.
One can also image the location of vitreous
hemorrhage such as confined within the PVD, preand post-hyaloid location, or diffusely dispersed
(Fig. 15.4). One can also differentiate old clotted
blood from fresh hemorrhage. We have earlier
reported that the overall accuracy of ultrasonic
diagnosis of vitreous hemorrhage and retinal
detachment in opaque media vis-a-vis the intraand postoperative findings were nearly 92%.3
Subhyaloid hemorrhage typically does not
clot. On echography, high gain settings are often
required to detect mild subhyaloid hemorrhage.

However, dense subhyaloid hemorrhage shows
high echo reflectivity (Fig. 15.5).
Endophthalmitis
Ultrasonography of the eye with endophthalmitis
depends on the degree and severity of infection
and the extent of vitreous involvement. Generally
opacities are noted, and membrane formation
becomes apparent in severe cases. Choroidal
thickening, choroidal detachment, retinal
detachment and retained IOFB are possible
associated findings (Fig. 15.6).
Evaluation of the Retina

The retina appears as a dense membrane on
B-scan, and in normal circumstances one can
not differentiate retina from the choroid. On
A-scan it typically gives a 100% tall spike.
Retinal Detachment
Retinal detachment appears as tall (100%
amplitude) spike separated from the choroidoscleral layer; it is attached, however, to the optic
nerve and the ora serrata. By serial scanning
Fig. 15.4: Vitreous hemorrhage: Intragel and subhyaloid in location and the
posterior vitreous is partially detached
Figs 15.5A to D: B-scan of posterior hyaloid detachment. A shows a high echoreflectivity due
to thickening of posterior hyaloid with medium echo reflectivity due to less dense subhyaloid
hemorrhage. Corresponding A-scan, B shows initial high reflective spike with low to medium echospikes.
In contrast, dense subhyaloid hemorrhage, C shows high echo reflectivity and corresponding
A scan, D shows medium to high echoreflectivity
Fig. 15.6: Endophthalmitis: Ultrasonogram shows low to medium

echoreflective vitreous opacities with choroidal thickening
the extent of retinal detachment can be

determined. Recent retinal detachments are
characterized by a mobile retina and translucent
subretinal space (Fig. 15.7).
With time when the proliferative vitreoretinopathy (PVR)4 sets in, the vitreous space becomes
limited, there is decreased mobility of the retina

in kinetic scanning, and membranes form and
adhere to the retina from all sides. This causes
a variety of configurations in the B-scan and
the most prominent one is the funnel configuration of the detached retina (Fig. 15.8 ). Two
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Fig. 15.7: Retinal detachment (fresh): B-scan shows detached retina as a thin, attached to the
optic disc and fanning peripherally. Vector A-scan showing a tall, highly echoreflective spike signifying
a retinal detachment. The subretinal space in fresh retinal detachment is usually sonolucent
Fig. 15.8: Closed funnel retinal detachment: Ultrasound shows a detached thick retina in a triangular
configuration, with apposition of the sides of the triangle in front of the optic disc
configurationsopen, and closed funnel are

described in PVR. In triangular retinal detachment the sides of the triangle represent the highly
detached stiff retina, and the base of the triangle
is the proliferating vitreous membrane.
An attempt was made to ultrasonically
differentiate advanced grades of PVR.5 In PVR
C1 the detached retinal leaves are thickened, and
the subretinal space is sonolucent in contrast
to PVR C2 and C3 where the subretinal space
is not sonolucent. In PVR D1 and D2 the retinal
leaves are thickened and shortened and
subretinal space is no longer sonolucent. In PVR
D3 three configurations are observedtriangular,
morning glory, and T-shape.
Long-standing retinal detachments may also

develop retinal cysts (Fig. 15.9) and become
partially calcified, and cholesterol debris may
accumulate in the subretinal space. It is important
to remember that an axial B-scan view may not
always demonstrate the insertion of a retinal
detachment into the optic nerve. Therefore, a
longitudinal approach should be used to
properly assess the relationship of a membrane
to the optic nerve.
Retinal Tear
Large retinal tears can be visualized easily, but
the smaller ones require a meticulous examina-
Fig. 15.10: Retinal tear: B-scan showing a breach of

retinal tissue. Vitreous is attached to this breach of tissue
suggesting the element of traction in causing retinal tear
Traction Retinal Detachment
Fig. 15.9: Longitudinal B-scan shows formation of intraretinal

cysts (white arrow) and retinal detachment with high
reflective surface spikes on corresponding A-scan. Often
intraretinal cysts may mimic a tractional retinal detachment
tion. It appears as a breach of tissue on B-scan,

and on A-scan it appears as a highly reflective
tissue separate from the other fundus spikes (Fig.
15.10). Giant retinal break with detachment
appears as a rolled out tissue on B-scan with
clear breach of tissue. In general, however,
detecting retinal tears on ultrasonography is not
easy and it is never as specific or sensitive as
on optical evaluation. It is useful in situations
when fresh vitreous hemorrhage due to retinal
tear obscures the fundus view; in these situations
the retinal tears are mostly located in the upper
half of the retina.
Traction detachment is a common finding in

vascular retinopathies, chiefly diabetic
retinopathy. It is caused by the strong adhesion
of vitreous membranes, bands, or the posterior
hyaloid face to the retina and subsequent traction.
The vitreoretinal adhesion could be focal causing
a tent-like, or broad, causing a table-top traction
of the retina (Fig. 15.11); the detached retina
appears to have a concave configuration, in
contrast to the convex configuration of the
rhegmatogenous retinal detachment.
Exudative Retinal Detachment

The configuration of the detachment is convex
and bullous. It is usually secondary to tumors,
inflammatory conditions, e.g. Vogt-KoyanagiHarada disease (VKH), or vascular disorders
such as hypertensive choroidopathy, and toxemia
of pregnancy. In VKH syndrome there is a diffuse
choroidal thickening with low to medium echo
reflectivity (Fig. 15.12).
Retinoschisis
This condition most often involves the
inferotemporal peripheral fundus. It may be
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Fig. 15.11: Tractional retinal detachment: B-scan shows a concave configuration of the retina with
a broad area of vitreoretinal adhesion signifying a table-top traction of the retina. The corresponding
vector A-scan showing a highly reflective spike, signifying RD
Fig. 15.12: Exudative retinal detachment and choroidal thickening in VKH syndrome: B-scan shows
diffuse choroidal thickening (better appreciated at the low gain of 77.0 dB), with overlying exudative
RD. Corresponding vector A-scan shows a highly reflective spike signifying retinal detachment and
low to medium reflective spikes behind it signifying choroidal thickening
demonstrate slight vertical after movement. It
differs from retinal detachment by its more focal,
smooth and thin character. A choroidal
detachment is thicker than retinoschisis and may
have a double peaked spike.
Cysticercosis
There is a characteristic echographic appearance
with a sharply outlined, oval cyst within the
vitreous cavity and/or in the subretinal space
(Fig. 15.14). The scolex of the parasite is seen
as a very highly reflective, echo-dense nodule
that is located adjacent to the inner wall of the
cyst.
Evaluation of the Choroid
Fig. 15.13: Retinoschisis: Transverse B-scan shows a

moderately elevated thin smooth dome-shaped membrane
echo (arrow) located in the inferotemporal periphery. Very
thin 100% spike is also seen on A scan
unilateral or bilateral. On B-scan it appears as

smooth, thin, dome-shaped membrane that does
not insert in the optic disc (Fig. 15.13). On Ascan, 100% high spike is produced, which may
The retinochoroidal layer has a smooth concave

configuration on B-scan and gives a tall spike
on A-scan.
Choroidal Thickening
Thickening of choroid can be localized or diffuse,
and is seen in a number of conditions. They
include posterior uveitis, sympathetic ophthalmia, Vogt-Koyanagi-Harada disease, late stage
of endophthalmitis and uveal effusion syndrome.
Fig. 15.14: Subretinal cysticercosis: B-scan shows a sharply outlined cyst in the subretinal space,
with a bright spot adjacent to the inner wall corresponding to the scolex. The vector A-scan through
the scolex shows a tall and highly reflective spike
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Fig. 15.15: Choroidal detachment: B-scan shows smooth, dome-shaped, thick membranous structure.
The corresponding vector A-scan, shows a series of medium to high reflective spikes behind the retinal
spike with a sonolucent suprachoroidal space
Choroidal Detachment
On B-scan a choroidal detachment appears as
a smooth, dome-shaped, thick membranous
structure that does not insert to the optic nerve
(Fig. 15.15). The choroidal detachment can be
localized, or involve the entire fundus (kissing
choroidal detachment). The B-scan also can
demonstrate the nature of suprachoroidal fluid;
in serous detachment, the suprachoroidal space
is echo-lucent, and in hemorrhagic detachment,
the suprachoroidal space is echo-dense.
On A-scan the thickened choroid appears as
a series of high reflective spikes just behind the
retinal spike. The detached choroid produces a
100% reflective, double peaked spike (retina and
choroid together). This spike exhibits little or no
after movement on kinetic scanning. The
suprachoroidal space appears sonolucent or with
low to medium height spikes depending on the
nature of suprachoroidal fluid.
patient cooperation. Ultrasonography permits

evaluation of the intraocular structures, locating
a retained intraocular foreign body, and
identifying any posterior wall disruption.
Vitreous Hemorrhage
The ultrasonic character of vitreous hemorrhage
is not different than vitreous hemorrhage in nontraumatic conditions. However, a large retinal
dialysis can be easily detected. Occasionally the
trail of hemorrhage in the solid vitreous can be
traced to the site of bleeding such as avulsion
of major vessel or scleral rupture (Fig. 15.16).
Evaluation of Traumatized Eye

Ultrasonography adequately supplements the
careful and meticulous evaluation a traumatized
eye needs.6 Very often indirect ophthalmoscopy
is not useful because of media opacity, or poor
Fig. 15.16: Traumatic vitreous hemorrhage: Intravitreous

gel trail of traumatic vitreous hemorrhage. B-scan shows
linearly placed bright spots in the vitreous cavity, leading
to site of retinal vessel avulsion causing vitreous hemorrhage
strands of vitreous might be attached to the
dislocated lens (Fig. 15.17).
Intraocular Foreign Body
Fig. 15.17: Dislocated lens: B-scan shows a globular

structure in the posterior vitreous signifying a dislocated
lens. Acoustic shadowing is seen, implying that the lens
could be cataractous or calcified
Dislocated Lens
Dislocated lens appears as a round or oval
globular structure in the posterior vitreous, and
Ultrasonography can detect both metallic and

non-metallic foreign bodies. Metallic foreign
bodies produce very bright signals on B-scan
that persist on lowering the gain (Fig. 15.18).
When the sound beam is focused on the metallic
foreign body, much of the sound waves are
absorbed by the foreign body, thus creating a
shadowing artifact on the adjacent orbit. Round
metallic foreign bodies classically produce
reverberation artifact just behind the foreign body,
and the sound signals gradually reduce as it
progresses to the orbit. On A-scan metallic foreign
bodies produce high (100%) reflective echoes,
and reduplication echoes are seen as progressively decreasing amplitude spikes behind the
Fig. 15.18: Intraocular foreign body: B-scan shows a bright signal in front of the optic
disk in the posterior vitreous, with a high 100% reflectivity on vector A-scan, that persists
on lowering of the gain. Orbital shadowing is also seen at low gain
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Fig. 15.19: Posterior globe rupture: B-scan shows breach of scleral tissue with
echolucent space in the subTenons space signifying fluid
round metallic foreign body. Glass and vegetative

matter (radiolucent) are more challenging, but
they also produce bright signals on B-scan, and
tall reflective echo on A-scan.
Posterior Globe Rupture

Traumatic posterior globe rupture (Fig. 15.19)
is seen as a breach of scleral and choroidal tissue
with associated choroidal thickening. Associated
findings may be vitreous hemorrhage, retained
intraocular or orbital foreign body, and retinal
detachment.
Optic Nerve Avulsion
Fig. 15.20: Optic nerve avulsion: B-scan shows a scleral

break near the optic disk signifying optic nerve avulsion
This is seen secondary to trauma. In acute injury,

vitreous hemorrhage may be present, and an
actual peripapillary scleral break may be seen
in B-scan (Fig. 15.20). In long-standing cases,
there may be proliferative tissue at the optic disk.
features such as shape, location, and extension.

A-scan provides information on structure,
reflectivity, vascularity, and height. Serial
ultrasonography is useful in measuring the
height and growth of the tumor over a period
of time.
Evaluation of Intraocular Tumors
Melanoma
The intraocular tumors display different acoustic

characteristics on ultrasonography because of
their vast difference in histologic composition.
B-scan provides information on topographic
Ultrasonically melanomas appear as solid,

regularly structured, vascular lesions of low to
medium reflectivity. Vascularity of the tumor is
well appreciated as distinct spontaneous
irregular contour, with a central elevation. They
have medium to high reflectivity, with minimal
to none internal vascularity. The large interface
between the choroidal tissue and the carcinoma
mass is responsible for the high reflectivity. On
A-scan, irregular spikes of medium to high
amplitudes are seen.
Choroidal Hemangioma
Fig. 15.21: Choroidal melanoma: B-scan shows a collarbutton-shaped mass from the choroid into the vitreous
cavity
movements of the lesion spikes during

examination in A-scan. While the most common
shapes are a dome or collar-button, they can also
be diffuse. A collar-button shape signifies rupture
of Bruchs membrane, and it is usually associated
with retinal detachment (Fig. 15.21). There can
be other signs such as acoustic hollowing
(decreased reflectivity at the tumor base due to
uniform echotexture of the tumor), choroidal
excavation at the tumor base and posterior scleral
bowing (noted in younger individuals).
Metastatic Choroidal Carcinoma

On B-scan metastatic choroidal carcinomas
appear diffuse; they have a typical bumpy,
These tumors appear as a flat, echogenic, solid,

subretinal mass, often located at the posterior
pole, with minimal sound attenuation, with or
without concomitant exudative retinal
detachment (Fig. 15.22).
On A-scan, it has a regular acoustic structure
with very high (95-100%) internal reflectivity,
that results from the large interfaces formed by
the vessel surfaces. By reducing the gain, the
vascularity of the tumor can be better appreciated.
Retinoblastoma
On B-scan retinoblastoma, if large, is seen as
an irregular echogenic mass involving the
vitreous, retina, and/or the subretinal space. Area
of calcification is seen as area of high echogenicity. This causes strong sound attenuation, and
is seen as an area of echolucency behind the
calcification (Fig. 15.23). This is because the
Fig. 15.22: Choroidal hemangioma: LeftOn B-scan, a flat echogenic solid subretinal mass
is seen with concomitant exudative retinal detachment of 4.16 mm thickness. RightA
decrease in thickness is seen after photocoagulation
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Fig. 15.23: Retinoblastoma: B-scan shows an irregular, large echogenic mass involving the vitreous
from the retina. Corresponding vector A-scan shows high internal reflectivity (70 to 90%), due
to spots of calcification
sound is almost totally reflected by calcification,

thus preventing its further propagation beyond.
On A-scan, the characteristic features are solid
consistency (absence of after movements
following a sudden ocular movement), high
internal reflectivity (70-90%), and presence of
vascularity. High internal reflectivity is due to
calcification and the large interface between area
of necrosis and viable tumor cells.7 The axial
length of the eye may be normal or increased
in case the tumor invades the ocular wall. The
increased axial length is thus an important point
in differentiating retinoblastoma from other
conditions causing leukocoria.
Disciform Macular Scar (Secondary to

Age-related Macular Degeneration)
Disciform macular scar is often confused with
choroidal melanoma due to its subretinal
location, and solid consistency, it can be

differentiated by its irregular acoustic structure,
medium to high reflectivity, absence of
vascularity, and rarity of associated retinal
detachment (Fig. 15.24).
Structural Anomalies
Structural anomalies of globe include phthisis
bulbi, atrophic bulbi, posterior staphyloma,
choroidal coloboma, optic nerve head drusen
and anophthalmos.
Phthisis Bulbi
In phthisis bulbi the globe is smaller than normal
with multiple echogenic vitreous opacities,
choroidal thickening, and calcification of ocular
coats, with resultant absence of high reflective
orbital echospikes due to shadowing (Fig. 15.25).
Fig. 15.24: Disciform macular scar: B-scan shows a solid subretinal lesion. In contrast to a
melanoma, it has an irregular acoustic structure, and medium to high reflectivity in the corresponding
vector A-scan
Fig. 15.25: Phthisis bulbi: B-scan shows a smaller than normal globe, with multiple echogenic vitreous
opacities and calcification of ocular coats. The corresponding vector A-scan shows the resultant
orbital shadowing
Atrophic Bulbi
Choroidal Coloboma
Atrophic bulbi is characterized by a normal globe

contour with calcification of ocular coats (Fig.
15.26). It has normal axial length.
Choroidal coloboma is seen as an excavation,

usually involving the posterior pole; but in
contrast to posterior staphyloma, its edges are
sharp. Associated findings include microphthalmos, and retinal detachment.
Posterior Staphyloma
Posterior staphyloma is seen as a shallow
excavation of the posterior pole with smooth
edges on sonographic evaluation of highly
myopic eyes.
Optic Nerve Drusen

Optic nerve drusen are calcified nodules seen
echographically to produce an echo of extremely
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256
Fig. 15.26: Atrophic bulbi: Ultrasonogram shows a normal globe contour

with calcification of the ocular coats
Fig. 15.27: Optic nerve head drusen: B-scan showing bright echogenic spot over the optic disk.
Corresponding vector A-scan showing a highly reflective spike that persists on lowering the gain
high reflectivity at or within the optic nerve head.
They are best seen with transverse and
longitudinal B-scan approaches, which bypass
the lens, and demonstrate the calcified nodules
better than the axial approach (Fig. 15.27).
Optic Nerve Head Coloboma

Coloboma involving the optic disk is easily
imaged by B-scan. These can be small and
shallow. The sharp edge of the defect margin
differentiates a coloboma from a staphyloma on
ultrasonography (Fig. 15.28).
Immersion B-scan
Immersion B-scan is used to study the anterior
segment structures (Fig. 15.29). A water bath is
used to incorporate the delay zone.
Ophthalmic ultrasonography is an invaluable tool in diagnosis and evaluation of the
posterior segment of the eye. Knowledge of
various features and appropriate clinical correlation is essential to gain maximum information
from this technology.
Fig. 15.28: Optic nerve head coloboma: Horizontal Bscan showing sharp defect over the optic disk area
suggestive of coloboma of the optic disk
Fig.15.29: Left: Immersion Bscan shows a total cataract with

intact posterior capsule. Right:
Immersion B-scan showing
partially absorbed cataractous
lens. Note the thickness of the
lens and increased reflectivity of
the posterior capsule
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258
References
1. Mundt GH, Huges WF. Ultrasonic in ocular
diagnosis. Am J Ophthalmol 1956;41:488-98.
2. Das T, Namperumalsamy P: Ocular ultrasound
in preoperative evaluation of posterior segment
of the eye. Indian J Ophthalmol 1983;31:1022-24.
3. Das T, Namperumalsamy P. Ultrasonographic
characterisation of vitreous hemorrhage and
retinal detachment. Afro-Asian J Ophthalmol
1985;4:10-16.
4. The Retina Society Terminology Committee.
The classification of retinal detachment with
proliferative vitreoretinopathy. Ophthalmology
1983;90:121-25.
5. Das T, Namperumalsamy P. Ultrasonic characterisation of proliferative vitreoretinopathy.
Afro-Asian J Ophthalmol 1987;5:180-85.
6. Das T, Namperumalsamy P. Ultrasonography

in ocular trauma. Indian J Ophthalmol 1987;35:
121-25.
7. Das T, Namperumalsamy P. Ultrasonic evaluation of retinoblastoma. Afro-Asian J Ophthalmol
1986;5:4-10.
Bibliography
1. Coleman DJ, Lizzi FL, Jack RL (Eds). Ultrasonography of the eye and orbit. Philadelphia, Lea
and Febiger, 1977.
2. Shammas HJ. Atlas of Ophthalmic Ultrasonography and Biometry. St Louis: CV Mosby Co,
1984.
Ultrasound Biomicroscopy in Ophthalmology
ROSHMI GUPTA, K KALYANI PRASAD, MOHAN RAM, SANTOSH G HONAVAR
16
Ultrasound
Biomicroscopy in
Ophthalmology
Ultrasound biomicroscopy (UBM) uses high

frequency sound waves to provide noninvasive
in vivo imaging of the anterior segment with
microscopic resolution. It acts on a principle
similar to that of the B-scan; sound waves in
the ultrasonic range are reflected off the structure
of interest, and the reflected waves form images.
However, frequency of the waves used in the
UBM range between 35 and 50 MHz, while the
ophthalmic B-scan probes generate sound waves
of 10 MHz frequency. The B-scan, with a lower
frequency, has better penetration, and can image
structures of the posterior segment well. Anterior
segment structures can be visualized only by
the immersion technique, the resolution being
poor compared to the UBM. The UBM, with
higher frequency sound waves, can penetrate
only about 5 mm into the eye; however, it can
form images of the anterior segment with a much
better resolution than the B-scan. UBM can be
used to image and assess the morphology of
structures easily seen on conventional examination (with slit-lamp) such as cornea, iris and
sclera, as well as structures hidden from clinical
observation, including the ciliary body and
zonule. The normal anatomical relations and
pathophysiologic changes in the anterior
segment structures can be examined both
qualitatively and quantitatively with the help

of UBM.
Basic Physics and Instrumentation

Signal processing for ultrasound biomicroscope
is similar to that in conventional B-mode
ultrasound. A monocycle high voltage (200V
peak to peak) 40 to 100 MHz pulse is used to
excite the transducer. The resulting 40-100 MHz
ultrasound pulse is transmitted into the tissue
while the transducer is moved linearly over the
imaging field (typically 4-8 mm). The commercially available machines use 50 or 35 MHz
transducers. The back-scattered ultrasound is
detected by the same transducer, the data being
collected at each of 512 equally spaced lines.
The radio-frequency signal is received and
amplified in proportion to the depth from which
it originated using time-gain compensation
(TGC). That is the signals from deeper structures
are amplified more than those from more
superficial structures, thus compensating for the
attenuation of the ultrasound beam in the tissue.
After the radio-frequency signals are processed
non-linearly to enhance the low level signals,
its envelope is detected to produce an A-scan
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260
Fig.16.1: Schematic diagram of the ultrasound biomicroscope. TGC, time gain compensation
signal. This signal is displayed as B-scan data

on a video monitor as real time images, the whole
process being controlled and synchronized by
a computer. B-mode imaging is currently
performed at 8 frames/second (Fig. 16.1).
By increasing the frequency in an ultrasound
biomicroscope, microscopic resolution is attained
over a limited depth. The units operating at
50 MHz provide a lateral and an axial resolution
of 50 m and 25 m, respectively. In contrast,
the axial resolution of a typical 10 MHz system
is 190 m. Tissue penetration of the UBM is
approximately 4-5 mm.
the ultrasound beam strikes the targeted surface

perpendicularly. In the UBM manufactured by
Paradigm Instruments, the probe is suspended
from a gantry arm to minimize motion artifacts,
and lateral distortion is minimized by a linear
scan format. In the OTI instrument, the probe
is small eliminating the need for a suspension
system, and a sector scanning method is used
(Fig. 16.2).
Procedure
Scanning is performed with the patient in supine
position. A flared plastic eyecup of the appropriate size is inserted between the lids, holding
methylcellulose or normal saline, which acts as
a coupling medium. The reflected signal is best
detected when the transducer is oriented so that
Fig.16.2: Ultrasound biomicroscope

The entire ciliary body can be defined from
the ciliary processes to the pars plana. The zonule
is imaged as a medium reflective line extending
from the ciliary process to the lens surface.
Quantitative Ultrasound
Biomicroscopy
Fig.16.3: UBM photograph showing normal ocular
structures, cornea, corneoscleral junction, sclera, anterior
chamber angle, iris, ciliary body and anterior surface of
lens
Ultrasound Biomicroscopic Anatomy

of the Normal Eye and Adnexa
The appearance of ocular anatomy on ultrasound
biomicroscopy is similar to a low power
microscopic section (Fig. 16.3). The superficial
cornea appears as two parallel highly reflective
lines; the first indicating the epithelial surface and
the second the Bowmans membrane. The corneal
stroma shows a lower internal reflectivity than the
sclera. The posterior corneal surface is depicted by
a high reflective line corresponding to the
endothelium and the Descemets membrane.
The anterior chamber can be outlined and
its depth to the lens or iris at any point can
be determined. The angle structures are well
outlined by ultrasound biomicroscopy.
The corneoscleral junction can be defined
well. The sclera has a high internal reflectivity
due to the irregular arrangement of the collagen
bundles. The high reflectivity of the sclera
differentiates it from the less reflective episcleral
tissue, ciliary body and peripheral choroid.
The scleral spur (thickest region) is located
where the trabecular meshwork meets the
interface line between the sclera and ciliary body.
It is utilized as a landmark for interpreting UBM
images of the anterior chamber angle and
analyzing angle pathology.
The ultrasound biomicroscopy provides precise

and reliable measurements and relationships of
the anterior segment structures. The UBM
measurement software measures distance by
counting the number of pixels along the
measured line, and multiply it by the theoretical
size of the pixel. The theoretical precision of
measurement of the lateral and axial distances
in the commercially available machines is 6 and
12 m, respectively, while the resolutions of the
two are 50 and 25 m. The UBM cannot
distinguish between two points along an axial
line which are less than 25 m apart, but if the
points are more than 25 m apart, the distance
between them can be measured with 6 m
precision. The axial and lateral measurements
of the UBM are accurate and reliable, as compared
to histologic sections and ultrasound pachymetry.
The reproducibility is good in intra-observer
UBM measurements, but not in the inter-observer
values. Both image acquisition differences and
measurement process contribute to the variability.
A semiautomated software that calculates the
parameters after a single user input of a reference
location has improved the reproducibility.
Multiple parameters have been proposed to
facilitate the quantitative study of UBM
measurements (Table 16.1).
Clinical Applications of UBM

Keratoplasty
The UBM may be useful in imaging underlying
structures and defining the state of the angle
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262

TABLE 16.1: PARAMETERS OF QUANTITATIVE ULTRASOUND BIOMICROSCOPY (PAVLIN ET AL)
Name
Abbreviation
Description
Angle opening distance
AOD
Distance between the trabecular meshwork and the iris

at 500 m anterior to the scleral spur
Trabecular-iris angle
TIA 1
Angle of AC angle recess
Trabecular-ciliary
process distance
TCPD
Distance between the trabecular meshwork and the ciliary

process at 500 m anterior to the scleral spur
Iris thickness
ID1
Iris thickness at 500 m anterior to the scleral spur
Iris thickness
ID2
Iris thickness at 2 mm from the iris root
Iris thickness
ID3
Maximum iris thickness near the pupillary edge
Iris-ciliary process distance
ICPD
Distance between the iris and the ciliary process along

the line of TCPD
Iris-zonule distance
IZD
Distance between the iris and the zonule along the line
of TCPD
Iris-lens contact distance
ILCD
Contact distance between the iris and the lens
Iris-lens angle
ILA 2
Angle between the iris and the lens near the pupillary
edge
of the anterior chamber prior to keratoplasty (Fig.

16. 4). In corneal transplant cases, the graft-host
junction can be defined. Posterior wound gape
and the Descemets stripping can also be imaged.
Fig.16.4: UBM of an eye with adherent leukoma:

visualization of anterior chamber and other structure helps
planning of management
Limbal Dermoid
Limbal dermoid can be well-delineated with the
help of UBM. The extent of the dermoid into the
cornea or intraocularly may be demonstrated,
and the surgical approach for removal can be
planned (Fig. 16.5). The UBM is capable of
Fig.16.5: UBM of a limbal dermoid showing extension

into the layers of the cornea, but no intraocular extension

detecting cystic as well as solid lesions of the
conjunctiva. The margins of the lesion and their
intraocular extension can be defined. However,
it is not yet possible to differentiate the different
types of solid and cystic tumors of the conjunctiva
based on the UBM image alone.
Refractive Surgery
Excimer laser keratoablation results in a loss of
Bowmans membrane and double lines of the
normal corneal surface are converted into a single
line.
crystalline lens, and the changes in the anatomic

relationships pre- and post-implantation of
different types of lenses.
Glaucoma
The ability of ultrasound biomicroscopy, to image
various angle structures and the ciliary body,
has helped to define mechanisms in various types
of glaucoma (Fig. 16.7).
Intraocular Lenses
The location of optic and haptic of an intraocular
lens can be assessed accurately by looking for
a strong echo at their interface plane (Fig. 16.6).
The technique is used to study different types
of intraocular lenses including accommodating
intraocular lenses. Studies have been conducted
on angle-fixated, iris-fixated (Artisan) and
posterior chamber phakic intraocular lenses
using the UBM. It is possible to assess distance
of phakic intraocular lenses from the corneal
endothelium, iris, and the surface of the
Fig.16.7: Iris bomb in uveitic glaucoma: Accumulation

of aqueous behind the iris balloons the iris forward
Relative Pupil Block Glaucoma

In primary angle-closure glaucoma (PACG), the
angle closure results from relative pupillary block.
The iris is always convex, with variable degrees
of angle-closure (Figs 16.8A to C). It is possible
to quantify the area of iris-lens touch present
in this condition. The iris-lens touch is generally
smaller than that seen in normal patients.
Plateau Iris Syndrome
Fig.16.6: UBM showing pupillary capture of

intraocular lens optic
Peripheral angle-closure persists in plateau iris

syndrome even in the presence of patent
iridectomy. It has been shown by the ultrasound
biomicroscopy that the peripheral iris is
supported by an anterior positioning of the ciliary
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Fig.16.8A: UBM of an eye with a narrow-angle glaucoma
Fig.16.8B: UBM of the same eye after laser

iridotomy, demonstrating opening of the angle
Fig.16.9A: UBM of an eye with plateau iris configuration

showing narrow-angle due to anterior location of ciliary
processes
Fig. 16.9B: UBM showing plateau configuration of

iris with a closed-angle
Fig. 16.9C: UBM of the eye (shown in Fig. 16.9B)

showing open-angle after laser iridoplasty
Fig.16.8C: Eye with angle-closure, UBM showing peripheral
anterior synechiae, iridotomy is unlikely to be effective
in opening the angle
processes. The ciliary processes provide

structural support behind the peripheral iris that
prevents it from falling away from the trabecular
meshwork following iridectomy. Peripheral
iridoplasty can produce thinning of the iris in
this region improving angle opening (Figs 16.9A
to C).
Supraciliary effusion can produce angleclosure by anterior rotation of the ciliary processes
producing direct angle-closure and pupil block
secondary to the anterior position of the lens.
Supraciliary fluid that is undetectable by other
means can be detected by the UBM.
Ciliary Block Glaucoma

Ciliary block glaucoma has been studied by the
ultrasound biomicroscopy. Swelling or anterior

rotation of the ciliary body with forward
movement of the lens-iris diaphragm and
relaxation of the zonular apparatus cause direct
angle-closure by morphologically pushing the
iris against the trabecular meshwork. UBM often
reveals a shallow supraciliary detachment not
evident on routine B-scan examination.
Pigment Dispersion and Pigmentary

Glaucoma
Pigment dispersion occurs most likely due to
mechanical contact between the posterior iris
and zonular pockets. The UBM demonstrates a
wide open-angle in pigmentary glaucoma. The
iris configuration is typically concave, with a
variable amount of irido-zonular contact (Fig.
16.10). The iris which is in apposition to the
anterior lens capsule acts as a flap valve that
does not permit the flow of aqueous from the
anterior chamber to the posterior chamber,
thereby increasing the pressure in the anterior
chamber compared with the posterior chamber,
a condition termed reverse pupillary block. It has
been shown both by clinical observation and
ultrasound biomicroscopic studies that miotics
and iridectomy can produce a straightening of

a bowed iris in this condition. It has also been
demonstrated by the ultrasound biomicroscopy
that accommodation can produce iris bowing
in pigmentary dispersion. With accommodation,
the anterior surface of the lens moves forward
(which increases anterior chamber aqueous
pressure) resulting in the pressure reversal that
produces posterior iris movement.
Failure of Filtering Surgery

Since it is possible to image the internal ostium
with ultrasound biomicroscopy it can be helpful
in determining the causes of filtering surgery
failure. The filtering bleb shows a spongy
appearance on the ultrasound biomicroscopy
with an occasional clear fluid space. The UBM
can accurately localize the site of obstruction
to aqueous flow (Figs 16.11A and B). Sites of
potential blockage include internal ostium
(within the eye), beneath the scleral flap (within
the surgical drainage tunnel), at the episclera
Fig. 16.11A: UBM of eye after trabeculectomy

showing a filtering bleb (white arrow)
Fig.16.10: UBM showing irido-zonular contact due to

posterior bowing of the iris in an eye with pigmentary
glaucoma
Fig. 16.11B: UBM showing scarred bleb (black

arrow) in failed trabeculectomy
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(caused by scarring immediately above the scleral
flap), and bleb encapsulation.
Ocular Trauma
Ocular trauma may result in hyphema, cyclodialysis, angle-recession and iridodialysis. UBM can
be used in the detection of these conditions,
especially in the presence of hazy media. It can be
used to locate a foreign body in the angle or the iris
(Fig. 16.12). Persistent hypotony after ocular
trauma may be due to cyclodialyisis (Fig. 16.13),
or cyclitic membrane (Fig. 16.14). The diagnosis
may be elucidated by the UBM.
Tumors of Uvea
Tumors of the iris, ciliary body and peripheral
choroid lie within the penetration limit of the
Fig.16.14: UBM demonstrating a cyclitic membrane

in an eye with persistent hypotony
ultrasound biomicroscope. This imaging method

is valuable in measuring tumor thickness,
defining tumor extent and differential diagnosis.
Iris Nevi
Iris nevi are benign tumors which do not require
any intervention. UBM is useful in measuring
the thickness and extent of nevus.
Leukemic Infiltration of Iris

Fig.16.12: UBM showing a high-reflective foreign
body in ciliary body
UBM is valuable in measuring the stromal

thickness in leukemic infiltration (Fig. 16.15A).
It can also be used to assess the effect of
radiotherapy (Fig. 16.15B), and follow-up.
Iris Melanomas
Fig.16.13: UBM showing cyclodialysis cleft in an

eye after blunt trauma (white arrow)
Iris melanomas have varied clinical presentations, and differentiation between melanomas
and nevi can be difficult, requiring serial
observations. UBM is useful in defining the tumor
boundaries and also detecting a change in its
characteristics.
Fig.16.16: UBM showing ciliary body cyst
Fig.16.15A: UBM showing leukemic infiltration of iris

in a patient of leukemia in remission
Fig.16.15B: UBM of the same eye after external

beam radiotherapy
Fig.16.17: UBM of ciliary body tumor extending

through the angle into the anterior chamber and iris
Iris Cyst
The iridociliary junction is a common location
for iris cysts. UBM is useful in differentiating
cysts from solid masses. The ultrasound
appearance consists of a thin-walled cyst with
no internal reflectivity (Fig. 16.16).
Ciliary Body Tumor

The UBM is very helpful in differentiating purely
iris tumors from ciliary body tumors. Ciliary body
tumors can be defined and identified at a stage
when they cannot be detected by conventional
ultrasound (Fig. 16.17).
Peripheral Choroidal Tumors

The UBM cannot define the full extent of the
peripheral choroidal tumors. The anterior borders

can be frequently detected and this information
can be helpful if radioactive plaque therapy is
contemplated.
Scleral Diseases
UBM can differentiate between the diseases of
sclera proper and diseases of episclera.
Nodular Scleritis
The involvement of the sclera can be detected
by a change in the reflectivity of the scleral tissue.
The edematous scleral tissue becomes weakly
reflective.
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Necrotizing Scleritis
Necrotizing scleritis implies thinning of the sclera
secondary to a destructive process. The UBM
can detect this thinning and provide a quantitative assessment of residual scleral tissue.
Scleral Staphyloma
The UBM can detect the thinning that occurs
in a scleral staphyloma and also the changes
in the underlying ciliary body.
Episcleritis
Episcleritis appears as a thickening of the
episcleral layer without involvement of the sclera
itself.
Conclusion
The strength of UBM lies in its ability to produce
cross-sections of the living eye at microscopic
resolution without affecting the relationships of
the structures imaged. It is a tool for qualitative
and quantitative assessment of the anterior
segment. It has already contributed considerably
to our understanding of ocular pathophysiology.
The scope of applications of UBM is increasing
in the diagnosis and management of various eye
diseases.
Bibliography
1. Buchwald HJ, Muller A, Spraul CW, Lang GK.
Ultrasound biomicroscopy of conjunctival
lesions. Klin Monatsbl Augenheilkd 2003;220(1-2):
29-34.
2. Hoops JP, Ludwig K, Boergen KP, Kampik A.
Preoperative evaluation of limbal dermoids
using high-resolution biomicroscopy. Graefes
Arch Clin Exp Ophthalmol 2001;239(6):459-61.
3. Iishikawa H, Schuman JS. Anterior segment
imaging: ultrasound biomicroscopy. Ophthal-
mology Clinics of North America 2004;17:7-20.

4. Jimenez-Alfaro I, Benitez del Castillo JM, GarciaFeijoo J, Gil de Bernabe JG, Serrano de La Iglesia
JM: Safety of posterior chamber phakic
intraocular lenses for the correction of high
myopia: anterior segment changes after
posterior chamber phakic intraocular lens
implantation. Ophthalmology 2001;108(1):90-9.
5. Jimenez-Alfaro I, Garcia-Feijoo J, Perez-Santonja
JJ, Cuina R. Ultrasound biomicroscopy of ZSAL4 anterior chamber phakic intraocular lens for
high myopia. J Cataract Refract Surg 2001;27(10):
1567-73.
6. Kawana K, Okamoto F, Nose H, Oshika T.
Ultrasound biomicroscopic findings of ciliary
body malignant melanoma. Jpn J Ophthalmol
2004;48(4):412-4.
7. Kunimatsu S, Araie M, Ohara K, Hamada C.
Ultrasound biomicroscopy of ciliary body cysts.
Am J Ophthalmol 1999;127(1):48-55.
9. Liebmenn JM, Ritch R, Esaki K. Ultrasound
biomicroscopy. Ophthalmology Clinics of North
America 1998;11:421-33.
8. Lanzl IM, Augsburger JJ, Hertle RW, Rapuano
C, Correa-Melling Z, Santa Cruz C. The role
of ultrasound biomicroscopy in surgical planning
for limbal dermoids. Cornea 1998;17(6):604-6.
10. Lin HC, Shen SC, Huang SF, Tsai RJ. Ultrasound
biomicroscopy in pigmented conjunctival cystic
nevi. Cornea 2004;23(1):97-9.
11. Marchini G, Pedrotti E, Sartori P, Tosi R.
Ultrasound biomicroscopic changes during
accommodation in eyes with accommodating
intraocular lenses: pilot study and hypothesis
for the mechanism of accommodation. J Cataract
Refract Surg 2004;30(12):2476-82.
12. Pavlin CJ, Foster FS. High frequency ultrasound
biomicroscopy, imaging the eye at microscopic
resolution. Ophthalmology Clinics of North America
1994;7:509-22.
13. Pavlin CJ, Foster FS. Ultrasound Biomicroscopy
of the Eye. New York: Springer-Verlag, 1995.
14. Pavlin CJ, Foster FS. Ultrasound biomicroscopy
in glaucoma. In Ritch R, Shields MB, Krupin
T (Eds). The Glaucomas, Basic Sciences 2nd ed.
St Louis: Mosby, 1996;1:471-90.
15. Pop M, Payette Y, Mansour M. Ultrasound
biomicroscopy of the Artisan phakic intraocular
lens in hyperopic eyes. J Cataract Refract Surg
2002;28(10):1799-803.
Optical Coherence Tomography
TOMOHIRO OTANI
17
Optical Coherence
Tomography
Optical coherence tomography (OCT) is a

diagnostic technology, which provides a crosssectional image of the anterior eye and the retina
in vivo with a high resolution similar to a
histological section by light microscopy.1-3 OCT
has demonstrated the intraretinal structure of
fundus diseases including macular hole, 4
macular edema,5, 6 highly myopic eye.7 It also
enables us to evaluate the surgical outcome of
macular diseases on the histopathologic level.
A third-generation OCT (OCT3), with less than
10-m axial resolution, provides more detailed
imaging of the retinal structures than the former
one.
In this chapter, the principle of OCT, procedures, limitations and the cross-sectional images
of various macular diseases using OCT conducted
in our institution are being described.
Instruments and Principle of OCT3

System
The OCT3 system hardware consists of the
patient module; the computer unit; the flat screen
video monitor; the keyboard, mouse and color
inkjet printer (Fig. 17.1).
OCT uses low-coherence interferometry to
produce cross-sectional images of optical
Fig. 17.1: OCT3 system
scattering from intraretinal microstructures (Fig.

17.2). These images are similar to those provided
by B-mode ultrasound. Low coherence light from
a super luminescent diode source connects with
a Michelson interferometer. Infrared light from
the source is divided at an optical beam-splitter
into reference beam and measurement beam. The
measurement beam is directed onto the patients
eye and is reflected from intraocular structures
at different distances. The reflected light (reflected
measurement beam) is composed of multiple
echoes which include information about the
range or distance and thickness of different
intraocular structures. The reference beam is
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Difficulties and Limitations

The use of OCT is limited by intraocular media
opacities such as vitreous hemorrhage, dense
cataract and corneal edema, which attenuate
measurement beam and reflected light.
Pattern of OCT in Macular Diseases

Normal Macula
Fig. 17.2: The optical interferometer (Courtesy from:

Schuman JS, Puliafito CA, Fujimoto JG. Principle of Optical
Coherence Tomography. In Optical Coherence
Tomography of Ocular Diseases (2nd edn). New Jersey,
SLACK Incorporated, 2004)
reflected from a reference mirror. The reflected

reference beam returns to the beam-splitter where
it combines with the reflected measurement beam.
Time delay information between the two light
pathways is then determined by a photo diode,
which detects back-scattered light along a
reference optical delay path. Once the light is
detected, a signal is sent which is processed
electronically and used within the OCT internal
computer data acquisition bank for analysis and
storage. Measuring the interferometric signal
creates A-mode type scans. Cross sectional
images are constructed from a sequence of single
longitudinal A-mode type scan. There is no
contact between the OCT scanner and the eye.
Slit-lamp biomicroscopy of the retina may be
performed simultaneously with the image
acquisition. The obtained OCT images are
displayed in a false color representation. The
intensity of the reflected optical signal is
represented on a logarithmic scale with varying
degrees of brightness. The maximum optical
reflection and back-scattering are represented by
red-white colors, while the minimum signals are
represented by blue-black colors.
Cross-sectional images of the normal macula

showed a physiological foveal depression with
an intraretinal layered structure (Fig. 17.3). A
high reflectivity was obtained from the retinal
nerve fiber layer, plexiform layers and the retinal
pigment epithelium (RPE). The boundary
between the photoreceptor inner segments and
outer segments (Fig. 17.3, bottom, arrows) was also
seen as a highly reflective band on OCT3.8, 9 The
ganglion cell and nuclear layers produced low
reflectivity. The thickness of the fovea
(center of the macula) averaged 144 m and
was independent of either age or state of
refraction.10
Macular Hole
Kishi and Takahashi evaluated the threedimensional structure of idiopathic macular hole
(Fig. 17.4) in 89 affected eyes using OCT and
scanning laser ophthalmoscopy (SLO).4 In stage
1 hole, OCT revealed retinal split or cystic changes
at the fovea in 11 of 15 eyes (73%) and foveal
retinal detachment in 4 eyes (27%). Intraretinal
splitting involving the perifoveal area was
present in 16 eyes with stage 2 hole. A break
was present in the anterior cyst wall. The outer
retina could not be identified at the fovea by
OCT. A full thickness hole surrounded by
intraretinal split or cystoid edema was present
in all of 50 eyes with stage 3 hole. Opercula
were seen in 32 of the 50 eyes. A detached vitreous
Fig. 17.3: Normal macula. Fundus photograph (top) and OCT3 (bottom). OCT3 shows a physiologic foveal depression
with an intraretinal layered structure. The boundary between the photoreceptor inner segments and outer segments
is also seen as a highly reflective band (arrows).
cortex could be observed in 24 of the 32 eyes.

Intraretinal split seen by OCT appeared as
radiating striae of elevated Henles fiber layer
by SLO. The findings show that idiopathic
macular hole initiates as intraretinal split or cysts

at the fovea and that a full-thickness macular
hole forms when the anterior cyst wall is
operculated.
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272
C
Figs 17.4A to C: Macular hole. A Stage 1 macular hole. OCT3 demonstrates a foveal cyst.
B Stage 2 macular hole. OCT3 shows a flap consists of retinal tissue extending from the
perifoveal retina. The perifoveal retina has cystic changes. C Stage 3 macular hole. The perifoveal
retina is elevated and has cystic changes. An operculum is seen above the hole
Preretinal Macular Fibrosis
High Myopic Eyes
Maruyama and coworkers examined 19 eyes with

preretinal macular fibrosis (Figs 17.5 and 17.6)
using OCT.11 The foveal thickness ranged from
300-650 m. The macula was swollen in 15 eyes
lacking the physiological foveal depression. In
4 eyes with pseudomacular hole, the foveal
structure showed sharp columnar depression
surrounded by thickened perifoveal retina.
Swelling of the retina was more pronounced in
the outer retinal layers showing a low reflective
zone. The findings show that preretinal macular
fibrosis is not a mere retinal surface disorder
but may also be associated with fluid accumulation in the outer retina.
Takano and Kishi evaluated the OCT features

of the retina in patients with severe myopia and
posterior staphyloma7 (Fig. 17.7). The study
included 26 phakic and 6 pseudophakic eyes.
The refractive errors of the 26 phakic eyes ranged
from 8 to 31 diopters (average 16.7 diopters).
Although refractive errors were within 8
diopters in the 6 pseudophakic eyes, the eyes
had apparent posterior staphyloma. The axial
lengths measured by A-mode ultrasonography
ranged from 25.7 to 32.7 mm (average, 29.2 mm).
Slit-lamp examination with a contact lens
showed that none of the eyes had a macular
hole. In 9 eyes with shallow retinal elevation
Fig. 17.6: Preretinal macular fibrosis with pseudohole.

Fundus photograph (top) and OCT3 (bottom). The foveal
structure showed sharp columnar depression (arrows)
surrounded by thickened perifoveal retina
Fig. 17.5: Preretinal macular fibrosis. Fundus photograph
(top) and OCT3 (bottom). Contraction of preretinal
membrane (arrows) caused retinal thickening with fluid
accumulation in the outer layer of the retina
on slit-lamp examination, optical coherence

tomography disclosed a foveal retinal detachment
with retinoschisis in 8 eyes and a foveal retinal
detachment in 1 eye. Two of the remaining 23
eyes had retinoschisis. Foveal retinal detachment
and retinoschisis are common features in severely
myopic eyes with posterior staphyloma. Retinal
detachment may precede the formation of a
macular hole in severely myopic eyes.
Diabetic Macular Edema

Otani and Kishi reported cross-sectional images
of diabetic macular edema by OCT.6 OCT showed
three patterns of structural changes in diabetic
macular edema (Figs 17.8 to 17.12): sponge-like
Fig. 17.7: Highly myopic eye. Fundus photograph (top)

and OCT3 (bottom). The fundus has retinochoroidal
atrophy within the staphyloma. OCT3 shows a localized
retinal detachment (*) and perifoveal retinoschisis ()
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Fig. 17.10: Diabetic macular edema with hard exudates.

Fundus photograph (top) and OCT3 (bottom). In OCT3
image, hard exudates are seen as highly reflective areas
located in the outer retinal layers (arrows)
Fig. 17.8: Diabetic retinopathy with cystoid macular

edema. Fluorescein angiography (top) and OCT3 (bottom).
In the late phase of angiogram, hyperfluorescent cystoid
spaces occupy most of the macula. OCT3 shows round
cysts mainly in the outer retina that caused the fovea
to protrude
Fig.17.11: Diabetic macular edema with subretinal

hard exudates. Fundus photograph (top) and OCT3
(bottom). Fundus photograph shows hard exudates at
the fovea. In OCT3 image, subretinal hard exudates
(arrows) are observed as highly reflective plaques, which
are slightly elevated from the retinal pigment epithelium
Fig. 17.9: Diabetic retinopathy with serous retinal

detachment. Fundus photograph (top) and OCT3
(bottom). OCT3 reveals a serous retinal detachment at
the fovea (arrows)
retinal swelling (88%), cystoid macular edema

(47%), and serous retinal detachment (15%). Some
eyes had more than one pathologic change.
Retinal swelling was more pronounced in the
outer than in the inner retinal layers. Cystoid
macular edema was located mainly in the outer
retinal layers. In eyes with long-standing cystoid
macular edema, cystoid spaces had fused,
resulting in a large cystoid cavity involving
almost the entire retinal layer. Hard exudates
are seen as highly reflective areas located in the
D
Figs 17.12A to D: Diabetic macular edema. A Before vitrectomy, the retina is thickened with
an area of low intraretinal reflectivity (yellow arrows) and cystoid cavities are seen in the retina.
The fovea protrudes. A serous retinal detachment is seen at the fovea (white arrows); the foveal
thickness is 780 m. The visual acuity is 20/500. B Two months after vitrectomy, a serous
retinal detachment (white arrows) is enlarged in diameter. The visual acuity is 20/300. C Four
months after vitrectomy, an intraretinal area of low reflectivity is diminished and the serous retinal
detachment has resolved; the foveal thickness decreased to 400 m. The visual acuity is
20/200. D Ten months after vitrectomy, the foveal pit is restored. The visual acuity is 20/70
outer retinal layers. In eyes with a serous retinal

detachment, hard exudates tend to deposit not
only in the retina but also in the subretinal space.12
Otani and Kishi also evaluated the retinal
structure before and after vitrectomy for diabetic
macular edema13 (Figs 17. 8 and 17. 9). The foveal
thickness (the distance between the inner retinal
surface and the retinal pigment epithelium) and
the retinal thickness (thickness of the neurosensory retina) were measured by OCT preoperatively and postoperatively. All 13 eyes had retinal
swelling with a low intraretinal reflectivity. In
addition to retinal swelling, there were cystoid
spaces in 5 (38%) of 13 eyes, a serous retinal
detachment in 3 (23%), and both cystoid spaces
and serous detachment in 3 (23%). Six months
postoperatively, the mean foveal thickness
significantly decreased from 630 to 350 m
(P <.01, paired t-test) and the mean thickness
of neurosensory retina decreased from 540 to
320 m (P <.01, paired t-test). A serous retinal

detachment occurred transiently in 3 eyes.
Compared with the preoperative level, the
postoperative visual acuity level improved by
more than 2 lines in 5 of the 13 eyes (38%),
remained the same in 7 eyes (54%), and decreased
in 1 eye (8%). Vitrectomy was generally effective
in treatment of diabetic macular edema. OCT
demonstrated the intraretinal changes of macular
edema and the process of edema absorption.
Central Serous Chorioretinopathy

Iida et al evaluated central serous chorioretinopathy with OCT during the acute phase
and after resolution of the phase14 (Fig. 17.13).
In a prospective study, 23 consecutive eyes of
23 patients with central serous chorioretinopathy
were examined. In the acute phase, neurosensory
retina was thickened within the area of serous
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the acute phase of central serous chorioretinopathy. The grayish-white lesion seems to
be a fibrinous exudate that accumulates in the
subretinal space and infiltrates into the outer
retina.
Rhegmatogenous Retinal Detachment
Fig. 17.13: Central serous chorioretinopathy. Fundus

photograph (top) and OCT (bottom). A fundus photograph
shows a serous retinal detachment. In OCT image through
the fovea, the detached retina is swollen, with intraretinal
areas of low reflectivity
retinal detachment in all 23 eyes. The detached

retina was thicker than the reattached retina after
resolution of the retinal detachment in all eyes.
The retinal thickness at the center of the fovea
during the acute phase (range 157 to 236 m;
mean SD 196.9 22.6 m) was significantly
thicker compared with that after resolution
(range, 105 to 152 m; mean SD, 124.8 10.7
m; P<.0001, Wilcoxon test). In the acute phase,
areas of low reflectivity localized within the
detached retina were observed in 18 of the 23
eyes. In the area of a grayish-white lesion, OCT
showed a moderately reflective mass bridging
the detached neurosensory retina and retinal
pigment epithelium in all 4 eyes; the outer layer
of the detached retina was more highly reflective
in these eyes. The retinal pigment epithelium
was focally detached beneath the subretinal
reflective mass in 3 of the 4 studied eyes. In all
eyes studied, neurosensory retina was thickened
within the area of serous retinal detachment in
Hagimura et al reported the pathologic changes

of the detached neurosensory retina in rhegmatogenous retinal detachment15 (Fig. 17.14). Retinal
images were prospectively examined by OCT in
25 eyes with rhegmatogenous retinal detachment.
OCT of the detached neurosensory retina,
adjacent to the center of the fovea, demonstrated
normal retinal structure in 10 eyes (40%),
intraretinal separation in 7 eyes (28%), and an
Fig. 17.14: Rhegmatogenous retinal detachment.

Fundus photograph (top) and OCT (bottom) show the
detached retina with intraretinal separation (arrows)

undulated separated outer retina in 8 eyes (32%).
Three statistically significant factors affected bestcorrected visual acuity: intraretinal separation
(P = <.001), intraretinal separation with
undulated outer retina (P = <.001), and height
of retinal detachment at the central fovea (P<.001).
Visual acuity was significantly worse in the 15
eyes with intraretinal separation with or without
an undulated outer retina than in the 10 eyes
with retinal thickening but no intraretinal
separation (P = <.036). The 8 eyes with undulated
separated outer retina showed significantly
higher retinal detachment at the central fovea
than the 7 eyes with intraretinal separation but
no undulated outer retina (P = <.009) and the
10 eyes without intraretinal separation (P =
>.016). The duration from onset of subjective
symptoms to OCT was not related to the
occurrence of intraretinal separation of the
detached retina. Intraretinal separation of the
detached retina occurred frequently and shortly
after retinal detachment in this condition and
was one of the factors associated with poor vision
in rhegmatogenous retinal detachment. Visual
acuity significantly decreased in the highly
detached retina.
Juvenile Retinoschisis
Ikeda et al reported a cross-sectional image of
juvenile retinoschisis16(Fig. 17.15). The retina was
split into two layers in the central fovea which
extended into the perifoveal area. The inner retina
contained two highly reflective zones corresponding to the nerve fiber and inner plexiform
Fig. 17.15: Juvenile retinoschisis. OCT3 shows

columnar-shaped structures bridging the separated two
layers
Fig. 17.16: Vitelliform macular dystrophy (Vitelliform

stage). Fundus photograph (top) and OCT (bottom): OCT
shows a highly reflective fusiform thickening of the layer
(white arrows) at the level of retinal pigment epithelium and
choriocapillaris
layers. Columnar-shaped structures, presumably

Meller cells, bridged the separated two layers.
Scanning laser ophthalmoscope showed
elevation of the Henles fiber layer. These findings
seemed to show that the retinal splitting occurs
at the outer plexiform layer.
Vitelliform Macular Dystrophy

Honma et al reported a cross-sectional image
of vitelliform macular dystrophy17(Fig. 17.16).
Eyes at the vitelliform stage showed a highly
reflective fusiform thickening of the layer at the
level of the retinal pigment epithelium (RPE) and
choriocapillaris. The vitelliform lesion lacked
background fluorescence due to blocking when
seen by fluorescein angiography. In eyes with
scrambled egg lesion, OCT showed two highly
reflective zones posterior to the sensory retina.
A flat dome-shaped space was present between
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the level of the RPE and the choriocapillaris.
The area of accumulated yellow material showed
a window defect on a fluorescein angiogram.
Findings showed this yellow material to have
accumulated within the RPE in the vitelliform
stage. The material was also located in the
subretinal space in the scrambled egg stage.
Conclusion
Examination of ocular fundus is a routine
examination in the clinical practice of
ophthalmology. Ophthalmologists can observe
ocular fundus at 10 m of resolution using a
direct ophthalmoscope or a biomicroscope.
Because biopsy of the retina is impossible,
histopathologic information of retinal disorders
has not been well known. OCT allows us to
investigate the clinicopathologic correlation of
fundus diseases in vivo. As described in this
review, OCT has made a great contribution to
our understanding of chorioretinal diseases.
References
1. Haung D, Swanson EA, Lin CP, et al. Optical coherence tomography. Science 1991;254:1178-81.
2. Puliafito CA, Hee MR, Schuman JS, Fujimoto
JG. Macular diseases. In Optical Coherence
Tomography of Ocular Diseases. New Jersey,
SLACK Incorporated, 1996.
3. Hee MR, Izatt JA, Swanson EA, et al. Optical
coherence tomography of the human retina.
4. Kishi S, Takahashi H. Three-dimensional
observation of developing macular holes. Am
J Ophthalmol 2000;130:65-75.
5. Hee MR, Puliafito CA, Wong C, et al.
Quantitative assessment of macular edema with
optical coherence tomography. Arch Ophthalmol
1995;113:1019-29.
6. Otani T, Kishi S. Patterns of diabetic macular

edema with optical coherence tomography. Am
J Ophthalmol 1999;127:688-93.
7. Takano M, Kishi S. Foveal retinoschisis and
retinal detachment in severely myopic eyes with
posterior staphyloma. Am J Ophthalmol 1999;128:
472-76.
8. Drexler W, Sattmann H, Hermann B, et al.
Enhanced visualization of macular pathology
with the use of ultrahigh resolution optical
coherence tomography. Arch Ophthalmol
2003;121:695-706.
9. Schuman JS, Puliafito CA, Fujimoto JG.
Interpretation of the Optical Coherence
Tomography Image. In. Optical Coherence
Tomography of Ocular Diseases, 2nd ed. New
Jersey, SLACK, 2004.
10. Hagimura N. Optical coherence tomographic
features of normal ocular fundus. Jpn J Clin
Ophthalmol 1998;52:1459-62.
11. Maruyama Y, Otani T, Kishi S. Optical coherence
tomographic features of preretinal macular
fibrosis. Jpn J Clin Ophthalmol 1999;52:1468-70.
12. Otani T, Kishi S. Tomographic findings of foveal
hard exudates in diabetic macular edema. Am
J Ophthalmol 2001;131:5054.
13. Otani T, Kishi S. Tomographic assessment of
vitreous surgery for diabetic macular edema.
14. Iida T, Hagimura N, Sato T, Kishi S. Evaluation
of central serous chorioretinopathy with optical
coherence tomography. Am J Ophthalmol
2000;129:519-20.
15. Hagimura N, Suto K, Iida T, Kishi S. Optical
coherence tomography of the neurosensory
retina in rhegmatogenous retinal detachment.
16. Ikeda F, Takahashi K, Kishi S. Optical coherence
tomographic features of juvenile retinoschisis.
Jpn J Clin Ophthalmol 1998;52:1479-82.
17. Honma R, Utsugi N, Maruyama Y, Kishi S.
Optical coherence tomographic features of
vitelliform macular dystrophy. Jpn J Clin
Ophthalmol 1998;52:1515-18.
Electrophysiological Tests for Visual Function Assessment
SUBHADRA JALALI, LS MOHAN RAM, GARIMA TYAGI, KALLAKURI SUMASRI
18
Electrophysiological
Tests for Visual
Function Assessment
Visual Electrophysiology Tests

Visual electrophysiology is an extremely powerful
tool to assess functional integrity of the visual
pathway. Visual pathway starts from the photoreceptor and retinal pigment epithelial layer,
proceeds through inner retinal layers, ganglion
cell layer and then via optic nerve through the
chiasma to the optic radiations in the brain, finally
ending at the occipital cortex. This chapter aims
to introduce some basic concepts of visual
electrophysiological tests (VET) with the help
of some representative clinical cases.
Visual electrophysiological tests include the
various types of electroretinogram (ERG),
electrooculogram (EOG) and visual evoked
potential (VEP). A patient may need some tests
to ascertain the abnormality. Before ordering the
tests a clear understanding of the nature of each
of these is absolutely essential to derive a valid
interpretation. A thorough clinical evaluation is
a prerequisite before ordering any visual
electrophysiological test.
History
To understand how visual electrophysiological
tests reached its present status, some of the
milestones are described here. DuBois-Reymond
of Berlin discovered standing potential of 6

millivolts in excised fish eyes and found that
cornea was positive with respect to posterior pole
of the eye in 1849. He thought that these signals
originate in optic nerve. Holmgren showed
electrical responses to light in excised frog and
demonstrated that these to originate in the retina.
Dewar and McKendrick showed that
electrical potentials could be recorded from intact
animal eyes on illumination of the retina. In 1877,
Dewar succeeded in recording ERG from the
human eye but the resulting curves were not
published. The first human ERG was published
by Kahn and Lowenstein.
Between 1933 and 1947 Ragnar Granit in
Oxford did extensive studies with various
chemical agents to analyze the origins of various
phases of the ERG. American psychologist Lorrin
Riggs, and Gosta Karpe at the Karolinska Institute
designed a contact lens electrode independently.
The credit for taking the science of ERG from
the laboratory to the clinic goes to Gosta Karpe
who invited ophthalmologists to visit his clinic
where routine diagnostic ERG was introduced.
Before ordering and interpreting these tests,
a thorough understanding of the nature and
limitations of each of test is a essential to arrive
at a valid interpretation and diagnosis.
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280

The visual electrophysiology tests follow a
hierarchal pathway along the various cell layers
of the visual system. The EOG examines the
function of the retinal pigment epithelium
(RPE). Following stimulation by light, the
electrical responses from retinal photoreceptors
and the inner retinal cells are assessed by the
a- and b-wave components of the Flash ERG,
respectively. The macular photoreceptor function
and the ganglion cells function is revealed and
separated by the technique of Pattern ERG
recording. The integrity of the visual pathway
from optic nerve via optic chiasma to the occipital
cortex is assessed by various techniques of VEP
recording.
For each of these recordings in the clinic,
certain minimum standards have been laid down
by the International Society for Clinical
Electrophysiology of Vision (ISCEV pronounced
as eyesev). These are available on the website
www.iscev.org.
Importance of Electrophysiological Tests

Sometimes, the clinical examination of the eye
cannot explain the exact cause of decrease in
vision. These tests help to detect and categorize
the site of lesion in the visual pathway. In other
cases, especially in retinal degenerations, these
tests help to know the type and extent of disease
and its prognosis. In vascular pathology, these
tests can assess the extent of ischemia of the
inner retinal layers. Other indications of the tests
include detection of drug or metal toxicity,
pediatric visual assessment and cause of poor
vision in infants. In a given situation, these tests
prove invaluable in the proper management plan.
side effect. ERG testing very rarely leads to

irritation and watering of the eyes for a few hours
after the test and can be easily treated with
lubricating eyedrops. Rarely, patient can get
infectious keratitis. The total test can take up
to 3 hours. Alcohol or sedatives should not be
taken for 24 hours before the tests as these can
interfere with the results. Other medicines such
as for diabetes, asthma and hypertension can
be continued. For VEP testing, the hair should
be preferably washed and dried a night before
so as to be free of oil and greasiness. The patient
should be electrically isolated according to
current standards for safety of clinical biologic
recording systems in the users country.
Electrooculogram
Electrooculogram (EOG) examines the function
of the retinal pigment epithelium (RPE) and the
interaction between the RPE and the rod photoreceptors.1All vertebrate eyes are like a dipole,
with a resting potential in which the cornea is
positive with respect to the back of the eye. This
creates a standing or resting potential of about
6 millivolts. This standing potential rises when
the retina is illuminated to a steady light. EOG
measures changes in the standing potential to
light and dark conditions. Clinically, EOG
measures the standing potential indirectly using
the fact that the spatial orientation of a polarized
eye is detected by skin electrodes placed nasal
and temporal to the eye. Saccadic eye movements
result in flow of current around orbit proportional
to the magnitude of standing potential of
each eye. Skin electrodes record these voltage
changes.
Side Effects and Precautions

Electrophysiology testing of the eye is very safe
and there are no major side effects. VEP and
EOG recording is done from skin and has no
Clinical Measurement
Geoffrey Arden and colleagues2,3described the
indirect method of recording of clinical EOG.

Skin electrodes are placed at the medial and
lateral canthi to detect the amplitude of the signal
between these two points. A ground electrode
is fixed to the forehead. Pupils are dilated. A
Ganzfeld is used to illuminate whole retina
uniformly. Eye should not be exposed to too bright
or too dim lights before EOG. After an initial
6 minutes of light adaptation, test is started. The
patient makes fixed 30-degree lateral eye
movements (using diode fixation lights) during
a period of 20 minutes of dark adaptation, and
then during a 12-15 minute period of light
adaptation. The eye movements are made every
1-2 seconds for approximately 15 seconds and
a pause of 45 seconds, every minute. The dipole
generated by the resting potential induces current
flow in the skin electrodes upon shift of the eye
position (Fig. 18.1).The changes in voltage are
amplified and displayed on a computer data

acquisition system (Fig. 18.2). The changes in
this indirectly measured potential, from darkness
to light is the light-induced rise of the resting
potential.3 In the dark, the resting potential
decreases while it slowly rises to a peak (Slow
oscillation of EOG) after the lights are switched
on (Fig. 18.2). The amplitude of the signal is
recorded at its minimum during dark adaptation
(the dark trough) and at its maximum during
light adaptation (the light peak). The ISCEV has
laid down standards for EOG testing.4The
normal light peak occurs in conditions of
normally functioning photoreceptors in contact
with a normally functioning RPE, and is caused
by progressive depolarization of the RPE basal
membrane. The EOG is quantified by calculating
the amplitude of the light peak in relation to
Figs 18.1A to C: EOG recording procedure. A Sites of skin electrode placement. B Ganzfeld fixating lights (LED)
15 degrees apart, with 30 excursion from right to left. C 16 to 20 sweeps per minute following a baseline recording
of 6 minutes in white light. Recording is for 15 minutes in dark and 15 minutes in light
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Fig. 18.2: Showing raw waveforms of the saccades (left) and the final EOG graph (right). Note the light rise
and normal Arden ratio of >200% in each eye
the dark trough as a percentage, the Arden

index.3A normal index would be > 185% (Fig.
18.2).
Clinical Uses
A normal ERG and abnormal EOG are classically
seen in Bests vitelliform macular dystrophy5 (Fig.
18.3) even in very early stages of the disease
with minimal fundus changes and in asymptomatic carriers. EOG abnormality is also seen in
a variety of RPE and rod-photoreceptor disorders
such as retinitis pigmentosa, choroideremia and
age-related macular degeneration. EOG is also
abnormal in choroidal melanomas and could
be an adjunct tool to differentiate melanoma from
nevi.6 EOG is normal in isolated inner retinal
cell dysfunction such as in congenital stationary
night blindness (CSNB) where RPE and photoreceptors are normal. EOG can be used to study
drug toxicity against RPE. One must remember
that because light is used to provoke the voltage
change in EOG, this test cannot separate the
photoreceptor and RPE dysfunction. In recent
years, Arden et al.7 have shown that after intake

of low doses of ethanol an EOG peak similar
to the light-induced EOG peak can be recorded.
This could test RPE layer function independent
of its interaction with the photoreceptors.7
Limitations of EOG Recording

Patient cooperation and central fixation limit the
clinical recording of EOG. Patients with poor
central fixation or variable eccentric fixation,
children, infants and uncooperative adults cannot be tested satisfactorily. Many testing variables
such as media opacities and illumination levels
can influence the voltages. Therefore, borderline
EOG abnormalities need to be interpreted with
caution and test may have to be repeated for
confirmation.1
Fast Oscillations of EOG

It was reported by Kolder and colleagues8 that
the EOG responses could be slow or fast, if the
frequency of the light and dark periods for
Fig. 18.3: Shows poor light rise on EOG in a patient with subnormal vision and bilateral macular lesions.
ERG recordings including macular photoreceptors (PERG) are normal as shown in ERG results
stimulation were altered. They found the slow

oscillations were greatest with repeated light and
dark periods of 12.5 minutes each, whereas, the
greatest amplitude of fast oscillations of EOG
were seen when the light and dark cycles were
of 1.1 minute each. The amplitude of fast
oscillations increased in dark phase and reduced
in light phase. The clinical value of these fast
oscillations needs further study.
Electroretinogram (ERG)
Due to selective transport of ions, the inside of
the photoreceptor cells is more negative than the
outside resulting in a standing membrane
potential in the dark. Once light falls on the retina,
it induces a change in the transmembrane
movement of especially sodium and potassium

ions, making the cells hyperpolarized, that is,
they become more negative to the extra cellular
space than in the dark. These voltage changes
are reflected in various ERG components.
Various techniques are in clinical use to
assess the electrical response of retinal cells to
light. The most common of these is the Full-field
Flash ERG. Others are Pattern ERG, Focal ERG
and Multifocal ERG (Table 18.1).
The Flash ERG is the mass response of the
neural and nonneural retinal cells to a full field
luminance stimulation. The test reflects the
function of the photoreceptors and inner nuclear
layers of the retina in response to light stimulation. It is recorded by using stimuli delivered
by an integrating sphere, called Ganzfeld, which
provides a uniform whole field illumination to
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TABLE 18.1: SPECIALIZED TYPES OF ERG
(NOT COVERED BY ISCEV STANDARD)10
1.
2.
3.
4.
5.
6.
7.
8.
9.
Macular or focal ERG

Multifocal ERG
Early receptor potential (ERP)
Scotopic threshold response (STR)
Direct-current ERG
Long-duration flash ERG (on-off responses)
Bright-flash ERG
Double-flash ERG
Chromatic stimulus ERG (including S-cone
response)
10. Dark and light adaptation of the ERG
11. Stimulus intensity-response amplitude analysis
(Naka-Rushton)
12. Saturated a-wave slope analysis
the retinal spherical surface.9 The Ganzfeld

provides both flash stimulation and a diffuse
background for photopic adaptation besides
fixation lights (Fig. 18.4)
By varying the background illumination, the
light or dark-adapted state of the eye and the
intensity of the stimulus flash, one can elicit and
isolate response from different retinal cells. The
ISCEV standard describes simple technical
procedures that allow reproducible ERGs to be

recorded under a few defined conditions, from
patients of all ages including infants.9,10 Details
of the equipment standardization is beyond the
scope of this chapter but is available in literature.11
Recording Electrode
The ERG is recorded using corneal or non-corneal
electrodes (Fig. 18.5). The closer the electrode is
to the cornea, the higher the amplitude one gets,
though latency will not change. Prototypes of
corneal electrode are Burian-Allen and Jet
electrodes. The corneal electrodes can be unipolar
like the Jet-electrode or bipolar like the BurianAllen electrode. The Burian-Allen electrode is
centrally transparent with a large optical opening
and incorporates a device to hold the lids apart.
Topical anesthesia and a nonviscous solution
like 0.5% methylcellulose are needed. More
viscous solutions can attenuate signal amplitude.
Corneal electrodes may be difficult to maintain
due to a silver coating that needs resurfacing
periodically, and are expensive and cause some
Fig. 18.4: An integrated sphere called Ganzfeld provides a uniform, whole field illumination to the retinal spherical
surface. It provides both flash stimulation and a diffuse background light for photopic adaptation. The inside surface
has three light emitting diodes as fixation targets for the eye and also for excursion of the eyes during EOG recordings.
A chin rest allows proper positioning of the subject. Two prototypes are shown
Fig. 18.5: Electrodes used in visual electrophysiology. Gold-foil and H-K loop electrodes
(Courtesy: Dr. G. Holder, London)
discomfort besides rare possibility of corneal

abrasion. The advantage, however, is that higher
amplitudes are recordable due to proximity to
the cornea. All reusable electrodes should be
cleaned and sterilized after each use to prevent
disease transmission.
The non-corneal electrodes include gold foil,
the DTL-fiber (Dawson-Trick-Litzkow) and our
own devised LVP-Zari electrode.12-14 The LVPZari electrode is disposable, inexpensive, rigid
and reliable and made from locally available
Zari-embroidery thread. It has a core of nylon
(traditionally had cotton thread core) covered
with layers of silver, copper and gold, making
it a good conductor of electric currents. Due to
its nylon core, and multiple metallic coatings,
the movement of the fiber across the limbus is
minimal, making the recordings very reliable.
The recording electrodes, bipolar or nonbipolar are placed on the cornea. Topical
anesthesia is necessary for contact lens electrodes
but may not be required for other types of corneal
and conjunctival electrodes. It is important to
learn the technical requirements of a chosen
electrode, to ensure good ocular contact, to ensure
proper electrode impedance, to ensure that
waveforms are comparable to standard
responses, and to define both normal values and
variability (which may be different with different
electrodes) for their own laboratory.9,10 Skin
electrodes are in general not recommended as
active ERG recording electrodes.
Reference electrodes: Reference electrodes may be
incorporated into the contact lens-speculum
assembly as in Burian-Allen (Fig. 18.5) or can
be placed near each ipsilateral outer canthus
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as a reference for the corresponding eye. The
forehead as a reference has a theoretical risk of
signal contamination by ocular crossover or from
cortical evoked potentials.
Ground electrode: A separate skin electrode, such
as an ear-clip (Fig. 18.5) should be attached to
an indifferent point and connected to ground.
Electrode Placement
After topical anesthesia, corneal electrodes are
filled with a mild viscous coupling solution such
as 0.5% methylcellulose and inserted gently like
a contact lens in the center of the cornea, with
the lid speculum holding the lids apart simultaneously. The non-corneal electrode is placed in
the lower fornix as close to the inferior limbus
as possible. It should be stable, non-mobile and
not injure the cornea. The reference electrode is
placed at the outer canthus. An ear-clip electrode
serves as a ground electrode. For all skinelectrodes, good contact is essential with low
impedance. To achieve this grease and dead cells
on the skin are removed by rubbing with an
abrasive and an alcohol pad. Figure 18.6 (left)
shows a subject with the LVP Zari electrode in
place, held across the fornix with a crocodile
clip (red color) and the reference electrode (blue
color) at the outer canthus. The ear-clip ground
electrode is also seen. All the electrodes are then
connected to a junction box (middle) which sends
the signals through an interface box into the
computerized amplifiers and recorders. Care

should be taken to connect the electrodes to the
correct site on the junction box. The outer canthal
electrodes go to the positive and recording electrodes to the negative poles of the junction box.
Flash Stimulus Characteristics

The light stimulus should consist of flashes
having a maximum of about 5 ms duration so
that duration of each flash is considerably shorter
than the integration time of any photoreceptor.
These short white flashes obtained by
stroboscopes and gas discharge tubes have a
color temperature of 7000 degrees K. A standard
flash (SF) strength is defined as one that produces
a stimulus strength (in luminous energy per
square meter) at the surface of the Ganzfeld bowl
of 1.5-4.5 photopic cd.s.m-2 (candela-seconds per
meter squared).10 In addition to producing flashes,
the stimulator must be capable of producing a
steady and uniformly even, white (colored in
rare special situations) background luminance
of 17- 34 cd.m-2 across the full field. Prolongedflash ERGs and chromatic lights are currently
used for studying slow potentials and for
separating on-and off-responses.
Technical Requirements
The system should be capable of attenuating the
flash strength from standard flash over a range
of at least 3 log units, either continuously or
Fig. 18.6: LVP electrode placement (left) and connections (middle) to junction box (arrow).
ERG in progress (right)

in steps of no more than 0.3 log unit. This
attenuation should not change the wavelength.
It is essential to periodically calibrate the stimulus
and background illumination by integrated and
nonintegrated photometers to achieve standard
test conditions.11
The bandpass of the amplifier and
preamplifier should include at least the range
of 0.3 to 300 Hertz and should be adjustable
for oscillatory potential recordings and other
specialized requirements. Amplifiers are
generally AC (alternating current) coupled.
The recording equipment should be able to
represent the full amplifier bandpass without
attenuation. The computer digitizers should
sample responses at the rate of 1000 Hertz or
higher. The observer should be able to watch
the displays so as to monitor and make
adjustments to get clean and less noisy recording.
The computerized digitizers are usually capable
of averaging multiple responses so as to remove
some of the artifacts.
Clinical Protocol9,10
ERG is recorded after full pupillary dilatation
so that all parts of retina get illuminated. Avoid
any extra illumination (as in fluorescein
angiography or fundus photography) but if these
examinations have been performed, a period of
dark adaptation of at least one hour is needed
before scotopic recording.
The subject is placed in a completely dark
room for 30 minutes. Next, the subject with
electrodes in place is seated comfortably with
the chin on the chin rest and eyes open with
the face inside the Ganzfeld bowl (Fig. 18.6). The
height of patient should be adjusted so that the
neck and back muscles are not in a tensed-up
position as this can induce muscle-generated
artifacts. The cable from junction box is fixed
to the shoulder at the subjects end and plugged
into the interface box at the other end, sending

the retinal signals into the amplifiers and
computer analyzers. Patients are encouraged to
fixate at the central target to reduce eye movement
and artifacts.
The ISCEV standard describes9,10 a minimum
of 5 basic ERG response recordings, three in dark
adapted or scotopic conditions and two in lightadapted or photopic state. These basic ERG waveforms are a mass response of the photoreceptors
and inner retinal cells. The retinal ganglion cells
do not contribute to the flash ERG. Various ERG
responses (Fig. 18.7) are described below.
Isolated Rod Response

To isolate the signals from the rod system of
photoreceptors, a dim white flash of strength
2.5 log units below the white SF is used. Serial
responses are recorded with a minimum of 2
second interval between the flashes to allow the
rods to return to dark-adapted state in between
the flashes. A blue stimulus is equally
appropriate if equated to the white standard.
At this low intensity level, the cones are
insensitive to the stimulus. The isolated rod
response has almost no a-wave and a slowly
rising, broad-peaked, b-wave. The b-wave in the
isolated rod-response waveform is a post-receptor
phenomenon, i.e. inner retinal cell response that
is driven by only the rod photoreceptors. At this
low luminance a-wave is not recordable due to
poor photoactivation. There is progressive
appearance and increasing amplitude of the awave as stimulus intensity is increased from low
level to the higher level of the standard flash
(intensity response curve). As the a-wave starts
appearing with increasing intensity of stimulus,
it represents activity of the rod photoreceptors
but with maximum flash intensity, the cones also
start contributing to the a-wave as is seen in
the maximal combined response.
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288
Fig. 18.7: Normal Flash ERG waveforms from a normal fundus. Under scotopic conditions, we can record the
isolated rod response (IRR), the maximal retinal response (MCR), and the scotopic oscillatory potentials (OPs).
The photopic responses include the single flash for cones (PSF) and the 30-Hertz flicker responses (30 Hz)
Maximal Combined Response

The maximal response is dominated by rod
responses but also has a small component of
cone activity. The initial negative a-wave is
generated by the photoreceptors, i.e. both rods
and cones. The positive b-wave is generated postreceptoraly in relation to depolarization of the
ON-bipolar cells.15 Under scotopic conditions,
flash ERG is obtained using the Standard white
flash which is 0 decibel attenuated. A sharp awave and a much larger, rapidly rising peaked
b-wave which comes to baseline very slowly,
are characteristic of this response. Duration
between two flashes should be at least 10 seconds
to remove effect of bleach of photoreceptors by
the bright flash of light.
Oscillatory Potentials
The oscillatory potentials (Ops pronounced as
opees) are small but high frequency oscillations
on the ascending limb of the b-wave of the

maximal combined response.
These are extracted and amplified to present
the oscillatory potentials as seen in Figure 18.7.
They are generated in relation to amacrine cell
activity in the middle and inner retinal cell layers.
Under scotopic condition and using standard
flash intensity as a stimulus, other wavelets are
removed by resetting of the filters. The high-pass
filter must be reset from the usual 0.3 Hz to 75 Hz,
so that an overall bandpass of 75 at high end and
300 Hz at low end is achieved. The response varies
with stimulus repetition rate and changes after the
first stimulus. Flashes should be given 15 seconds
apart to the dark-adapted eyes (1.5 seconds apart
to light-adapted eyes), and only the second or
subsequent responses should be retained or
averaged.9,10 Normal response is characterized by
3 major peaks followed by 1-2 smaller peaks.
Comparison with normal individual laboratory
values is often adequate to assess any abnormality.

Single-Flash Cone Response
To record the photopic responses, the retina is
exposed to 10 minutes of light adaptation by
using the background light in the dome of
17-34 candelas per meter square of luminance
(that saturates rods and makes them unresponsive). After this the retina is exposed to a standard
flash (SF) to obtain the photopic single flash (PSF)
cone response. Inter-stimulus intervals should
not be less than 0.5 seconds. This cone response
is characterized by a small a-wave and a very
sharply rising b-wave that rapidly returns to
the baseline. Better localization of cone functions
is seen with the single flash cone response than
with the flicker response. The photopic cone awave has contribution from the hyperpolarizing
(OFF) bipolar cells and also cone photoreceptors.16 The cone b-wave probably reflects postphototransduction activity. Separation of the cone
ON (depolarizing bipolar cells) and OFF
(hyperpolarizing bipolar cells) pathways is done
by using a long duration stimulus with a photopic
background.17
30 Hz Flicker Cone Response

Under the photopic condition repetitive standard
flashes are presented at a frequency of 30 stimuli
per second. Rods are suppressed by the photopic
condition and are incapable of responding to
the highly repetitive stimuli. The amplitude is
measured from trough to peak of each response.
The latency is measured as the distance between
stimulus onset and time-to-peak. A vertical line
in the trace should indicate the time of onset
of the stimulus. The 30 Hz response is a sensitive
measure of cone dysfunction, but is generated
at an inner retinal level.18 The response is affected
in inner retinal ischemic states.
amplitude of the initial cornea negative a-wave

is measured from baseline to the trough, while
b-wave amplitude is from the trough of a-wave
to peak of cornea positive b-wave. Latency of
each wave is measured from stimulus onset,
marked by a vertical line across the baseline,
to peak of the response (Fig. 18.8). Both amplitude
and implicit time should be measured for each
component of the waveform. For practical
purposes, the variables most often measured are
the b-wave amplitudes of the isolated rod
response, maximal combined response and of
single flash cone response. The time-to peak of
the single flash 30 Hz flicker response and bwave latency of maximal combined response is
measured. Amplitudes and appearance of the
oscillatory potentials9,10 are highly dependent
upon stimulus conditions, adaptation and
amplifier filter characteristics, but most authors
describe three major peaks often followed by a
fourth smaller one. Comparison of the response
to the laboratory normative wavelets may be
adequate for many clinical purposes at our
present state of knowledge. An overall index of
oscillatory potential amplitude can be obtained
by adding up measurements of the three major
peaks, preferably from lines spanning the bases
ERG Measurements and Recording

A typical flash ERG record is a double peak
waveform. According to current convention the
Fig. 18.8: Methodology of ERG amplitudes and

latency measurements (see text for details)
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of the adjacent troughs, but alternatively from
the adjacent troughs directly (to allow use of
measuring cursors with digitized systems). Some
authors advise measurement of individual peaks.
waveforms and choose the best and largest of

these reproducible responses.
Normal Values
ERG has following limitations:

1. Flash ERG is affected only if the retinal
dysfunction is widespread. In localized
conditions, even if they involve high-cell
density area say of the macula, the flash ERG
can be normal. This is seen in conditions
like Stargardts heredomacular degeneration
and early stages of cone dystrophy or
localized RP. Ganglion cell function is not
reflected in flash ERG. Flash ERG does not
correlate with visual acuity.
2. Diurnal variation exists in rod-ERG b-wave
amplitudes, therefore, it should be accounted
in serial measurements or research protocols.
3. A number of artifacts such as a blink reflex,
muscular tension artifacts (photomyoclonic
response) or improper electrode placement
and contact can lead to erroneous results.
The electrophysiologist should be aware of
these and know how to get valid recordings.
4. ERG recordings require a certain level of
cooperation from the patient. Fixation is not
critical in ERG recording but photophobia,
claustrophobia and excessive blinking and
anxiety are known to alter the response.
5. Hazy media and miotic pupils can cause
erroneous results, as sufficient light does not
reach the photoreceptors. Appropriate
adjustments would be required to get
meaningful data.
6. Adjustments are also needed for age and high
refractive error as these affect the ERG
responses.
Due to multiple variables that can affect the ERG

waveforms, it is recommend that each laboratory
should confirm normal values for its own equipment and patient population taking an appropriate sample size. All ERG reporting should
include normal values and the limits of normal.
Reporting of the ERG

The reports or communications of ERG data
should include two representative waveforms
of each of the standard responses displayed with
amplitude and time calibrations and labeled with
respect to stimulus variables and the state of
light or dark adaptation. Details of the standardized reporting conditions are available in the
literature.9,10
Pediatric ERG Recording

The ERG can be recorded from infants and young
children9,10but one needs to account for immature
eyes and limited cooperation. Special care is
required to monitor electrode position and compliance in order to avoid artifactual recordings.
Pediatric subjects can be studied without sedation or general anesthesia. Non-cooperative
children are given oral sedation and rarely
general anesthesia. The latter can modify the
ERG responses. Repeat measurements may be
needed to confirm the findings, especially in cases
of poor recordable waveforms. Pediatric ERG
responses should ideally be compared to those
from normal subjects of the same age, even though
there may be little normative data available.
Several examples of each response should be
recorded in order to recognize reproducible
Limitations of ERG
Pattern Electroretinogram
Some of the limitations of flash ERG can be
overcome by more recent techniques of pattern

electroretinogram (PERG) and multifocal ERG.
Pattern ERG is a contrast response driven by
macular photoreceptors but originates in the
ganglion cell layer of retina. It allows both a
measure of central retinal function, and retinal
ganglion cell function. It is the only electrophysiological test that can provide direct assessment
of the ganglion cells. PERG helps in improved
interpretation of VEP abnormalities and helps
to differentiate optic nerve pathology from the
macular pathology.19
Recording Parameters and Measurement

The PERG is recorded (Fig. 18.9) with refractive
correction in place, without mydriasis, using noncontact lens electrodes.12,13,19 Reference electrodes
are placed on ipsilateral outer canthus, and not
on forehead or ear, to avoid the contamination
from the cortically generated VEP. Binocular

stimulation and recording is usually preferred,
except in cases of squint, so the better eye can
maintain fixation and accommodation. It is a
small response and may be difficult to record
without stringent controls. Diurnal variation and
test-retest variability may be important in
longitudinal studies.
PERG is measured as the electrical response
to a pattern reversal checkerboard stimulus where
the overall luminance is unchanged during
pattern reversal. A high contrast (near 100%)
black and white checkerboard pattern of 15 and
30 minute check size with pattern reversal
method is recommended. Field size of stimulus
should be between 10 and 16 degrees, and the
frame rate of the Cathode rate tube should be
a minimum of 75 Hz or above. Stimulus strength
of the white checks should be 80 cd m-2. Steady
Fig. 18.9: PERG measurements (Top). Bottom left shows PERG stimulus
and bottom right shows actual recording of PERG from two eyes
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fixation is very important because eye movement
and blinking will cause severe artifacts. As the
amplitudes of PERG signals are small, more
averaging is needed. Often more than 150
responses are averaged to get each response.
Sweep time of recording is about 150 milliseconds. Computerized artifact rejection is
essential and this should be set at no higher
than 100 microvolts peak to peak. Background
illumination should not be very bright or dim.
Ordinary background room light suffices and
should be kept constant for all recordings.
At a stimulus reversal rate of 16 reversals
per second a sinusoidal waveform called Steadystate PERG is obtained. This needs Fourier
analysis to measure the amplitude and phase
shift and is not often used clinically. At a slow
rate of 1-3 Hz (2 to 6 reversals per second) pattern
reversal, a transient PERG is obtained. Three
components are seen in PERG. There is an
initial negative wave (N35) at 35 milliseconds,
a positive peak (P50) at 50 milliseconds and a
final negative N95 wave at 95 milliseconds from
stimulus onset. Clinically, the transient PERG
has two main components (Fig. 18.9). P50 is an
inner retinal component driven by the macular
photoreceptors. N95 is the second component
which is contrast related and is generated by
the ganglion cells.19 PERG P50 amplitudes can
vary from 0.5 to 8 microvolts depending on
stimulus characteristics such as the temporal
frequency of the stimulus.20 Bandpass filters of
the AC coupled amplifiers are set from 1-100
Hz and notch filters should be switched off.
P50 amplitude is measured from trough of
N35 to the peak of P50, the N95 is measured
from peak of P50 to the trough of N95 (Fig. 18.9).
P50 latency is a more consistent measurement
and used clinically while peak of N 95 is often
broad and this precludes accurate latency
measurement for N95. If N35 is poorly defined
then N35 is replaced by the average time
between time zero and onset of P 50. Age-matched

control data should be generated in each
laboratory.
Clinical Uses
Pattern ERG is most useful in assessing the visual
loss of unknown etiology. It helps in differentiating visual loss due to macular photoreceptors/
macular inner retinal cells from diseases of
ganglion cell and optic nerves. PERG also helps
to monitor early drug toxicity.21
Primary evaluation of macular function: In macular
disorders, the P50 component of the PERG is
abnormal, often with preservation of the N95:P50
ratio. P50 amplitude is usually affected, with
latency changes only, occasionally being seen,
particularly in association with macular edema
or serous detachment at the macula.19 Primary
macular dysfunction such as Stargardt-fundus
flavimaculatus, will usually have a normal (rarely
subnormal) flash ERG and an abnormal PERG.
In generalized retinal dysfunction with macular
involvement (cone-rod dystrophy) both ERG and
PERG are abnormal. In patients with rod-cone
dystrophy, but normal central retinal function,
the PERG may be normal even when the Flash
ERG is almost extinguished.
Ganglion cell dysfunction: Primary ganglion cell
dysfunction is associated with marked N95
component loss, particularly in Lebers hereditary
optic atrophy and advanced dominant optic
atrophy.19 Very severe optic nerve disease will
also reduce P50 amplitude, and P50 latency.
Complete extinction of the PERG in relation to
optic nerve disease rarely if ever occurs, providing
at least one eye has enough vision to maintain
fixation for binocular PERG recording. The PERG
may still readily be detectable in an eye with
no light perception.19 It must be remembered that
though pattern VEP is primarily used to detect

optic nerve dysfunction, macular diseases can
cause delayed VEP latency. PERG P50 defects
associated with or without VEP abnormalities,
point to macular dysfunction. Normal or a defect
of only N95 component of PERG with an
abnormal VEP suggests optic nerve/ ganglion
cell dysfunction.19
Limitations of PERG
1. The PERG amplitudes are very small and
due to technical demands, not all laboratories record PERG as a routine. Stringent
controls are required to avoid artifacts. The
ISCEV standards are available for PERG
recordings.20
2. Patient cooperation is essential in recording
the PERG.
3. All equipments for ocular electrophysiology
do not have the capability to perform PERG.
4. In eyes with hazy media where the pattern
stimulus cannot be projected on the macula,
results can be erroneous.
Visual Evoked Potential

Visual evoked potential (VEP) is a sensitive
indicator of optic nerve function. It is an evoked
electrophysiological signal that is recorded at
the scalp in response to visual stimuli. The
responses are much smaller than the full-field
flash ERG responses, typically measuring only
5-10 microvolts in amplitude, which lie buried
in the electroencephalographic (EEG) noise of
50 microvolts or greater. Averaging of the
recorded signals over a given time period after
repeated stimulation can help in extraction of
VEP from the background EEG activity.
Recording and Measurement

The visual stimuli used to elicit VEP are of three
types: flash, pattern-reversal and pattern-onset.22
The standard flash used in ERG recording can

be used for Flash VEP also. The pattern stimulus
consists of an isoluminant checkerboard or
grating of various spatial frequencies. Skin
electrodes used are silver-silver chloride or golddisk electrode (Fig. 18.5). Good contact of the
electrodes using conducting paste and thorough
cleaning of skin, help in obtaining clean and
reliable recordings. The electrodes are placed on
the scalp relative to bony landmarks in relation
to the head size as per the international
10/20 system23 (Fig. 18.10). The anteroposterior
midline measurements are based on the distance
between the nasion, inion and vertex. The active
electrode is placed on the midline over the visual
occipital cortex (OZ) while reference electrode
at the frontal pole (FZ). The ground electrode
is at the forehead or earlobe.
Recordings are done with refractive correction
without mydriasis using monocular stimulation.
Prechiasmal lesions are reliably detected by
pattern-reversal stimulation while flash stimulus
is used in difficult and uncooperative patients
or those with dense media opacities and very
poor vision. Pattern-onset/offset stimulus is
especially useful in malingerers and patients with
nystagmus, due to short stimulus duration and
inability of the subject to consciously defocus
this stimulus. For chiasmal and postchiasmal
lesions, multichannel recordings are required as
a single midline channel with active electrode
only over the occipital cortex can miss lesions.
The VEP traces (two reproducible records of each)
can be presented as positive upwards (Fig. 18.11)
or negative upwards. The polarity convention
and stimulus parameters used should be
indicated in the report besides the amplitude
and latency. Latency is measured from the
stimulus onset to peak of the component
measured. It must be remembered that interocular
difference in the pattern-reversal VEP indicates
dysfunction of the entire prechiasmal pathway
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Fig. 18.10: The international 10/20 system of electrode placement for midline
single channel VEP. Inset shows Pattern VEP recording in progress
Fig. 18.11: Normal pattern-reversal to three different check sizes (top-15, 30 and 60 minutes), Pattern-onset
(bottom left) and Flash (bottom right) VEP

and includes ocular, retinal and optic nerve
causes.
Normal Waveforms22
1. Flash VEP: It consists of a series of positive
and negative peaks that are designated in
numerical sequence. Commonest components
recorded are N2 and P2 at 90 and 120 msec,
respectively (Fig. 18.11).
2. Pattern-reversal VEP: The peaks are named
as negative or positive followed by the latency.
Commonest wave used for clinical cases is
the P100 component, (positive peak at 100
msec) since it is a very robust measure with
minimal interocular and inter-subject
measurement variation (Fig. 18.11).
3. Pattern-onset/offset VEP: Three components
described are C1 (positive at 75 msec), C2
(negative at 125 msec) and C3 (positive at
150 msec). With a stimulated hemifield, the
response will appear contralateral to the
hemifield stimulated.
Limitations of VEP
VEP has following limitations:
1. Age, refractive error, inattention and
conscious defocusing of the pattern affect the
VEP latency.
2. Stimulus parameters such as contrast,
luminance, check size and field size are
important determinants of the waveform
(Fig. 18.11) and it is essential for each
laboratory to establish their own normal
controls.
3. Since the amplitudes of VEP are very small,
surrounding noise can easily contaminate
them and, therefore, strict vigil has to be kept
on the recording equipment, recording
technique and the stimulus parameters used.
4. Numerous specialized types of VEP22 are
being assessed and these are still used as
TABLE 18.2: SPECIALIZED TYPES OF VEP

NOT COVERED BY THE ISCEV STANDARD22
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Steady state VEP

Sweep VEP
Motion VEP
Chromatic (color) VEP
Binocular VEP
Stereo-electro VEP
Multichannel VEP
Hemifield VEP
Multifocal VEP
Multifrequency VEP
LED goggles VEP
investigational tools (Table 18.2). Knowledge

in these areas is still evolving.
Clinical Uses of Visual

Electrophysiological Tests
A number of ocular disorders may require visual
electrophysiology testing for proper diagnosis
(Tables 18.3 and 18.4). It must be remembered
that ERG needs to be interpreted in the context
of other clinical features and investigative reports
to arrive at the correct diagnosis. One can be
way off the true diagnosis if it is based on ERG
recording alone.
Photoreceptor Dysfunction
In widespread genetic retinal photoreceptor
disorders like retinitis pigmentosa (RP) or
choroideremia, a profound reduction of ERG is
seen even when retina looks apparently normal.
The diagnosis of RP is often obvious in patients
with history of night blindness, progressive
peripheral field constriction and typical retinal
changes including equatorial pigment migration,
arterial attenuation, RPE atrophy and disk pallor
as seen in a 40 years male with visual acuity
of 20/50 and residual visual fields of 10 degrees
centrally (Fig. 18.12A, top). ERG has a limited
role in diagnosis but helps to assess residual
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TABLE 18.3: COMMON INDICATIONS FOR ELECTRORETINOGRAPHY
1. Evaluation of nyctalopia (vitamin A deficiency in children and adults,
congenital stationary night blindness, primary diffuse retinal
degenerations, high myopia, malingering
2. Retinitis pigmentosa and allied diseases
3. Other pigmentary retinopathies (pseudo-RP)
4. Juvenile macular degeneration
5. Assessment of ischemia in ocular vascular disease
6. Infantile vision impairment and nystagmus
7. Evaluation of hemerelopia with or without visual impairment
8. Detection of carrier state for X-linked diseases (X-linked RP, CSNB,
achromatopsia, cone- or cone-rod dystrophies)
9. Evaluation of eyes with metallic foreign bodies to detect siderosis
10. Evaluation of any retinal toxicity to established retinotoxic drugs like
chloroquine, quinine, viagra, anti-epileptic drugs
11. Evaluation of any potential retinal toxicity of newer pharmacologic
products
12. Evaluation of course of various inflammatory diseases (birdshot
retinopathy, MEWDS, AZOOR)
13. Diagnosis
macular photoreceptor function. In the test ERG

may not be recordable with routine testing using
standard flash. With extensive filtering and
averaging (Fig. 18.12B, bottom), response (arrow)
can be elicited identifying residual cone function.
PERG is a more reliable method of eliciting
residual central macular function (Fig. 18.13).
Fields are also important in such cases to define
legal blindness and functional disability in the
patient. ERG, however, is essential in research
studies to demonstrate diffuse, severe photoreceptor dysfunction that characterizes even early
stages of RP. A normal ERG recorded beyond
6 years of age practically rules out possibility
of developing RP in future. ERG helps to diagnose
patients with atypical findings and also in carrier
detection. Flash ERG in RP (Figs 18.12 to 18.14)
can be either extinguished, or show a rod-cone
or rarely a cone-rod or even a negative type of
ERG dysfunction. All such types usually point
to a progressive disease especially if implicit time
abnormalities are present. True sector or localized
central (restricted) disease (Fig. 18.15) may give
amplitude reduction with no implicit time
change, whereas diffuse or generalized disease

is usually associated with abnormal implicit
time.24,25
Localized Photoreceptor Loss with

Pigmentary Retinal Dystrophy
In atypical retinal pigmentary dystrophies, ERG
may help to confirm the diagnosis and
differentiate various conditions. For example in
a 65 years old female patient with BCVA of
20/80 in each eye, there was no history of night
blindness or reduced dark adaptation but
gradual progressive loss for reading since 5 years.
Posterior pole showed RPE atrophy and mild
pigment migration while the rest of the retina
was normal (Fig. 18.15). Retinal arteries showed
attenuation and disk had temporal pallor. ERG
was not extinguished or severely affected,
excluding the diagnosis of typical RP. However,
both scotopic and photopic responses showed
20-40% reduction in amplitudes with only mild
increase in latency. The condition can be interpreted as an Inverse RP / Central RP26 or central

TABLE 18.4: INDICATIONS OF ELECTROPHYSIOLOGY TESTS IN SPECIFIC DISEASES
A. Retinal and Choroidal Disorders
1. Congenital and infantile forms of blindness
(a) Leber congenital amourosis (LCA)
(b) Stationary congenital retinal dysfunction
(1) Congenital achromatopsia (complete
blue cone monochromatacy)
(2) Congenital stationary night blindness
(incomplete and complete CSNB)
(3) Fundus albipunctatus
(4) Oguchi disease
(c) Blindness as part of a pediatric neurologic
syndrome
(1) Infantile Refsum syndrome, Zelweger
syndrome (retinal degeneration
associated
with
generalized
peroxisomal disease)
(2) Neuronal ceroid lipofuscinoses
(infantile, late infantile, juvenile)
(3) Mucolipidosis type IV
(4) Hallervorden-Spatz syndrome (iron
storage in basal ganglia, mental
retardation, spasticity, RP)
(5) Senior-Loken syndrome (LCA or
severe early-onset RP with renal
failure)
(6) Joubert syndrome (retinal aplasia,
cerebellar hypoplasia, neonatal
tachypnea)
2. Rod-cone photoreceptor dystrophy/degeneration (hereditary dystrophies)
(i) Rod and rod-cone dystrophy/degeneration
(retinitis pigmentosa)
(1) Autosomal dominant, autosomal
recessive, X-linked
(2) RP with slightly greater cone loss
(3) RP with electronegative ERG
(ii) Cone and cone-rod dystrophies
3. Macular Dystrophies
(a) Peripherin/Retinal degeneration slow type
(RDS)
(b) X-linked (juvenile) retinoschisis
(c) Stargardts macular dystrophy
(d) Bests macular dystrophy
(e) Pattern dystrophy
B. Choroidal dystrophies
(a) Choroidal atrophy
(b) Gyrate atrophy of the choroid and retina
(c) Choroideremia patients and carriers
(d) Central areolar choroidal atrophy
C. Retinal dystrophies associated with other diseases
(a) Usher syndrome (RP and congenital deafness)
(b) Bardet-Biedl syndrome (RP, hexadactyly,
obesity, hypogenitalism, and mental retardation)
(c) Kearns-Sayre syndrome [mitochondrial myopathy, chronic progressive external ophthalmoplegia (CPEO), RP, heart block]
(d) Chronic progressive external ophthalmoplegia
plus (CPEO+)
D. Bruchs membrane disorders
(a) Angioid streaks (PXE)
(b) Dominant drusen
E. Hereditary vitreoretinal disorders
(a) X-linked juvenile retinoschisis
(b) Goldmann-Favre syndrome
(c) Enhanced S-cone syndrome (ESCS)
F. Inflammatory conditions
(a) Multiple evanescent white dot syndrome
(MEWDS)
(b) Birdshot retinochoroidopathy
(c) Pars planitis
(d) Syphilis
(e) Pigmented paravenous retinochoroidal atrophy
(PPRCA)
(f) Diffuse unilateral subacute neuroretinitis
(DUSN)
(g) Rubella
G. Vascular disorders
(a) Sickle-cell retinopathy
(b) Ophthalmic artery occlusion
(c) Central retinal artery occlusion
(d) Central retinal vein occlusion
(e) Carotid insufficiency (ocular ischemic
syndrome)
(f) Diabetic retinopathy
H. Toxic disorders
(a) Chloroquine and hydroxychloroquine
(b) Quinine
(c) Digoxin
(d) Thioridazine
(e) Chloropromazine
(f) Indomethacin
(g) Methanol
I. Miscellaneous
(a) Albinism
(b) High myopia
(c) Acquired retinal dysfunction/degeneration
(i) Vitamin A deficiency (malabsorption
syndromes)
(ii) Autoimmune retinopathy, including cancerassociated retinopathy (CAR) and
melanoma-associated retinopathy (MAR)
(d) Retinal (cone-rod) dystrophy with supernormal
and delayed rod ERG b-waves
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Fig. 18.12: Unrecordable PERG and flash ERG in advanced retinitis pigmentosa depicting macular involvement
VA 20/80 OU, Fields central 10 degrees, night blindness present (Top row). Extensive filtering and averaging of
the maximal combined response to elicit a microvolt ERG (arrow, outside ISCEV standard) showing residual retinal
function in patient of RP with visual acuity of 20/800 and macular atrophy (Bottom row)
Fig. 18.13: Preserved PERG in a patient of RP with extinguished flash ERG responses showing macular
sparing. Visual acuity of a 25-year male was 20/25 and visual fields showed central island of 10 degrees
Fig. 18.14: Cone-rod dystrophy: Retinal dystrophy with Bulls eye macular lesion, arterial narrowing, peripheral
RPE degeneration and disk pallor. ERG showed absent cone functions with subnormal but recordable isolated rod
response suggestive of cone-rod dystrophy in a 29 years patient with VA 20/80. Note large blink artifacts towards
end of recordings (arrows) that are not uncommon due to photophobia in these subjects
Fig. 18.15: Central RP: Fundus photograph showing central location of pigmentary retinopathy with normal periphery.
ERG shows subnormal rod and cone functions and ERG is not extinguished. The disease is likely to remain localized
and minimally progressive. Visual acuity of patient 20/80, central scotoma on fields but with no night blindness
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300

pigmentary retinopathy that is likely to be only
slowly progressive and may not lead to less than
20/400 vision.
dystrophy is a patient with visual loss of

unknown etiology (Fig. 18.17) where ERG gives
the correct diagnosis.
Cone Dystrophies
Inner Retinal Dysfunction:

Negative ERG
Cone dystrophies (Fig. 18.16) have normal rod

responses, but subnormal, though not extinguished, cone responses.27 The 30 Hz flicker response
usually shows both amplitude reduction and
delayed implicit time. In early stages, the patient
may present with normal macula and mild
temporal disc pallor and be misdiagnosed as
optic nerve dysfunction if abnormal VEP is
demonstrated, without recording the ERG. In
later years such patients develop typical Bulls
eye lesion. Some patients can have supernormal
rod responses. One common presentation of cone
In a negative ERG the a-wave is unaffected but

the b-wave in the scotopic maximal retinal
response has a selective reduction of amplitude.
It usually signifies diseases sparing the photoreceptors and involving the dysfunction of
post-photo transduction and probably postreceptor cells in the middle retinal layers. In a
majority of cases an etiology can be detected after
correlating clinical and ERG findings, but in some
cases the clinical entity cannot be labeled as
specific.
Fig. 18.16: Cone dystrophy: Male 36 year with VA 20/200, color vision loss and central scotoma. Localized cone
dystrophy involving only macular photoreceptors, it shows severely reduced and delayed P50 in PERG. Other flash
ERG responses are normal including photopic responses as the peripheral cones (that are more in numbers than
macular cones) are uninvolved
Fig. 18.17: One of the commonest indications for ERG testing in a patient with a visual loss of unknown etiology.
This 42-year-old female had history of mild visual loss since 4-5 years. The best corrected visual acuity was 20/
40 in each eye. Clinically, ocular examinations including detailed anterior and posterior segment evaluation were
normal. Visual fields showed no abnormality. ERG showed markedly subnormal, but not absent, cone flicker response
(arrow) with normal rod response suggestive of an early adult-onset cone dystrophy. The photopic single flash
is not depicted
Causes of negative ERG28 include congenital

stationary night blindness (CSNB, complete and
incomplete), fundus albipunctatus, Oguchi's
disease (Figs 18.18 to 18.20),29 X-linked retinoschisis,30 quinine toxicity, melanoma associated
retinopathy (MAR),31 Battens disease, and
occasionally in cone-rod dystrophy (Table 18.5).
Carcinoma associated retinopathy (CAR) does
not usually give a negative ERG but profound
global ERG reduction in keeping with dysfunction at the level of the photoreceptor.31 It occurs
due to damage from circulating antibodies.
Central retinal artery obstruction (CRAO) also
has a negative ERG (vide infra). In patient of
Oguchis disease an increased amplitudes of
responses in PERG and single flash cone ERG
(Fig. 18.19) may occur after prolonged dark
adaptation that also changes the golden metallic
color of retina to a relatively normal color.
Ischemic Vascular Retinal Disorders

ERG changes are profoundly helpful to detect
inner retinal ischemia since fundus fluorescein
TABLE 18.5: CONDITIONS ASSOCIATED WITH

ELECTRONEGATIVE ERG
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
CSNB/Oguchi
Juvenile retinoschisis
CRAO, CRVO
Familial optic atrophy
Siderosis bulbi
Quinine
Some forms of RP and cone-rod dystrophy
Melanoma associated retinopathy, CAR
angiography or fundus appearance may not

detect the true extent of retinal ischemia.32,33 ERG
is an indispensable and extremely powerful but
unfortunately underutilized tool to differentiate
ischemic from non-ischemic obstruction of the
central retinal vein (Figs 18.21 and 18.22).
Reduced b-wave amplitude has 80-90%
sensitivity and 70-80% specificity to detect inner
retinal ischemia. An absolute increase of more
than 37 msec in latency of the flicker ERG
responses or a difference of more than 7 msec
between affected and normal eye are almost
pathognomic of ischemic type of CRVO in a given
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302
A1
B1
Figs 18.18A and B: Oguchi's disease. A & A1 Fundus appearance before and B & B1 2 hours
after dark adaptation. Corresponding ERG are shown in Figure 18.19
clinical setting. Reliable information from FFA

may be available only in 50-60% cases of CRVO
due to media haze, extensive hemorrhages, poor
quality photographs and inability to visualize
peripheral retina. ERG circumvents all these
limitations as it is a global response from the
whole retina and is not too much affected by
media haze.
Other conditions like ocular ischemic
syndrome34 (Fig. 18.23), central retinal artery
occlusion (Fig. 18.24) and ophthalmic artery
occlusion (extinguished ERG) 35 are also very well
detected on ERG. The negative ERG in central
retinal artery occlusion (CRAO) 35 occurs due to
the double blood supply of the retina. The RPE/

photoreceptors (a wave) are spared as they are
supplied via choroidal circulation, but bipolar
cells and amacrine cells (b-wave and oscillatory
potentials) are affected as they are supplied via
central retinal artery. In ophthalmic artery
obstruction where both retinal and choroidal
circulation are affected, the ERG is unrecordable
as all retinal cell layers are involved.35
In ocular ischemic syndrome ERG is
extremely useful since clinical presentation of
this under diagnosed clinical entity is variable.36
In diabetic retinopathy37progressive abnormalities in ERG are seen with progression of the
Fig. 18.19: Oguchi's disease: ERG findings after 20 minutes and after 2 hours of dark adaptation in Oguchi's
disease. In each case the left graph is before and right graph is after the prolonged dark adaptation. The OPs
and on-off responses were recorded only once before prolonged dark adaptation and show absence of off-response.
Baseline findings are similar to those seen in complete form of CSNB with normal fundus with the exception of
a much smaller or nearly absent MCR b-wave in classical complete CSNB
Fig. 18.20: Oguchi's disease: Negative ERG with preserved isolated rod responses and photopic flash and
flicker ERG suggestive of incomplete CSNB
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304
Fig. 18.21: Non-ischemic CRVO: A 28-year male had mild blurring of vision since 5 days due to CRVO with
mild macular edema. The full field ERG of right eye is very much comparable to the left eye; both of which are
within normal limits suggestive of non-ischemic CRVO. Note the PERG is showing reduced P50 amplitude in the
right eye compared to left eye. Although the vision is same (20/20) in both eyes but the macular function of the
right eye is not same as the left eye possibly due to macular edema leading to symptomatic reduced contrast
sensitivity in the patient
retinopathy. The oscillatory potentials show

profound reduction in case of disk new vessels
(NVD). The ERG can be subnormal even before
clinical retinopathy, possibly due to metabolic
effects on the retinal cells. ERG, however, cannot
predict accurately the presence of PDR and is,
therefore, not used clinically for monitoring
diabetic retinopathy.
Drug Toxicity and Monitoring Health

of Retina 25
ERG helps to differentiate nyctalopia due to
vitamin A deficiency from CSNB and RP. ERG
is indicated particularly in adults such as those
with alcoholic liver disease, chronic pancreatitis,
or malabsorption syndromes. The rod responses
are markedly affected and white flecks may be

seen in the retina. Visual acuity is unaffected.
Similarly, ERG abnormalities can be seen in drug
toxicity especially with hydroxychloroquine,38
chloroquine, quinine and thioridazine. VEP is
useful to detect ethambutol toxicity (Fig. 18.25).
ERG can detect and prognosticate siderotic
changes in eyes with retained iron IOFB.31 Initially
ERG has a subnormal b-wave on maximal
combined scotopic response that can progress
to a negative ERG with time and ultimately
become extinguished. Removal of IOFB in eyes
with recordable ERG, may lead to improvement
in ERG changes and a stable outcome. In
advanced siderosis, removal of IOFB will not
stop progressive visual loss and sometimes
phthisis bulbi develops.
Fig. 18.22: Ischemic CRVO in right eye and non-ischemic in left eye. Right eye has reduced b/a wave ratio
and increased latency of b-wave in MCR; reduced amplitudes and delayed stimulus-to-peak time of 30 Hz flicker
with absence of PERG, isolated rod response and oscillatory potentials. Left eye has no delays in responses but
reduced amplitudes of all waveforms
Pediatric Visual Impairment39

ERG is indispensable in evaluating the cause
of poor vision in children. Commonly seen conditions include Lebers congenital amaurosis
(LCA), rod monochromatism (Fig. 18.26),
Stargardts macular dystrophy, ocular albinism
and delayed visual maturation. Correct
identification of the underlying dysfunction helps
in proper counseling as regards risks to relatives,
long-term prognosis and sometimes identi-
fication of an underlying systemic disease such

as abetalipoproteinemia, neuronal ceroid
lipofuscinosis, mucopolysccharidoses and
cystinosis.
Carrier Stage Detection

ERG can be helpful in detection of the carrier
stage of certain X-linked conditions such as
X-linked RP,40 blue-cone monochromatism,41 and
X-linked cone dystrophy.
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306
Fig. 18.23: Ocular ischemic syndrome: A 68-year female with VA 20/50 and early cataract in each eye. Fundus
had features of NPDR, dilated veins and minimal disk pallor. ERG showed reduced amplitude of rod mediated inner
retinal responses (IRR), and reduced b/a wave ratio in maximal combined response (MCR).The inner retinal ischemia
was depicted by reduced amplitudes and poorly recordable oscillatory potentials, with delayed stimulus-to-peak time
of 30-Hz flicker ERG. Carotid artery doppler (not shown) showed moderate atheromatous changes. Patient developed
neovascular glaucoma six months later without worsening of retinopathy in the right eye
Optic Nerve and Visual Pathway

Optic nerve and visual dysfunction42 include
following conditions:
1. Optic nerve demyelination: The pattern VEP
(PVEP) latency (P100) is usually delayed in
optic nerve demyelination and the delay may
be subclinical, i.e. it may occur with no signs
or symptoms of optic nerve involvement.43,44
This may significantly affect clinical management in a patient with spinal cord disease
and possible multiple sclerosis (MS). The VEP
is almost invariably delayed following
symptomatic optic nerve involvement in MS,
even when vision has returned to normal.
2. Papilledema: In papilledema the VEP is normal
unless secondary optic atrophy occurs.
3. Anterior ischemic optic neuropathy: In anterior

ischemic optic neuropathy (AION) the PERG
shows normal P50 amplitude and latency,
elevation of N95, normal flash ERG and
reduced amplitude with normal P100 latency
in VEP (Fig. 18.27). Using multichannel VEP
recordings, the chiasmal lesions, such as
pituitary tumors, show a crossed asymmetry where there is an abnormal distribution over the two hemispheres which is in
an opposite direction for the two eyes.45
Stimulus parameters are crucial for accurate
localization. In general, use of a large field,
large check stimulus gives paradoxical
lateralization 45 whereas a small field,
small check stimulus gives anatomical
lateralization. Retrochiasmal lesions give an
Fig. 18.24: CRAO: Left eye with CRAO shows preserved a-wave and absent b-wave (negative ERG) in maximal
combined response depicting preservation of outer retinal cell layers supplied by choroidal vasculature and ischemia
in inner retinal layers supplied by central retinal artery. Right eye responses are normal
uncrossed asymmetry where there is an

abnormal distribution that is the same for
the two eyes. Serial VEP recordings can help
detect recurrences or non-responsiveness to
medical therapy as VEP abnormalities can
occur before visual fields or visual acuity
become abnormal.
4. Ocular albinism: In some cases of ocular
albinism, the condition may not be apparent
in the absence of typical phenotypic expression of skin or iris, but child can have nystagmus and poor vision due to an albino
genotype. All albinos, irrespective of genotype
or phenotype exhibit misrouting. Heterozygote carriers do not demonstrate misrouting.
The diagnosis of the intracranial misrouting
of albinism, where the majority of optic nerve

fibers from each eye do not decussate to the
contralateral hemisphere, is readily demonstrated by multichannel VEP. Abnormalities
may occur in response to either pattern
appearance or diffuse flash stimulation, but
the flash VEP appears to be more effective
in infants and the pattern appearance VEP
in adults.
5. Visual acuity assessment: Objective assessment
of visual acuity is performed with pattern
appearance stimulation using a very brief
appearance time in order to minimize the
possibility of voluntary closure or defocusing.
6. Other optic nerve diseases: Lebers hereditary
optic neuropathy (LHON), toxic and nutri-
307
308
Fig. 18.25: Ethambutol toxicity: This 18-years male has rapidly progressive, bilateral sequential loss of vision
from 4 months (20/400). There was bilateral optic disk pallor with ill-sustained pupillary reactions but no RAPD.
The pattern VEP was unrecordable. Flash ERG was normal. In PERG, the N95 was absent (arrow) and P50 was
preserved confirming the patient to have bilateral optic neuropathy. Visual fields showed central 7 degrees of scotoma
in both eyes. History of antitubercular treatment in the past pointed to a diagnosis of possible ethambutol toxicity
tional optic neuropathies and traumatic optic

neuropathy show variable changes in
amplitude and latency of VEP depending on
extent of involvement.
7. Visual loss assessment in infants and children:
VEP is a useful tool along with ERG and
other clinical assessments to differentiate
various conditions such as cortical visual
impairment, delayed visual maturation, and
amblyopia.
8. Malingering: Along with other tests, VEP helps
to differentiate malingering from visual
pathway lesions. Pattern onset is a useful
technique as subjects cannot voluntarily blur

this stimulus.
Recent Advances in Multifocal

ERG and Multifocal VEP
Multifocal ERG (mfERG) technique developed
initially by Bearse and Sutter46 allows local ERG
responses to be recorded simultaneously from
many regions of the retina. The response is
thought to originate from outer retina with relatively little contribution from the ganglion cells.47
Fig. 18.26: Rod monochromatism: Showing poorly recordable PERG (due to nystagmus), and absent cone-mediated
responses (PSF, 30 Hz) with normal scotopic rod-mediated responses (IRR, MCR). This child of 8 years had
VA of 20/400, congenital nystagmus that had reduced with time and photophobia with complete achromatopsia
Responses are recorded to a scaled hexagonal

pattern-reversal stimulus in photopic conditions
(Fig. 18.28) although some laboratories are
attempting to record scotopic mfERG also. MfERG
helps to distinguish between diseases of the outer
retina and ganglion cells or optic nerves. Along
with multifocal VEP (mfVEP),48 the mfERG helps
to differentiate organic and non-organic causes
of visual loss.
There are some limitations of these techniques.
Since it is an evolving technology the recording
parameters and interpretation are still not standardized, though guidelines have been formulated.49
The techniques are still not widely available. Full
field ERG helps to evaluate the function of the
retina as a whole. However, it cannot detect focal
areas of abnormal function. Multifocal ERG is a
new technique. It allows analysis of local ERG
responses to assess focal retinal function. Basic
technology is similar to full-field ERG in some
aspects. In mfERG the recording, ground and

reference electrodes and their placement close to
or on the cornea, lateral canthus and ear lobe are
similar to the routine ERG. Recording is
done with dilated pupils with subject placed in
ordinary room light for 15 minutes before testing.
Effect of Stimulus on mfERG
46,47
Stimulus can be delivered by a cathode ray tube

(CRT), i.e. monitor LCD projectors, LED arrays
or scanning laser ophthalmoscope. The commonest frame frequency of the CRT is 75 Hz
and should never be 50 or 60 Hz as this is similar
to the line current frequency which interferes
as noise with the recordings. Stable fixation is
essential to get reliable mfERG recordings and
various fixation targets and monitoring devices
may be used that do not interfere with the
recordings.
309
310
Fig. 18.27: Anterior ischemic optic neuropathy: A 48-year-old male had one month reduction of vision in the
left eye. VA was 6/6 and 6/60 in the right and left eyes respectively. Left eye showed diffuse field loss (not shown).
Right eye color fundus (Top left) and red free photograph (Middle left) showed normal color of the disk with few
RPE changes at macula. Color fundus photograph of the left eye (Top right) showed small disk with no cup and
diffuse pallor. Red free photograph of left eye (Middle right) showed 3 quadrants disk pallor with sparing of inferotemporal
segment. Pattern ERG showed normal P50 and N95 responses in right eye. Left eye showed reduced amplitude
and delayed latency of P50, with secondary elevation of N95 component (arrow) (Extreme top right). The pattern
VEP had normal amplitude and latency in right eye (Bottom right) but was poorly recordable in the left eye (Bottom
left)
The retina is stimulated with a black and

white pattern of hexagonal elements each of
which has a 50% chance of being illuminated
every time the frame changes. The hexagonal
pattern was designed to compensate for the local
differences in signal density (cone density) across
the posterior retina. Thus the central hexagons

are smaller than the peripheral ones (Fig. 18.28).
Each hexagon element follows a fixed
predetermined sequence called m-sequence that
controls the order of flicker of the stimulus
elements between light and dark. This sequence
Fig. 18.28: Normal multifocal ERG stimulus and variety of output display
is designed in such a way that the overall

luminance of the screen over the time of recording
is relatively stable, i.e. equiluminant. The overall
stimulus pattern should subtend a visual angle
of 20-30 degrees on either side of fixation. The
stimulus region can be divided into different
numbers of hexagons such as 61, 103 or 241.
Duration of recording varies from 4-8 minutes
depending on whether 61 or 103 elements are
used. Various artifacts in mfERG recordings
include electrical noise, movement errors due to
fixation losses, eccentric fixation, shadowing
errors due to edge of refraction lenses, and errors
due to too much averaging.
Multifocal ERG Responses

By correlating the continuous ERG signal with
the on or off phases of each stimulus element,
the focal ERG signal associated with each

element is calculated. The data obtained can be
displayed in various ways; commonly as a
topographic array, a three-dimensional plot or
as group averages (Fig. 18.28). The trace arrays
are essential to display as they not only show
the topographical variations due to focal
pathology but also demonstrate the quality of
the records. It is important to remember that the
tracings of mfERG are not responses in the sense
of direct electrical signals from a local region
of the retina. The mfERG waveforms are a
mathematical extraction of signals that correlate
with the time that one portion of the screen is
illuminated. The signals are hence influenced
by adaptation effects from previous stimuli and
by scattered light from other fundus areas.
The typical waveform of the primary mfERG
(first order or first order kernel K1) is a biphasic
311
312

wave. The initial negative deflection is called
N1, which is followed by a positive deflection
PI and a second negative deflection called N2.The
cellular origins of these responses is still under
study but the N1 may be from photoreceptors
while P1 may have contributions from the inner
retinal cells. The amplitude and latency
measurements of N1 and P1 follow the same
convention as for the a- and b-waves of routine
flash ERG. Each laboratory needs to establish
its normative data for meaningful comparisons.
Clinical Uses of Multifocal ERG

Multifocal ERG is still under evaluation for
clinical usage. However, it is used in the study
of following conditions:
1. Maculopathies such as cone dystrophy,
central areolar atrophy (Fig. 18.29), and
Stargardt's macular dystrophy (Fig. 18.30).
2. Retinal vascular disorders
3. Inflammatory conditions of optic nerve
4. Field loss due to ocular and non-ocular

pathology
5. Toxic retinal pathology and
6. Visual loss of unknown etiology.
Focal Macular ERG

Focal macular ERG50 is another technique to
record ERG responses from the macular area
alone. There is, however, no consensus on the
best technique or standardized technique for focal
macular ERG. With advent of PERG and
multifocal ERG there is still a need to assess
as to which of these techniques is useful in clinical
situations. Presently, focal macular ERG is not
in widespread use.
Conclusion
The objective information provided by
electrophysiological examination of the visual
Fig. 18.29: Central areolar atrophy: It shows subnormal PERG, normal full-field ERG and
reduced multifocal ERG. Right bottom shows clinical fundus picture
Fig. 18.30: Multifocal ERG in Stargardt's heredomacular degeneration showing reduced central cone function
system is important in the diagnosis and

management of diseases of visual pathway. The
clinician recording the waveforms and the
one interpreting the test results should be
thoroughly conversant with the pitfalls and
interrelation of various tests ordered. The
electrophysiology results must always be
interpreted and correlated to the clinical and

other test parameters to avoid misdiagnosis.
Newer techniques in this field such as multifocal
ERG, multifocal VEP, focal macular ERG and
motion VEP are constantly evolving to improve
our diagnostic ability and understanding of the
visual pathway.
TABLE 18.6: NORMAL VALUES IN THE LVPEI LABORATORY USING THE METROVISION
SYSTEM (FIG. 18.7)
Response
Isolated rod response

Maximal retinal response
Photopic cone
30 Hz Flicker
a-wave
Amplitude
Latency
(microvolts)
(milliseconds)
105-130
20.0-22.0
b-wave
Amplitude
Latency
(microvolts)
(milliseconds)
130-160
350-450
120-180
100-150
90-110
45.004
27-31
33-35
313
314

Note:
1. The website of the International Society for
Clinical Electrophysiology of Vision (ISCEV)
www.iscev.org provides full text of all standards
and guidelines for ocular electrophysiology
recording. Each laboratory involved in such tests,
whether for clinical or research purposes, must
attempt to meet these standards so as to have
meaningful international communications.
2. The recordings shown in this chapter are on two
types of electrophysiology recording systems:
LKC UTAS-2000 and Metrovision. Due to space
constraints only one waveform of each eye is
shown instead of two reproducible waveforms.
The normal values in our laboratory are given
in Table 18.6.
References
1. Welber RG, Eisner A. Retinal function and
physiological studies. In: Retinal Dystrophies
and Degenerations. Newsome DA (Ed). New
York, Raven Press 1988;44-69.
2. Arden GB, Barrada A, Kelsey JH. New clinical
test of retinal function based on the standing
potential of the eye. Br J Ophthalmol 1962;46:
449-67.
3. Arden GB, Fojas MR. Electrophysiological
abnormalities in pigmentary degenerations of
the retina. Arch Ophthalmol 1962;68:369-89.
4. Marmor MF, Zrenner E (for the International
Society for Clinical Electrophysiology of Vision):
Standard for Clinical Electrooculography. Doc
Ophthalmol 1993;85:115-24.
5. Krill AE, Morse PA, Potts AM, Klein BA.
Hereditary vitelliruptive macular degeneration.
6. Brink HM, Pinckers AJ, Verbeek AM. The electrooculogram in uveal melanoma: A prospective
study. Doc Ophthalmologica 1990;75:329-34.
7. Arden GB, Wolf JE. The human electrooculogram: interaction of light and alcohol. Invest
Ophth Vis Sci 2000;41:2722-29.
8. Kolder H, Brecher GA. Fast oscillations of the
corneoretinal potential in man. Arch Ophthalmol
1966;75:232-37.
Standard for Clinical Electroretinography (1994
Update). Doc Ophthalmol 1995;89:199-210.

Standard for Clinical Electroretinography (1999
Update). Doc Ophthalmol 1999;97:143-56.
11. Brigell M, Bach M, Barber C, Kawasaki K,
Kooijman A. Guidelines for calibration of
stimulus and recording parameters used in
visual clinical electrophysiology. Doc Ophthalmol
1998;95:1-14.
12. Dawson WW, Trick GL, Litzkow CA. Improved
electrode for electroretinography. Invest
Ophthalmol Vis Sci 1979;18:988-91.
13. Ram LSM, Jalali S, Reddy PSR, Rao VS, Das
T, Nutheti R. Safety and efficacy evaluation of
a new Electrode (The LVP Electrode) Part I.
Pattern ERG pilot study. Doc Ophthalmol 2003;
107:171-77.
14. Ram LSM, Jalali S, Faheemuddin S, Das T, Nutheti
R. Safety and efficacy evaluation of a new ERG
electrode (The LVP Electrode) Part II. Flash ERG
pilot study. Doc Ophthalmol 2003;107:179-83.
15. Shiells RA, Falk G. Contribution of rod, onbipolar and horizontal cell light responses to
the ERG of dogfish retina. Vis Neurosci 1999;
16:503-11.
16. Bush RA, Sieving PA. A proximal retinal
component in the primate photopic ERG a-wave.
Invest Ophthalmol Vis Sci 1994;35:635-45.
17. Bush RA, Sieving P A. Inner retinal contributions
to the primate photopic fast flicker electroretinogram. J Opt Soc Am A 1996;13:557-65.
18. Sieving PA. Photopic ON- and OFF-pathway
abnormalities in retinal dystrophies. Trans Am
Ophthalmol Soc 1993;91:701-73.
19. Holder GE. The pattern electroretinogram and
an integrated approach to visual pathway
diagnosis. Prog Retin Eye Res 2001;20:531-61.
20. Bach M, Hawlina M, Holder GE, Marmor MF,
Meigen T, Vaegan, Miyake Y. Standard for
Pattern Electroretinography. Doc Ophthalmol
2000;101:11-18.
21. Neubauer AS, Steifelmyer S, Berninger T, Arden
GB, Rudolph G. The multifocal pattern
electroretinography in chloroquine retinopathy.
Ophthal Res 2004;36:106-13.
22. Odom JV, Bach M, Barber C, Brigell M, Marmor
MF, Tormene AP, Holder G, Vaegan. For the
International Society for Clinical Electrophysiology of Vision. Visual evoked Potential standard
(2004). Doc Ophthalmol 2004;108.

23. American Encephalographic Society. Guideline
thirteen: Guidelines for standard electrode
placement nomenclature. J Clin Neurophysiol
1994;11:111-13.
24. Marmor MF. The electroretinogram in Retinitis
pigmentosa. Arch Ophthalmol 1979; 97:1300-04.
25. Berson EL. Retinitis pigmentosa and allied
diseases: applications of electroretinographic
testing. Int Ophthalmol 1981;4:7-22.
26. Marmor MF, Aguirre G, Arden G, et al. Retinitis
pigmentosa: Symposium on terminology and
methods of exmination. Ophthalmology 1983; 90:
126-31.
27. Krill AE, Deutman AF, Fishman M. The cone
degenerations. Doc Ophthalmol 1973;35:1-80.
28. Koh AH, Hogg CR, Holder GE. The incidence
of negative ERG in clinical practice. Doc
Ophthalmol 2001;102:19-30.
29. Miyake Y, Yagasaki K, Horiguchi M, Kanda
T. Congenital stationary night blindness with
negative ERG. A new classification. Arch
Ophthalmol 1986;104:1013-20.
30. Tantri A, Vrabee TR, Cuunjieng A, Frost A,
Annesley WH Jr., Donoso LA. X-linked
Retinoschisis. A clinical and molecular genetics
review. Surv Ophthalmol 2004;49:214-30.
31. Scholl HP, Zrenner E. Electrophysiology in
acquired retinal disorders. Surv Ophthalmol 2000;
45:29-47.
32. Hayreh SS, Klugna MR, Beri M, Kimera AL,
Podhajsky P. Differentiation of ischemic from
non-ischemic CRVO during the early acute
phase. Graefes Arch Clinical and Exp Ophthalmol
1990;228:201-17.
33. Johnson MA, McPhee TJ. Electrophysiologic
findings in iris neovascularization due to acute
central retinal vein occlusion. Arch Ophthalmol
1993;111:808-14.
34. Brown GC, Magragal LE. The ocular ischemic
syndrome: clinical, fluorescein angiographic and
carotid angiographic features. Int Ophthalmol
1988;11:243-51.
35. Brown GC, Magragal LE, Sergott R. Acute
obstruction of the retinal and choroidal
circulation. Ophthalmology 1986;93:1373-82.
36. Hussain N, Jalali S, Kaul S. Carotid artery diseases
and ocular disorders. Ind J Ophthalmol 2001;49:514.
37. Tzekov R, Arden GB. The electroretinogram in

diabetic retinopathy. Surv Ophthalmol 1999;44:5360.
38. Tzekov RT, Serrato A, Marmor MF. Electroretinogram findings in patients using hydroxychloroquine. Doc Ophthalmol 2004;108:87-97.
39. Kriss A, Jeffrey B, Taylor D. The Electroretinogram in infants and young children. J Clin
Neurophysiol 1992;9:373-93.
40. Berson EL, Rosen JB, Simonoff EA. Electroretinographic testing as an aid in detection of carriers
of X-chromosome linked Retinitis pigmentosa.
41. Berson EL, Sandberg MA, Maguire A, Bromley
WC, Roderick TH. Electroretinograms in carriers
of blue cone monochromatism. Am J Ophthalmol
1986;105:254-61.
42. Heckenlively JR, Weleber RG, Arden GB. Testing
levels of the visual system. In: Heckenlively JR and
Arden GB (Eds). Principles and Practice of Clinical
Electrophysiology of Vision. St Louis, Mosby Year
Book, 1991;485-93.
43. Holliday AM, McDonald WI, Mushin J. Visual
evoked response in the diagnosis of multiple
sclerosis. Br Med J 1973;4:661-64.
44. Holder GE. Multiple sclerosis. In: Heckenlively JR
and Arden GB (Eds). Principles and Practice of
Clinical Electrophysiology of Vision. St Louis,
Mosby Year Book 1991;797-805.
45. Holder GE. Chiasmal and Retrochiasmal lesions.
In: Heckenlively JR and Arden GB (Eds).
Principles and Practice of Clinical Electrophysiology of Vision. St Louis, Mosby Year Book,
1991;557-64.
46. Bearse MA Jr., Sutter EE. Imaging localized retinal
dysfunction with the multifocal ERG. J Opt Soc Am
A 1996;13:634-40.
47. Hood DC, Odel JG, Chen CS, Winn BJ. The multifocal ERG. J Neuroophthalmol 2003; 23: 225-35.
48. Hood DC, Odel JG, Winn BJ. The multifocal VEP.
J Neuroophthalmol 2003;23:279-89.
49. Marmor MF, Hood DC, Keating D, Kondo M,
Seelinger MW, Miyake Y. For The International
Society for Clinical Electrophysiology of Vision.
Guidelines for basic multifocal ERG. Doc
Ophthalmol 2003;106:105-15.
50. Miyake Y. Focal macular electroretinography.
Nagoya L Med Sci 1998;61:79-89.
315
316
SAVITRI SHARMA, SREEDHARAN ATHMANATHAN
19
Diagnostic
Procedures in
Infectious Keratitis
Microbial keratitis may be caused by bacteria,

fungi, parasites or viruses and each of these may
produce a spectrum of disease which may or
may not have distinctive clinical appearance.
Many a time it may not be possible to discriminate
between infected or non-infected corneas. To
minimize morbidity that may occur secondary
to delay in diagnosis and to achieve favorable
outcome within a reasonable cost and time,
laboratory investigations are indicated in patients
with suspected microbial keratitis.
Two entirely different protocols are required
to be followed while investigating viral and nonviral corneal ulcers, so determined on the basis
of clinical features. A combination of the two
protocols may be called for when a distinction
of viral versus non-viral is not obvious clinically.
In the interest of clarity, this chapter is divided
in two parts to describe microbiologic procedures
required for work-up of clinically non-viral and
viral corneal ulcers.
Familiarity of ophthalmologists to the functions, limitations, and scopes of microbiology
laboratory is important for proper and meaningful interpretation of results. A well equipped
ocular microbiology laboratory with well trained
technical personnel has great advantages over
a general microbiology laboratory, in handling
and processing minute quantity of ocular

samples, especially corneal samples. Special
orientation towards processing and interpretation of results is of paramount importance.1
Protocol for Non-viral

Keratitis: Bacterial, Fungal
and Acanthamoeba
Ideally, samples for the microbiologic
investigations of a suspected microbial keratitis
must be collected before the start of any antibiotic
treatment. Treatment can be initiated based on
the result of the smears and, if required, modified
in accordance with the culture and sensitivity
results. The protocol essentially consists of four
steps, viz: collecting, transport, and processing
of the clinical samples and interpretation of the
results.
Collection of Samples
Prior to the collection of sample from the corneal
ulcer itself, it is generally recommended to obtain
a culture from the lids and conjunctiva of both
the infected and the uninfected eye.2 This
procedure is supposed to help in two ways:
firstly, the organism(s) grown from the uninvolved
Diagnostic Procedures in Infectious Keratitis

eye (indicating normal flora) may be used for
comparative purposes, secondly, in the absence
of growth from the ulcer the organism(s) from
the cul-de-sac of the involved eye may well be
the causative organism(s).2 Despite recommendation for this procedure in several textbooks,
in our experience, samples from lids and conjunctiva have not yielded useful results in the
management of corneal ulcers.3 Similar observation has been made in the newer edition of
Laboratory diagnosis of ocular infections published
by the American Society of Microbiology,4 which
is a deviation from the earlier edition recommending collection and processing of samples from
the eyelid margins and conjunctiva. Samples
collected from the site of lesion, i.e. the infected
corneal tissue are the most valuable for
microbiological diagnosis of microbial keratitis.
If available, any foreign body on the cornea,
contact lens, contact lens case, or lens solutions
may be collected.
Corneal samples can be collected using the
slit-lamp or operating microscope after
instillation of topical anesthetic (4% Lignocaine
hydrochloride or 0.5% Proparacaine hydrochloride). These anesthetic agents may have
variable effect on the growth of organisms,5
however, allowing some time interval between
instillation of anesthetic agent and collection of
sample would help reduce their effect, if any.
Cotton swabs are not recommended for
collection of corneal samples, however, calcium
alginate swabs, if available, may be used in cases
of bacterial keratitis. 6 Platinum spatula,
disposable blade (#15), bent needle, surgical knife
and disposable cautery have all been used for
collection of corneal scrapings for microbiological
processing. We routinely use blade no. 15 on
Bard Parker handle. No difference was found
by us in the quantitative yield of organisms from
bacterial and mixed (fungal with bacterial)
keratitis while comparing the use of calcium
alginate swab with blade no. 15.7 Although the

yield of fungi was more with calcium alginate
swab than with blade in this study we did not
recommend replacing blade with swab. Swabs
are likely to get contaminated by normal flora
in the tear film and are less efficient in transferring
clinical material onto slides and culture media.
While collecting samples from the corneal ulcer
the eyelids must be held widely apart to reduce
inadvertent contamination by the lid margins
or eyelashes. Adherent exudate on the surface
of the ulcer may be removed using a sterile cotton
swab prior to collection of scrapings.
The blade or spatula is scraped over the
surface of the area of suppuration by a series
of short, moderately firm strokes in one direction
to sample both the central and peripheral margins
of the infiltrated area of the cornea. Each scraping
is used to inoculate one medium or to prepare
one smear. Viable organisms may be present
throughout the inflamed area or localized to the
advancing margin or the ulcer crater.
In the absence of accessible corneal
suppuration, a corneal biopsy can be done with
a disposable skin punch, diamond knife or small
corneal trephine.8 The tissue specimen is placed
in a sterile petri dish for sectioning. Additional
corneal scrapings can be obtained from the base
of a partial thickness corneal biopsy.
Collection of anterior chamber exudates is
advised only under exceptional circumstances
owing to risk of inoculating organisms into the
eye. The possible circumstances are deep stromal
suppuration that cannot be sampled by an
anterior approach and infections that have
extended into the anterior chamber.4
Transport of Corneal Samples to the

Microbiology Laboratory
Transportation of corneal scrapings in any
transport medium is not recommended. The
317
318

TABLE 19.1: SEQUENCE OF SMEAR PREPARATION
AND CULTURE MEDIA INOCULATION FOR THE
DIAGNOSIS OF NON-VIRAL KERATITIS
Smears
Media
Fig. 19.1: Corneal scraping collection tray containing culture

media, blades, glass slides marker pen, reagents and
coverslips
Optional
Smears/
media
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1.
2.
3.
4.
5.
scrapings are plated directly onto culture media

or smeared onto clean glass slides by the side
of the patient in the clinic or operating room.
It would help to maintain a corneal collection
kit in the clinic or operating room containing
a set of media, sterile slides (wrapped in foil),
spatula/blades, glass marking pencil and swabs
(Fig. 19.1) in case the microbiology laboratory
cannot be reached and requested to provide the
materials whenever required.
Corneal biopsy tissue can be transported
to the microbiology laboratory in a sterile dry
Petri dish or in a sterile bottle with sterile saline.
Aqueous fluid is usually collected and transported in a tuberculin syringe. Exudates from
the anterior chamber may also be directly plated
on culture media and smeared on slides.
Processing of Corneal Scrapings

A complete microbiological work-up of a nonviral corneal ulcer may require up to 10 corneal
scrapings for a number of smears and culture
media (Table 19.1). In case of small ulcer, with
limited material availability, high priority needs
to be given to inoculation of blood agar or
chocolate agar and to prepare only one or two
Potassium hydroxide and/or

Calcofluor white
Gram stain
Giemsa stain
Blood agaraerobic
Blood agaranaerobic
Chocolate agar
Brain heart infusion broth
Thioglycollate broth
Non-nutrient agar
Sabouraud dextrose agar
Potato dextrose agar
Lowenstein-Jensen medium
Brain heart infusion broth with
antibiotic
Additional non-nutrient agar
Extra smear on slide
smears. Preferred media may be selectively

included based on clinical impression, for
example, non-nutrient agar for a suspected
Acanthamoeba keratitis patient. A schematic
diagram to guide non-viral corneal ulcer workup is shown in Figure 19.2.
Direct Smear Examination Methods

Material is transferred from the blade/spatula
to a glass slide over an area of approximately
1 cm in diameter within a wax-pencil marked
(on the reverse) area to avoid needless searching
under the microscope. While the specimen is
thinly spread for dry smears (Gram, Giemsa,
GMS) it can be just placed within the circle for
wet smears (KOH, CFW, LPCB) under a coverslip. Table 17.2 outlines the various staining
procedures in brief.8 At least two smears should
be prepared. For several years, a combination
of KOH + CFW, Gram, and Giemsa-stained
smears has provided a high sensitivity and
specificity in our laboratory for the detection of
bacteria, fungi, and Acanthamoeba in corneal
scrapings. Common laboratory light microscope
Fig. 19.2: Schematic diagram for microbiology processing of non-viral keratitis
suffices in most instances for the examination

of the smears except when fluorescent stains
(calcofluor white or acridine orange) are used
which require a fluorescence microscope.
Culture Methods
Inoculation: Agar plates such as blood agar (BA),
chocolate agar (CA), are inoculated by lightly
streaking both sides of the blade/spatula over
a surface in a row of separate C-shaped marks
without penetrating the agar. This procedure
helps distinguish valid growth from plate
contaminants (Fig. 19.3). Slopes of Sabouraud
dextrose agar (SDA) or potato dextrose agar
(PDA) in bottles are similarly inoculated by
making a row of streaks from below upwards.
Liquid media such as brain heart infusion broth
Fig. 19.3: Blood agar inoculated with corneal scraping

and incubated at 35C for 48 hours showing confluent
gray, moist colonies (Pseudomonas aeruginosa) on the
inoculum (C streaks) and a contaminant colony away
from the inoculum
(BHI) is inoculated by agitating the blade/spatula

directly in the broth. To facilitate this procedure
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320

without inviting contamination, the BHI should
be available in screw-capped tubes with the top
level of the medium not below 1 cm from the
brim of the tube. The inoculation of thioglycollate
broth (thio) requires transfer of the scraped
material onto a cotton or calcium alginate swab
and insertion to the bottom of the tube to facilitate
growth of anaerobic bacteria. It is a good practice
to limit the inoculation of non-nutrient agar
(NNA) with 1-2 strokes in the center of the plate
with minimal disturbance of the surface of the
medium. While inoculating the plates/bottles,
care must be taken to minimize exposure of the
medium to the atmosphere.
Corneal biopsy tissue can be cut into small
fragments and inoculated into media or it can
be emulsified in sterile saline using tissue
homogenizer and then distributed in culture
media, preferably under a bio-safety laminar flow
hood.
Aqueous fluid drops can be placed over agar
plate surfaces as such without streaking and
dropped directly into liquid media, preferably
under a bio-safety laminar flow hood.
Incubation The inoculated culture media are
placed in appropriate incubators. NNA (after
sample inoculation) requires to be overlaid with
a few drops of heat killed or live E coli suspension
prior to incubation. While BA (aerobic), BHI broth,
thio broth, NNA, SDA and PDA are incubated
under normal atmospheric conditions, CA is
incubated in a candle jar which provides 5%
CO2, and another BA (anaerobic) is incubated
in anaerobic jar or cabinet, if available. All media
are incubated at 35C ( 1) except SDA and PDA
which are kept at 27C ( 1) in BOD incubator.
Petri dishes are incubated with lids facing
downwards to prevent condensed moisture from
dripping onto the medium. Broth tubes are held
upright in racks. Early growth may be detected
on culture plates in most instances within 2448 hours of incubation, however, media such
as BA (aerobic), CA, thio and BHI that show

no growth, should be incubated until at least
7 days before discarding. In case of no growth
BA (anaerobic), SDA, PDA and NNA may be
incubated until 2 weeks. Incubation beyond 2
weeks, in our experience, has not resulted in
increased positivity. Instead, incubation longer
than 2 weeks may lead to drying of media, and
growth of contaminants due to repeated opening
of plates for observation.
Observation: On solid agar plate growth on
inoculation marks (C streaks) are regarded
important while growth outside the inoculation
marks is disregarded as contaminants (Fig. 19.3).
All culture media [except BA (anaerobic) in a
jar/cabinet] must be examined daily for detection
of any growth. BA (anaerobic) may be examined
at intervals of 2-3 days for 2 weeks.
Size, color, texture, consistency, and number
of colonies on the inoculation marks are counted
and recorded. An arbitrary semiquantitative
growth estimation graded in our laboratory is
+ (10 colonies), ++ (10-50 colonies), and +++
(50 colonies). While bacterial and fungal colonies
are examined with unaided eyes, the observation
of Acanthamoeba growth requires use of
microscope. NNA plates (with lid on) are placed
under X4 or X10 objective lens of the microscope
and presence of trophozoites is looked for in
the vicinity of the inoculation mark on the surface
of the medium. No colonies are formed by
Acanthamoeba.
Growth in liquid media appears as turbidity
which requires to be subcultured and Gramstained for identification.
Identification: Microbiological identification
details of various organisms that may be isolated
from cases of non-viral keratitis are neither the
intent nor the scope of this chapter. Bacterial
colonies are usually Gram-stained and identified
after consideration of colony characteristics,
Gram-reaction, morphology, and results of

biochemical tests. Conventional procedures may
be adopted for biochemical tests or commercial
kits from a number of companies (bioMerieux,
France, Lachema, Czech Republic; Organon
Technika, USA)9 may be obtained. Some of these
companies have recently launched their products
in India.
Identification of fungal species requires
observation of rate of growth, color, consistency
and texture of the colony and characteristic
microscopic features. Though most species are
identified easily more than 20% of filamentous
fungal isolates may remain unidentified because
of the lack of characteristic spores. Biochemical
tests for identification are needed only in case
of yeast or yeast-like fungal growth. Helpful hints
for identification are available.10
Presence of characteristic cysts and trophozoites on the surface of NNA (Fig. 19.4) helps
to identify Acanthamoeba genus. Specification of
this genus is presently controversial11 and has
no place in the realm of a clinical ocular
microbiology laboratory.
Fig. 19.4: Acanthamoeba trophozoites (irregular,

vacuolated) on the surface of NNA with E. coli (original
magnification 500)
Antimicrobial Susceptibility Testing

Antimicrobial susceptibility testing is done in
vitro to identify the response of an organism to
a panel of selected drugs. Commercially available
panels for Gram-positive and Gram-negative
Fig. 19.5: Antibiotic susceptibility test for Pseudomonas

aeruginosa isolated from corneal ulcer. The diameter of
zone of inhibition around antibiotic discs is measured and
reported as sensitive, intermediate, or resistant (Disk
diffusion test)
bacteria are used to determine sensitivity by diskdiffusion method. In this method (Kirby-Bauer)
the bacteria is cultured on Mueller-Hinton agar,
and antibiotic impregnated disks are applied.
After incubation, the diameter of the zone of inhibition around each disk gives an approximation
of susceptibility or resistance of the organism
(Fig. 19.5). Commercially available kits provide
a zone size interpretative chart to facilitate
interpretation. Slow-growing bacteria and
anaerobes cannot be reliably tested with diskdiffusion method. Estimating the minimal
inhibitory concentrations (MIC) of antibiotics may
provide a more useful information than labeling
organisms as sensitive or resistant,4 especially
because the results of disk-diffusion tests relate
to levels of drug achievable in serum and do
not relate directly to concentration of drug
produced in the preocular tear film and ocular
tissues by standard routes of administration.
The MIC of a drug can be tested by broth
dilution or agar dilution method. The antibiotic
is serially diluted and added to tubes with broth
or wells of a microtiter plate or incorporated into
agar plates. A standard suspension of the
organism is then inoculated. The MIC is recorded
as the lowest concentration with no visible
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322

growth. The tubes or wells with inhibited growth
can be subcultured and the lowest concentration
with no growth is recorded as minimum
bactericidal concentration.
The availability of antifungal and antiamoebic susceptibility testing is limited. In vitro
test methods are diverse for fungi 12 and
Acanthamoeba13 and clinically predictive value of
the results obtained is not known.
Immunological and Molecular Methods

Immunology and molecular biology based
diagnostic tests that are applicable to eye
infections including keratitis have been described
in the literature.14,15 Such methods are most useful
for the identification and characterization
of microorganisms for which culture methods
are difficult, time consuming or unavailable.
Macroscopic latex and co-agglutination methods
may be applicable for certain bacterial and fungal
eye infections.16
Diagnostic molecular microbiology is an
emerging field that applies the principles of
nucleic acid hybridization and nucleic acid
amplification, notably polymerase chain reaction
(PCR), to the detection and characterization of
pathogenic microorganisms. There is an
explosive growth in the number and variety of
applications of PCR in microbiology and ocular
microbiology is no exception. PCR based
diagnosis of fungal keratitis17 and Acanthamoeba
keratitis18,19 have been published recently.
Interpretation of Microbiology Results

Smears
Commonly used stains for evaluation of smears
and the organismal identification are listed in
Table 19.2. Results of smear examination form
the basis for provisional diagnosis and initial
choice of an antimicrobial agent.
Figs 19.6A and B: Corneal scrapings stained with

KOH + CFW showing A Septate fungal filaments, and
B Acanthamoeba cysts under fluorescence microscope
(original magnification 500)
Though reported to be useful in the detection

of bacteria in corneal scrapings,20 we do not have
much experience with acridine orange. However,
we have used calcofluor white (CFW) for several
years and find the stain very useful in the
detection of fungi and Acanthamoeba in corneal
scrapings (Figs 19.6A and B). The Gram-stain
is useful in identifying bacteria, fungi, as well
as Acanthamoeba cysts (Figs 19.7A to D).
Precipitated stain, carbon, salt crystals, and
necrotic debris can lead to troublesome artefacts
in Gram-stained smears. It is easier to detect
Gram-positive bacteria (especially S. pneumoniae)
than Gram-negative bacteria. Gram-variable
bacteria may sometimes be seen.21 Fungal hyphae
and Acanthamoeba cysts stain variably since their
cell walls do not stain well and may often be

TABLE 19.2: COMMON STAINING PROCEDURES FOR CORNEAL SCRAPINGS IN
THE DIAGNOSIS OF NON-VIRAL KERATITIS
Stain
Steps
Gram stain
1.
2.
3.
4.
5.
6.
7.
8.
9.
Fix smear in 95% methanol

Flood smear with crystal violet for 1 minute
Rinse with tap water
Flood smear with Grams iodine solution for 1 minute
Decolorise with acetone-alcohol solution
Flood with safranin or dilute Carbol Fuchsin for 30 seconds
Rinse with tap water and allow to dry
Giemsa stain
(quick)
1.
2.
3.
4.
Fix smear in fixative for 5 (Diff Quik)TM seconds

Dip in reagent A for 5 seconds
Dip in reagent B for 5 seconds
Rinse with water and allow to dry
Giemsa stain
1. Flood with Giemsa solution for 45-60 minutes

2. Rinse in 95% ethanol
Potassium
hydroxide
(KOH) preparation
1. Add one drop of 10% KOH with 10% glycerol

2. Place a coverslip
3. Apply nail polish around the coverslip edges to prevent drying
KOH+
Calcofluor white
1.
2.
3.
4.
Add one drop of 10% KOH

Add one drop of 0.1% calcofluor white with 0.1% Evans blue solution
Place a coverslip
Examine under UV light
Ziehl-Neelsen
acid fast
1.
2.
3.
4.
5.
6.
Flood fixed smear with hot (steaming) strong carbol fuchsin and leave for 5 minutes
Rinse with water
Decolorize with 20% H2SO4 for 1-2 minutes
Rinse with water
Flood with methylene blue counter stain for 2 minutes
Kinyouns
modification
of Acid fast
stain
1.
2.
3.
4.
5.
6.
Flood fixed smear with strong carbol fuchsin for 2 minutes

Rinse with water
Decolorize with 1% H 2SO4
Rinse with water
Flood with methylene blue counter stain for 2 minutes
LactophenolCotton blue
1. Mix specimen colony in a drop of LPCB

2. Apply coverslip
3. Apply nail polish around edges of coverslip to prevent drying
Acridine orange
1. Mix specimen in 0.01% of acridine orange

2. Apply coverslip
3. Examine under UV light
seen as negative outlines (Fig. 19.7). Trophozoites

of Acanthamoeba are difficult to recognize owing
to their irregular morphology and similarity to
macrophages.22 Giemsa-stained smear serves as
a supportive smear. Cytological details are seen
well and bacteria, fungi as well as Acanthamoeba
cysts can be seen.
Arbitrary quantification of bacteria per high

power field may help determine the significance
as bacteria comprising the indigenous microflora
of the conjunctiva and tear film may be detected
in small numbers. Smears with more than ten
organisms are more determine. However,
detection of bacteria in smears often needs to
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324
Fig. 19.7D: Corneal scrapings stained with Gram stain

showing Acanthamoeba cysts (original magnification 500)
Presence of partially stained or unstained

bacilli in Gram or Giemsa-stained smears has
often indicated possibility of atypical mycobacteria (Fig. 19.8) and successful diagnosis of the
same.23 Thin, branching and beaded filaments
in these smears are indicative of Nocardia sp.
To confirm the diagnosis, acid fast stains using
20% H2SO4 (Ziehl-Neelsen technique) in the
former and 1% H2SO4 (Kinyoun method) in the
latter (Fig. 19.9) are very rewarding.
Cultures
While smear examination provides preliminary
evidence, culture isolation gives diagnostic
Figs 19.7A to C: Corneal scrapings stained with Gram

stain showing A Gram-positive cocci in pairs, B Gramnegative bacilli (arrow), C Septate fungal filaments
be correlated with corresponding bacterial

growth in culture for determining significance.
Failure of an organism, seen in smears, to grow
in culture would indicate either non-viable
organism or sample variation. Sampling error
must always be ruled out in case of discrepant
results.
Fig. 19.8: Corneal scraping from a case of Mycobacterium

chelonae keratitis (post-LASIK surgery) showing acid fast
bacilli by Ziehl-Neelsen staining (20%H2SO4) (original
magnification 500)

medium of the same organism identified in
smears, confluent growth at the inoculation site
on at least one solid medium, or repeat isolation
from the same patient. These criteria are more
applicable to bacteria and fungus than
Acanthamoeba as it is neither a normal commensal
nor a laboratory contaminant.
Antibiotic Susceptibility
Figs 17.9A and B: Corneal scraping from a case of

Nocardia keratitis showing A Gram-positive, thin, beaded,
branching filaments in Gram stained smear, and B Acid
fast, thin, beaded, branching filaments in the same smear
stained by Kinyoun method (1% H2SO4) after decolorization (original magnification 500)
Interpretation of agar disk diffusion test (for

bacterial susceptibility) that relates to levels of
drug in serum is often controversial. However,
since higher antibiotic concentrations can be
achieved in the cornea by topical administration
of antibiotics, an organism labeled as resistant
or intermediate in sensitivity by this test may
respond to the drug in vivo. The reverse is unlikely
to be the case.
The quantitative MIC can be compared to the
antibiotic concentration expected at the site of
infection. However, resistance breakpoints for
ocular isolates have not been determined and
there are no generally accepted cut off points.
Polymerase Chain Reaction (PCR)

confirmation. Culture report should indicate the
day the growth appeared and its quantification
or significance. Less than 10 colonies on only
one solid medium or growth in only one liquid
medium is usually equivocal. Growth of
organisms such as S. epidermidis, Corynebacterium
sp. and Propionibacterium sp. in small numbers
or in a single liquid medium is generally of
uncertain significance. The same organisms,
however, may be significant in the presence of
a strong predisposing factor in the patient. All
isolates must be considered in the light of clinical
relevance and laboratory significance. Laboratory
criteria for definitive infection include growth
on two or more media, growth on at least one
The results of PCR on corneal scrapings are

usually as good as the choice of primers
(oligonucleotide sequence for a particular gene
of a particular organism) and the stringent
performance of the test. It is a highly sensitive
test but instances of false positives can be high
if PCR test is not handled carefully. Any
laboratory that undertakes molecular diagnostics
must comply with all requirements to contain
contamination, use appropriate controls and
provide reliable results. The PCR results are
best viewed in conjunction with the clinical
impression and, if possible, with another
supporting laboratory evidence towards the
diagnosis.
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326
Protocol for Viral Keratitis
Transport of Samples
The advancement made in the field of laboratory

techniques for the diagnosis of viral infections
in the past decade has been enormous with the
introduction of newer techniques and improvisation of earlier techniques. These techniques
have been extensively employed for the diagnosis
of viral keratitis, especially in developed countries.
However, owing to the cost constraints, the
techniques are yet to become a routine in most
laboratories in India, including large university
laboratories. Several factors may need to be
considered before a laboratory chooses to adopt
techniques for the diagnosis of viral keratitis or
in fact any viral disease. These factors include
information regarding the prevalence of a
particular viral infection, need of screening for
the same in a given population, cost of the
technique, availability of the infrastructure, and
whether a rapid diagnosis can be provided. An
ideal technique should be cost-effective, provide
a rapid diagnosis in a reasonable frame of time,
easy to perform and interpret, and adaptable in
routine microbiology laboratories.
As pertinent in non-viral keratitis, the
collection, transport, and processing of corneal
samples for the diagnosis of viral keratitis have
a distinct protocol which may be combined with
the former in case of clinical uncertainty.
Unlike the banishment for transport of corneal

scrapings (in a transport medium to the
laboratory) in the protocol for non-viral corneal
ulcer diagnosis, the sample for viral diagnosis
always needs to be collected in an appropriate
transport medium (except the smears) and sent
to the laboratory. Methods of transport would
vary according to the type of sample collected.
Table 19.3 outlines the methods of transportation
of samples to the virology laboratory.
Collection of Samples
A variety of samples including corneal scrapings,
corneal swabs, corneal impression smear, and
corneal button may be submitted for viral
diagnosis. In addition or instead of corneal
samples, conjunctival scrapings/swabs or
aqueous fluid may also be helpful in some
situations. As is true for most diseases, collection
of clinical sample early in the disease prior to
administration of antimicrobial agents, is most
useful for laboratory diagnosis.
Processing of Samples
Samples received in a virology laboratory may
be processed using a variety of techniques. The
choice of technique would depend on the type
of sample and the specific virus that is being
looked for. Most of the procedures can be
performed in a moderately equipped laboratory.
The procedures standardized and adopted by
us for the diagnosis of Herpes simplex virus
(HSV) keratitis are outlined in Table 19.4. Of all
available laboratory techniques for diagnosis of
viral infections only a few can be adopted in
a particular laboratory. The choice is made based
on the advantages, disadvantages and cost
effectiveness of the techniques and their overall
utility.
Direct Smear Examination (Cytology)

A rapid diagnosis of viral keratitis can be
established by observing stained smears of
corneal scrapings, conjunctival scrapings/
swabs, or centrifuged deposits of aqueous fluid
(cytospin).24 These may be accomplished using
non-specific staining techniques such as Giemsa,
Papanicolaou, and Hematoxylin-Eosin stain.
These techniques help visualize multinucleated
giant cells, koilocytic changes (Fig. 19.10A), and
intranuclear/intracytoplasmic inclusions (Fig.
19.10B), and various inflammatory cells which

TABLE 19.3: METHODS OF TRANSPORTATION OF SPECIMEN TO THE VIROLOGY LABORATORY
FOR INVESTIGATION OF VIRAL KERATITIS
Corneal scrapings
1. Smear on glass slide, air dry and send for staining/immunofluorescence (IF)/immunoperoxidase (IP)
2. Transfer in a vial (0.5 to 1 ml) of viral transport medium (VTM) and send for culture. Can be stored at
4C. Do not freeze
3. Transfer on a cellulose acetate membrane, air dry, fix in acetone/methanol and send for staining/IF/IP
4. Transfer in 1 ml of phosphate buffered saline/minimum essential medium/Hanks balanced salt solution and
send for PCR
Corneal impression smear on glass slide or cellulose acetate membrane
Air dry, fix in acetone/methanol/15 minutes and send for staining/IF/IP
Corneal/conjunctival swab
1. Use cotton swab to collect material and transfer in VTM and send for culture. Can be stored at 4C. Do
not freeze
2. Dry swab and calcium alginate swabs are unacceptable
Corneal button
1. Place in VTM and send for culture
2. Place in 10% buffered formalin and send for histopathology
3. Place in phosphate buffered saline/minimum essential medium/Hanks balanced salt solution and send for PCR
Aqueous humor
1. Place few drops in VTM and send for culture
2. Place in sterile tube/eppendorf and send for PCR or staining/IF/IP
are predominantly lymphocytes. Koilocytic

changes are characteristic perinuclear clearing
(halo) with increase in density of surrounding
rim of cytoplasm, classically described in human
papilloma virus infected squamous epithelial
cells of the cervix. Intranuclear inclusions are
more efficiently seen in Papanicolaou stain than
Giemsa-stained smears, however, Giemsa stain
is good for enumerating cell types. Though these
staining techniques have the advantage of being
rapid and inexpensive, they are often non-specific
and offer low sensitivity in the diagnosis of viral
infection. For example, these stains cannot
TABLE 19.4: METHODS FOR LABORATORY
DIAGNOSIS OF VIRAL KERATITIS FOLLOWED AT
LV PRASAD EYE INSTITUTE
1. Non-specific smear examination (cytology) methods:
Papanicolaou stain
Giemsa stain
2. Cell-associated antigen detection methods
Direct/indirect immunofluorescence assay (IF)
Indirect immunoperoxidase assay (IP)
3. Virus isolation (tissue culture) methods
Conventional tissue culture
Shell-vial technique
4. Molecular virology method
Polymerase chain reaction
Figs 17.10A and B: Corneal scrapings from a case of

HSV keratitis showing. A Multinucleated giant cell (arrow)
and koilocytic changes (arrowhead), and B Intranuclear
inclusion, in an epithelial cell (Papanicolaou stain, original
magnification 500)
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328

differentiate the intranuclear inclusions of HSV
from that of Varicella zoster virus (VZV).
Specific cytology techniques used for viral
diagnosis are techniques that indirectly suggest
the presence of viral antigen in the clinical
sample. Detection of cell associated viral antigen
in a corneal scraping or conjunctival scraping
is very useful in the diagnosis of viral keratitis.
We have been routinely using direct and indirect
immunofluorescence (Fig. 19.11), and indirect
immunoperoxidase (Fig. 19.12) assays in the
diagnosis of HSV, VZV keratitis and adenoviral
keratoconjunctivitis. Both these tests are rapid,
Fig. 19.11: Corneal scraping from a case of HSV keratitis

showing presence of HSV-1 antigen in the epithelial cells
(indirect immunofluorescence assay, original magnification
250)
specific and sensitive when suitable monoclonal

or purified polyclonal antibodies are used in the
test system. Relatively higher sensitivity and
lower specificity is achieved with purified
polyclonal antibodies tests while monoclonal
antibodies show high specificity but low
sensitivity. Indirect immunoperoxidase (IP) assay
has distinct advantages over indirect immunofluorescence (IF) assay. The former provides a
permanent preparation for records and utilizes
an ordinary light microscope while the latter has
the inherent problem of quenching (fading) of
fluorescence and requires a sophisticated and
expensive fluorescence microscope. In addition,
the IP technique can be used on paraffin
embedded tissue while the IF technique provides
better results with frozen tissue sections.
Detection of soluble viral antigens in corneal
scrapings collected in buffer and body fluids
including tears, aqueous, and vitreous, have been
described using enzyme-linked immunosorbent
assay (ELISA),25latex agglutination,26 and radio
immunoassay (RIA). Results obtained by ELISA
and RIA are more objective compared to IF and
IP assays (which tend to be subjective), however,
we do not have experience using these techniques
for the diagnosis of viral keratitis. Some of the
rapid methods of antigen detection in viral
keratitis are described in Table 19.5.
Tissue Culture Methods
Fig. 19.12: Corneal scraping from the same patient of

HSV keratitis (Fig. 19.11) showing presence of HSV-1
antigen (stained brown) in epithelial cells (indirect
immunoperoxidase assay, original magnification 500)
Classically described techniques of virus

isolation have been embryonated eggs and
animal inoculation, which are not favored by
most virology laboratories for routine diagnostic
purposes. A much favored technique is that of
tissue culture, especially cell cultures. Established
cell lines such as HeLa, Vero, HEp 2 and MRC5 have been used for isolation of HSV from corneal
scrapings.27We have recently succeeded in using
immortalized human corneal epithelial cell line28
for isolation of HSV.

TABLE 19.5: RAPID DIAGNOSTIC TESTS FOR VIRAL KERATITIS
Type of test
Less than 1 hour
1. Giemsa stain (Diff Quik) TM
2. Papanicolaou stain
3. HSV test kit
(Sure cell herpes)(R)
4. Latex agglutination
(Virogen)(R)
Between 1-6 hours
1. Immunofluorescence
2. Immunoperoxidase
3. HSV antigen detection (Herp check)(R)
4. ELISA
Time
Viruses detected
5 minutes
45 minutes
20 minutes
HSV 1 & 2, VZV, Adenovirus

HSV 1 & 2
35 minutes
HSV 1 & 2
2-3 hours
4-5 hours
5 hours
3-4 hours

HSV-1
HSV 1 & 2
Growth of virus in the cell lines can be

determined either by characteristic cellular
changes or cytopathic effect (CPE) as shown in
Figure 19.13 or by IF or IP technique, which detect
viral antigens in the infected cell lines.
Appearance of CPE may take several days but
antigens can be detected even before CPE occurs,
therefore, IF or IP is a more rapid method. Viruses
may be cultured in cell lines maintained in tubes
(tube culture) or on cover-slips in vials (shell
vial) as shown in Figure 19.14. Shell vial technique
is a modification of conventional tissue culture
technique wherein entry of virus into the
monolayer of susceptible cells (on a cover-slip
in a vial) is facilitated by centrifugation of the
Fig. 19.13: Monolayer of vero cell line showing cytopathic

effect caused by HSV-1 indicating growth of the virus
in the cells (tube culture, phase contrast, original
magnification 200)
vial containing cells and the clinical sample (spin

amplification).29 The virus growth occurs in a
shorter period (18-72 hours) by this method and
additionally, both IF and IP techniques can be
performed easily on the cover-slips retrieved from
the vials for antigen detection. Both these factors
are responsible for increased sensitivity of shell
vial technique in isolation of viruses.
Molecular Virology Methods

In recent times, the PCR technique has been
employed extensively for the detection of viral
DNA in clinical samples which is one of the
best indications for diagnostic use of this
technique.30 By virtue of being extremely sensitive
and specific, and at the same time simple and
rapid, PCR is presently the most sought after
technique for viral diagnosis. In our experience,
combination of cytology coupled with antigen
detection by IF or IP technique and viral DNA
detection by PCR may obviate the role of
cumbersome procedures of viral isolation by
tissue culture, in the diagnosis of viral keratitis.
By cost considerations, setting up and running
a molecular virology laboratory may be less
expensive than tissue culture laboratory.
Diagnosis of atypical herpetic epithelial keratitis
using primers for 142 base pair segment of the
DNA polymerase gene of the HSV genome by
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330

herpetic keratitis diagnosis has also been
described.35
Proper safe guard against false positives in
PCR based test is a great challenge to a molecular
virology laboratory. Top of the line quality control,
appropriate controls and good laboratory
practices are mandatory to obtain reliable
laboratory reports.
Interpretation of Virology Results

Our laboratory routinely performs a variety of
techniques for the laboratory diagnosis of viral
keratitis which includes cytology by Papanicolaou and Giemsa stain, antigen detection by
IF/IP technique, culture by shell vial technique
and PCR (Fig. 19.15). In an analysis of 70
clinically suspected cases of HSV keratitis whose
corneal scrapings were tested by PCR, shell vial
culture, antigen detection by IF/IP, and cytology
by Papanicolaou stain, the sensitivity of the tests
was 55.8%, 28.3%, 22.7% and 15.6%, respectively
(unpublished data). A laboratory diagnosis of
HSV keratitis was offered when HSV-1 antigen
was detected and/or HSV-1 was isolated and/
or HSV DNA was detected by PCR with or
Figs 19.14 A to C: Virus cultures using cell lines. A Tube

culture, B Shell vial culture, C Containing cover-slip
PCR has been reported.31,32 A variety of primers

for PCR diagnosis of HSV type 1 and 2 and VZV
infections of the eye (other than keratitis) has
been described and can be adapted for the
diagnosis of keratitis.33,34 A nested PCR for stromal
Fig. 19.15: Detection of HSV 1 and 2 by PCR in a corneal

scraping from a case of HSV keratitis. Agarose gel
electrophoresis (Ethidium bromide stained) showing positive
control (lane 1), negative control (lane 2), test sample
(lane 3), and molecular weight marker (lane 4). Note the
band of 179 bp size (DNA polymerase gene specific)
in lane 3 corresponding to positive control

without cellular changes in Papanicolaou
stained smear. PCR results were interpreted with
caution when this test alone was positive. It was
always correlated with clinical findings and with
the results of other tests. False positives were
avoided by using a different primer set and
adopting a reduced sensitivity PCR.36
It is evident from our observations that
adopting a single technique alone may result
in under diagnosis. Papanicolaou stain, though
less sensitive than others, is a valuable test.
Presence of multinucleated giant cells,
intranuclear inclusions, and koilocytic changes
are indicative of HSV/VZV infection. Initiation
of antiviral therapy is indicated based on these
smear findings coupled with positive antigen
detection by IF or IP assays. Both IF and IP assays
detect viral proteins in the absence of viable
virions when cultures would be negative. We
have often been more successful in detecting the
viral antigen than isolating the virus. It is,
therefore, recommended that antigen detection
assays and Papanicolaou staining should be
done in the laboratory diagnosis of viral keratitis
where facilities for culture and PCR are not
available.
References
1. Agarwal V, Biswas J, Madhavan HN, et al.
Current perspectives in infectious keratitis. Ind
J Ophthalmol 1994;42:171-92.
2. Burd EM. Bacterial keratitis and conjunctivitis.
In: Smolin G, Thoft RA (Eds). The Cornea:
Scientific Foundations and Clinical Practice.
Boston: Little Brown and Co, 1994.
3. Sharma S, Sankaridurg PR, Ramachandran L, et
al. Is the conjunctival flora a reflection of the
pathogenic bacteria causing corneal ulceration?
Invest Ophthalmol Vis Sci 1994;35(Suppl): S1947.
4. Wilhelmus KR, Liesegang TJ, Osato MS, et al.
Cumitech 13A, Laboratory Diagnosis of
Ocular Infections. Coordinating (Ed). Specter
SC, American Society for Microbiology,
Washington, DC 15, 1994.
5. Badenoch PR, Coster DJ. Antimicrobial activity

of topical anaesthetic preparations. Br J
Ophthalmol 1982;66:364-67.
6. Benson WH, Lanier JD. Comparison of
techniques for culturing corneal ulcers.
7. Jacob P, Gopinathan U, Sharma S et al. Calcium
alginate swab versus Bard Parker blade in the
diagnosis of microbial keratitis. Cornea 1995;14:
360-64.
8. Sharma S. Diagnostic methods in ocular
microbiology. In: Modern Ophthalmology.
Datta, LC, (Ed). 2nd ed. New Delhi: Jaypee
Brothers Medical Publishers 1999;216-24.
9. Murray PR, Baron EJ, Pfaller MA et al. Manual
of Clinical Microbiology. 6th ed. American
Society of Microbiology, Washington DC, 1995.
10. Larone DH. Medically Important Fungi: A Guide
to Identification (3rd edn). Washington DC: ASM
Press, 1995.
11. Gast RJ, Ledee DR, Fuerst PA et al. Subgenus
systematics of Acanthamoeba: Four nuclear 18S
rDNA sequence types. J Euk Microbiol 1996;43: 498504.
12. Thomas PA. Mycotic keratitis: An underestimated
mycosis. J Medical Veter Mycology 1994;32:
235-56.
13. Saunders PPR, Proctor EM, Rollins DF et al.
Enhanced killing of Acanthamoeba cysts in vitro
using Dimethylsulfoxide. Ophthalmology
1992;99:1197-2000.
14. Rao NA. A laboratory approach to rapid
diagnosis of ocular infections and prospects for
the future. Am J Ophthalmol 107: 283-91,1989.
15. Gordon YJ. Rapid diagnostic tests for infectious
ocular disease. Int Ophthalmol Clin 1993;33:15361.
16. Sobol WM, Gomez JT, Osato MS et al. Rapid
streptococcal antigen detection in experimental
keratitis. Am J Ophthalmol 1989;107:60-64.
17. Alexandrakis G, Gloor P. Diagnosis of Fusarium
keratitis in an animal model using the
polymerase chain reaction (abstract). Invest
Ophthalmol Vis Sci 1994;35:S1676.
18. Mathers WD, Nelson SE, Lane JL et al. Confirmation of confocal microscopy diagnosis of
Acanthamoeba keratitis using polymerase chain
reaction analysis. Arch Ophthalmol 2000;118: 17883.
19. Lehmann OJ, Green SM, Morlet N, et al.
Polymerase chain reaction analysis of
331
332
20.
21.
22.
23.
24.
25.
26.
27.
28.
Acanthamoeba. Invest Ophthalmol Vis Sci 1998;39:

1261-65.
Groden LR, Rodnite J, Brinser JH et al. Acridine
orange and Gram stains in infectious keratitis.
Cornea 1990;9:122-24.
Choudhury K, Sharma S, Garg P et al. Clinical
and Microbiological profile of Bacillus keratitis.
Cornea 2000;19:301-06.
Sharma S, Srinivasan M, George G: Acanthamoeba
keratitis in non-contact lens wearers. Arch
Ophthalmol 1990;108:676-78.
Garg P, Bansal AK, Sharma S et al. Bilateral
infectious keratitis following laser in situ
keratomileusis: A case report and review of
the literature. Ophthalmology, 2000.
Jack I, Marmion BP: Direct virus diagnosis. In:
Collee JG, Duguid JP, Fraser AG, Marmion BP
(Eds). Mackie, McCartney Practical Medical
Microbiology (13th ed). Edinburgh, Churchill
Livingstone,1989.
Kowalski RP, Gordon YJ, Romanowski EG et
al. A comparison of enzyme immune assay and
polymerase chain reaction with the clinical
examination for diagnosing ocular herpetic
disease. Ophthalmology 1993;100:530-33.
Kowalski RP, Gordon YJ. Evaluation of immunologic tests for the detection of ocular herpes
simplex virus. Ophthalmology 1989;96:1583-86.
Simon MW, Miller D, Pflugfelder SC et al.
Comparison of immunocytology to tissue
culture for diagnosis of presumed herpes virus
dendritic epithelial keratitis. Ophthalmology
1992;99:1408-13.
Sasaki KA, Ohashi Y, Sasabe T et al. An SV40immortalized human corneal epithelial cell line
and its characterization. Invest Ophthalmol Vis
Sci 1995;36:614-21.
29. Johnson FB, Luker G, Chow C. Comparison

of shell vial culture and the suspension-infection
method for the rapid detection of herpes simplex
viruses. Diagn Microbiol Infect Dis 1993;16:6166.
30. Podzorski RP, Persing DH. Molecular detection
and identification of microorganisms. In Murray
et al (Eds). Manual of Clinical Microbiology (6th
ed). American Society of Microbiology,
Washington DC, 1995.
31. Tei M, Nishida K, Kinoshita S. Polymerase chain
reaction detection of herpes simplex virus in
tear fluid from atypical herpetic epithelial keratitis
after penetrating keratoplasty. Am J Ophthalmol
1996;122:732-35.
32. Koizumi N, Nishida K, Adachi W et al. Detection
of herpes simplex virus DNA in atypical epithelial
keratitis using polymerase chain reaction. Br
J Ophthalmol 1999;83:957-60.
33. Yamamoto S, Langston DP, Kinoshita S et al.
Detecting herpes virus DNA in uveitis using
polymerase chain reaction. Br J Ophthalmol
1996;80:465-68.
34. Cunningham ET, Short GA, Irvine AR et al.
Acquired immunodeficiency syndrome
associated herpes simplex virus retinitis. Arch
Ophthalmol 1996;114:834-40.
35. Kudo E, Shiota H, Kinouchi Y et al. Detection
of herpes simplex virus DNA in tear fluid of
stromal herpetic keratitis patients by nested
polymerase chain reaction. Jpn J Ophthalmology
1996;40:390-96.
36. Yamamoto S, Shimomura Y, Kinoshita S et al.
Detection of herpes simplex virus DNA in
human tear film by the polymerase chain
reaction. Am J Ophthalmol 1994;118:160-63.
Diagnostic Procedures in Uveitis
JYOTIRMAY BISWAS, SURBHIT CHAUDHARY, S SUDHARSHAN, SHAHNAWAZ KAZI
20
Diagnostic
Procedures in
Uveitis
In recent years, there have been remarkable

advances in the diagnosis and management of
uveitis/intraocular inflammation. The advances
are in part, from the progress noted in the arena
of ocular immunology, immunopharmacology,
vitreoretinal surgical techniques and laboratory
investigations. This chapter on diagnostic
procedures in uveitis provides an overview of
the advances in the field of clinical and laboratory
diagnosis of uveitis, indications and surgical
techniques of chorioretinal biopsy.
and erythrocyte sedimentation rate (ESR) can

give initial clues to the systemic association of
the uveitic disease and also provide a base-line
to therapeutic response and drug side effects.
ESR may be raised in non-infectious uveitic
diseases such as connective tissue disorders and
sarcoidosis and also in infectious conditions
such as tuberculosis and syphilis and is, therefore,
included in routine investigations of uveitis.
Clinical and Laboratory

Diagnosis of Uveitis
Rheumatoid Factor
Fifty percent of cases of uveitis are considered

idiopathic. Many others are associated with, or
form a part of, other systemic immune-mediated
disease. Diagnostic laboratory based immunological tests often provide not only the differential
diagnosis of uveitis but also aid in the management of these patients. Moreover, in combination
with other serologic, laboratory-based investigations, these assays assist in defining a noninfectious entity.
Basic Investigations
Total and differential white blood cell counts
Serological Tests
Rheumatoid factor per se is not associated with
uveitis and can be ordered in cases of
sclerouveitis. Rheumatoid factor is negative in
cases of juvenile rheumatoid arthritis (JRA) and
ankylosing spondylitis (AS).
Antinuclear Antibody
Antinuclear antibody (ANA) is elevated in a
number of diseases such as: AS, JRA, dermatomyositis, systemic lupus erythematosus (SLE),
scleroderma, Sjogrens syndrome, chronic
hepatitis, apical pneumonia and lymphoma.
ANA testing, therefore, gathers more
relevance when limited to patients with a
333
334

reasonable likelihood of disease, where a positive
result is more likely to be true positive. Obtaining
diagnostic titres adds to the significance of the
test.
Antineutrophil Cytoplasmic Antibody Test

Antineutrophil cytoplasmic antibody (ANCA)
test is positive in Wegeners granulomatosis,
Churg-Strauss syndrome, microscopic polyangitis and polyarteritis nodosa. Two distinct subtypes are noticedperinuclear ANCA (pANCA)
and cytoplasmic ANCA (cANCA). The sensitivity of cANCA is as high as 85-96% in patients
with widespread Wegeners granulomatosis, but
sensitivity falls to 80% in patients with limited
disease. There are a number of conditions where
a false-positive cANCA is demonstrated. These
include: atrial myxomas, human immunodeficiency virus (HIV) infection, bronchial carcinoma, non-Hodgkins lymphoma, endocarditis,
eosinophilic myalgia syndrome and mycobacteriosis.
Scleritis is more common with Wegeners
granulomatosis than anterior uveitis. Therefore,
ANCA is not routinely done in uveitis and should
be done in selected cases like uveitis with scleritis
or peripheral ulcerative keratitis.
Angiotensin Converting Enzyme

Many cells in the body including normal capillary
endothelial cells and monocytes, particularly
macrophages, produce angiotensin converting
enzyme (ACE). Normal levels in males are 1255 mole/min/ml and in women 11-29 mole/
min/ml. The levels are elevated in active systemic
sarcoidosis and reduced with oral steroid intake.
However, serum ACE is not specific for
sarcoidosis and is also elevated in leprosy,
tuberculosis and histoplasmosis. As patients
with ocular sarcoidosis are usually in systemic
remission, a normal serum ACE level does not
rule out sarcoidosis.1
In combination with gallium scan and a

roentgenogram of the chest, serum ACE has
acquired more significance in the diagnosis of
sarcoid uveitis.2 In one of the studies the aqueous
ACE levels were found to be more specific than
the serum ACE values.3
Serological Tests for Syphilis

Fluorescent Treponemal Antibody
Absorption Test
Fluorescent treponemal antibody absorption
(FTA-AbS) test is positive in all cases of syphilis,
a negative test rules out syphilis. Once the patient
has had syphilis, he remains positive throughout
life.
Venereal Disease Research

Laboratory Test
Venereal disease research laboratory (VDRL)
test measures non-specific reaginic antibody.
The test is negative in many cases of tertiary
syphilis. As uveitis is often a feature of late
stage of syphilis, the test may be negative. It
is a titrable parameter and turns negative
following adequate treatment. If syphilis is
suspected as a cause of uveitis, both FTA-AbS
(for high degree of sensitivity and specificity)
and VDRL (to determine state of activity) must
be ordered.
Human Leucocyte Antigens

Human leucocyte antigens (HLA) are located on
the sixth chromosome. The position on the
chromosome is indicated by A, B, C (class I) or
D (class II). HLAs are found to be associated
with several specific diseases. Some of the
anterior uveitic entities have been found to have
a strong HLA association and are listed in Table
20.1.

TABLE 20.1: HLA ASSOCIATION WITH UVEITIS
Disease
HLA association Comments
Acute retinal necrosis
DR 9
HLA DQw7
50% of patients with fulminant disease;

55% of of patients vs 19% of control subjects
Behet disease
B5101*
80% of patients vs 26% of control subjects
Birdshot retinochoroidopathy
A29.2
80% of patients vs 7% in control subjects
Inflammatory bowel disease
B27
6 of 13 patients
Juvenile onset arthritis with iridocyclitis
DRw5
Pars planitis
DR2
Presumed ocular histoplasmosis
DRw2
HLA B7
81% of patients with disciform scarring vs 28%

in control subjects
Psoaritic arthritis
B27
6 of 9 B27 positive patients
Spondyloarthritis
B27
56 of 63 patients with either AS or Reiters syndrome
Recurrent anterior uveitis
B27
Vogt-Koyanagi-Harada(VKH) syndrome
DRB1*0405,
DRB4*0101,
DRQA1*0301
HLA DR1, DR4
Several class II alleles associated, depending on the

racial group
DR1 (36% vs 9% of control subjects) and
in Hispanics DR1 56%
Systemic lupus erythematosus (SLE)
DR2 and DR3
36% vs 24% of control subjects
Diagnostic Biopsies
Diagnosis of isolated intraocular inflammatory
process (without accompanying systemic
manifestations) is characteristically based on
observation of clinical signs, the evolution of
affection and the final outcome. Laboratory tests
based on findings in the serum are of some value,
especially when the intraocular inflammation
is associated with disease involving other organs.
When, however, the affection involves the eye
only, these tests are of little value. Sampling of
the ocular tissue may be more revealing.
Following improvement in instrumentation and
aseptic microsurgical techniques, intraocular
material for diagnostic purpose and testing is
more commonly being utilized by ophthalmologists.
Histopathology is a part of the ophthalmologists armamentarium that is useful in the
diagnosis and management of intraocular
inflammation/uveitis. Initially, uveitis is broadly

classified based on a thorough history and
physical examination. Once classified, the
ophthalmologist can efficiently use special tests
and procedures to aid in the diagnosis and
management of uveitis.
Indications for Diagnostic Biopsies

A large number of new diagnostic laboratory
techniques allows for the identification and
characterization of cells, proteins, and histopathologic specimen and even for flow cytometric
studies of very small samples obtained by
paracentesis. The diagnostic paracentesis of the
eye, keratocentesis of the anterior chamber fluid
and vitreous biopsy, have definite value in the
following situations.
1. Diagnosing the presence of specific microbial
pathogens that are the likely cause of
infectious disease in the eye.4,5
335
336

2. Detecting a predominance of a certain cell
types (e.g. macrophages, epithelial ingrowth,
ghost erythrocytes, phacolytic cells) that may
provide a clue as to the etiology of an inflammatory disease, which may be autoimmune
or allergic in nature6 (Table 20.2).
3. For the identification of:
a. Specific antibody in the aqueous humor
or the vitreous aspirate that would be suggestive of infection (toxocara,7 toxoplasma8).
b. Serum ACE in the aqueous humor would
be indicative of granulomatous inflammation (sarcoidosis).3
c. Miscellaneous conditions include
immune complex and antibody associated
with Behets disease9 and identification
of tumor cell infiltration of the eye such
as large cell lymphoma, 10 leukemia,
retinoblastoma, malignant melanoma,
and metastatic cells11,12 (Fig. 20.1).
It is recommended that diagnostic paracentesis be performed in all cases of postoperative
endophthalmitis.4,5Anterior chamber tap should
also be done to rule out infectious etiology
(particularly Propionibacterium acne) in delayed
onset postoperative uveitis following intraocular
Fig. 20.1: Anterior chamber tap of a patient showing

metastatic cells
lens implantation. Furthermore, any elderly

patient who presents with deteriorating vision
(usually with vitritis as predominant feature) of
undetermined etiology, should undergo vitreous
biopsy to rule out reticulum cell sarcoma (Table
20.3).. The biopsy is also indicated in a malignant
neoplasm that involves the eye, the central
nervous system or the visceral organs. In one
series, the diagnosis of ocular reticulum cell
sarcoma was made by vitreous biopsy in 56%
of the eyes.13 In cases diagnosed by vitreous
biopsy, the average interval from onset of
symptoms to the diagnosis was 13 months, as
TABLE 20.2: INDICATIONS AND FINDINGS ON DIAGNOSTIC

PARACENTESIS
Indications
Findings
Endophthalmitis
Retinoblastoma, malignant melanoma,
reticulum cell sarcoma, leukemia
metastatic tumor
Toxocara canis
Toxoplasma gondii, T. canis,
Reticulum cell sarcoma, syphilis,
Behets disease
Sarcoidosis
Retinoblastoma
Phacolytic glaucoma
Hemorrhagic glaucoma
Epithelial ingrowth
Persistent hyperplastic primary vitreous
Amyloidosis
Bacteria, fungi
Tumor cells
Eosinophils
Antibodies (ELISA)
ACE
LD isoenzymes
Macrophages/lens matter
Ghost erythrocytes
Epithelial cells
Mesenchymal fibrous cells
Amyloid

TABLE 20.3: INDICATIONS FOR AND
FINDINGS ON VITREOUS TAP
Indications
Findings
Endophthalmitis
Retinoblastoma, malignant
melanoma, reticulum cell
sarcoma, leukemia,
Metastatic cancers
T. canis, T. gondii
Reticulum cell sarcoma,
syphilis, Behets disease
Sympathetic ophthalmia
CMV retinitis
Behets disease
Asteroid hyalosis
Amyloidosis
Bacteria, fungi
Tumor cells
Eosinophils
Antibodies
Macrophages
PCR of virus DNA
Monoclonal antibodies
Calcium soaps
Amyloid
opposed to 21 months in patients where the

diagnosis was made by histology of any other
sites.13 Ocular reticulum cell sarcoma often
responds to radiation and chemotherapy.
Therefore, an early diagnosis with prompt
therapeutic intervention may contribute to the
preservation of visual function and prolongation
of life. Similarly, any patient suspected of being
an intravenous drug abuser presenting with
endogenous endophthalmitis-like picture should
undergo diagnostic anterior chamber
paracentesis and vitreous biopsy.14
anesthetic is instilled. One may also use sterile

cotton tipped applicator soaked in antibiotic
and applied at the planned site of needle
insertion.
2. A tuberculin or 2 ml syringe with a 27 to
30 gauge needle is used (Fig. 20. 2). However,
in case of granulomatous uveitis, it is
preferable to use a large bore 25-26 gauge
needle. Conjunctival toothed forceps may be
used to stabilize the globe.
3. The needle entry into the anterior chamber
is oblique through the stroma via the lower
limbus. This acts as a valvular self-sealing
paracentesis wound on withdrawal of the
needle. One should avoid touching the corneal
endothelium and particularly the lens in
phakic patients and should stay over the
peripheral iris at all times. The needle should
not be aimed towards the center of the pupil
and the beveled end should face upwards
throughout the procedure.
4. Obtain a 0.1 to 0.3 ml yield of aqueous, and
on withdrawal external pressure is applied
to the entrance with sterile cotton tipped
applicator. A drop of antibiotic is instilled
in the conjunctival sac and the eye is patched
Anterior Chamber Paracentesis

Paracentesis of anterior chamber is a relatively
simple outpatient procedure, which can be
performed when the patient is seated at the slitlamp or lying in a supine position.
Many techniques have been described for the
anterior chamber paracentesis. A simple and safe
technique, which can be performed in an OPD
setting taking adequate aseptic precautions is
described below:
1. Broad-spectrum antibiotic drops should be
instilled. After 30 seconds, a drop of local
Fig. 20.2: Shows the technique of anterior chamber

paracentesis using limbal approach with a 30 gauge needle,
in a patient suspected to have postoperative endophthalmitis
337
338

for half an hour after which the patient is
re-examined on the slit-lamp to ensure
anterior chamber reformation.
Vitreous Tap or Diagnostic Vitrectomy

A vitreous tap has to be considered in cases with
intraocular inflammation of suspected infectious
etiology, masquerade syndrome, or intraocular
inflammation not responding to treatment.
Tapped vitreous is often small, but can provide
valuable diagnostic information if processed
properly. Diagnostic vitrectomy provides a large
amount of material, though diluted. In the
presence of a hazy vitreous precluding
visualization of the fundus, the combination of
vitreous sampling for diagnostic purpose with
a therapeutic vitrectomy is certainly a sound and
logical approach.
Technique of Vitreous Tap

1. The procedure can be carried out in the
operation theatre using a surgical microscope
after a sub-conjunctival or retrobulbar
injection. However, it can also be performed
in the OPD. When performed in the OPD,
the technique is similar to that of anterior
chamber paracentesis. As the perforation of
the sclera is more painful than performing
a keratocentesis, a sub-conjunctival injection
of 0.1 ml of 2% lidocaine can be given at
the site of scleral perforation and entry into
the vitreous space 3-mm posterior to the
surgical limbus.
2. The vitreous sampling is done using 25 to
23 gauge needles. Most eyes with longstanding intraocular inflammation have
liquefied vitreous or fluid pockets within the
vitreous. In such a situation fine bored 25G needle can be used. When organization
of vitreous is seen 23-G needle is preferred.
The vitreous sample may be easier to obtain
with the use of a three-way stopcock. One

end is attached to the needle and the other
two openings are attached to two tuberculin
syringes. The globe is immobilized with a
conjunctival forceps, and the needle is
inserted in the vitreous cavity under direct
visualization with slit-lamp. The empty
syringe withdraws the vitreous, and
manipulating the stopcock, a similar quantity
of antibiotic is injected into the vitreous cavity.
After the injection the needle is slowly
withdrawn from the eye.
For analysis of the vitreous, it is essential
to obtain an undiluted vitreous specimen under
sterile conditions intraoperatively. Newer
techniques using vitrectome with attachments15
and pneumovitrector16 have been described. Doft
et al17 obtained vitreous samples in eyes with
endophthalmitis by directly connecting a syringe
to the aspiration tube of the vitreous cutter. Others
have used a collecting bottle with openings at
both sides integrated into the aspiration system.18
Smiddy et al19 obtained vitreous samples through
a three-way stopcock through a manual aspiration. Scholda and co-workers15 have developed
a new technique, in which a metal devise is
integrated into the aspiration system of the
vitrectomy unit which fits on standard laboratory
plastic containers with integrated caps. Recently,
Peyman has described a full functional vitrectomy
instrument (pneumovitrector) composed of an
aspiration and a cutting system combined with
an infusion line for injecting air or gas into the
vitreous cavity.16 By simultaneous injection of
air and removal of vitreous, the pneumovitrectomy allows to obtain a large undiluted vitreous
biopsy specimen.
A more thorough standard three-port
vitrectomy can be performed especially when
therapeutically indicated in cases of endophthalmitis. The undiluted vitreous can be sampled
and aspirated via a side-port.20
Tests and Handling of Aqueous and

Vitreous Specimen
The specimen should be handled in such a way
as to allow maximum number of tests to be
performed for the diagnosis. The volume of
sampled vitreous is relatively large, compared
to the aqueous specimen, increasing the yield
on various agar plates and the chances of
obtaining a positive culture. To maximize the
chance of detecting the offending factor, the
aqueous humor and vitreous specimen obtained
should be divided in two equal volumes. One
volume is used for the following tests:
Microbiology
Direct smears are prepared for Gram stain,
Giemsa stain, Gomoris methanamine silver and
calcofluor white stain.The samples should also
be immediately inoculated onto blood agar,
chocolate agar, brain-heart-infusion-broth
(BHIB), thioglycolate fluid (maintained at body
temperature), Sabourauds agar, Brucella agar
and BHIB with gentamicin (maintained at room
temperature for fungal isolation).
Polymerase Chain Reaction

A minimum volume of 0.05 ml should be reserved
for this test especially when P. acne, fungal
endophthalmitis and uveitis of viral etiology is
suspected. The details of PCR are mentioned later.
The other half of the original sample can be
processed for the following tests:
1. Cytology: The entire sample can be spinned
down, the supernatant transpipetted and the
pellet resuspended in formalin or glutaral
dehyde. These pellets are passed through two
or more millipore filters and number of
specific staining including immunohistochemistry is carried out to identify the
infiltrating cell types.20 The other technique
includes cytocentrifuge by cytospin method

(about 1000 revolutions for 5 minutes).
2. Antibodies: The supernatant obtained after
spinning down the cellular components within the aqueous humor should be subjected
to ELISA. The local production of specific
antibodies within the ocular fluids is an
important indication for the possible etiology
especially when Toxocara or Toxoplasma is
suspected.20
3. Flow cytometric analysis: 21 Flow cytometry
(FCM) measures the physical and chemical
properties of individual particles or cells
moving in a single file in a fluid stream.
Constituent cells must be dispersed in a fluid
medium before a specimen can be analyzed
by FCM. Intact tissue specimens (for example,
solid tumors) must first undergo disintegration by mechanical, chemical, or enzymatic
methods. Some of these methods allow the
cytoplasm to remain intact, thereby permitting
analysis of cytoplasm or cell surface
membrane properties.
The most clearly defined application of FCM
is in diagnostic surgical pathology. It is an
adjunct to histologic examination in the diagnosis
of lymphoproliferative and leukemic processes.
FCM is applied to the study of uveal melanomas,
retinoblastomas and ocular lymphoid proliferations, especially masquerade syndrome. It is now
also being used to provide valuable information
regarding the ratio between the cytotoxic and
helper T-cells, an indication for the immunologic
events taking place during the course of the ocular
disease.
Biopsy
Iris and Ciliary body Biopsy
Biopsy of iris and ciliary body are usually
performed in suspected tumors in these regions.
339
340

These lesions include glioneuromas, medulloepitheliomas, iridociliary cysts, leiomyomas,
malignant melanomas and nematode
granulomas.22 Indications of iris and ciliary body
biopsy in uveitic conditions are few and include:
1. Metastatic lesions to the iris and ciliary body
masquerading as uveitis.
2. Ruptured iris cysts mimicking as anterior
uveitis.
3. Iris and ciliary body nodules secondary to
granulomatous conditions like tuberculosis
and sarcoidosis. In a recent publication,
Moorthy and co-workers were able to diagnose
3 patients with coccidioidomycosis iridocyclitis following biopsy of iris nodules.23
Choroidal and Retinochoroidal

Biopsy
Lesions within the choroid can be difficult to
differentiate clinically, although technological
advances in non-invasive imaging have helped
to monitor the size and the growth. When the
inflammatory process is relentless and the
anterior chamber tap and/or vitreous tap (or
vitrectomy) are unrevealing, the ophthalmologist
has to consider the option of performing a
choroidal or retinochoroidal biopsy. With
advances in instrumentation and microsurgical
techniques, endoretinal biopsy and chorioretinal
biopsy can be performed more easily. There are
several reports of retinochoroidal biopsy
establishing etiological diagnosis of uveitis,
especially to differentiate subretinal lesions of
infective origin from non-infective ones. 24
The diagnosis of ocular reticulum cell sarcoma
can usually be made on the basis of vitrectomy
alone, sometimes it requires a more aggressive
approach with choroidal biopsy, when pars
plana vitrectomy and extensive medical
examination fail to confirm the diagnosis of
reticulum cell sarcoma.25
Chorioretinal Biopsy (External Approach)

Trap-door approach of Stallard: After a conjunctival
peritomy, a Flieringa ring is sutured to the bare
sclera. A lamellar scleral flap is dissected in a trapdoor fashion over the lesion. Penetrating diathermy
is applied around the lesion with adequate
margins. The lesion is dissected leaving the retina
intact. This procedure is not in use any more.
Full-thickness eye wall resection of Peyman:
Preoperatively, the mass lesion is surrounded
by rows of heavy laser photocoagulation burns,
which is performed in two sessions 3 to 4 weeks
apart.26-31 The resection is performed 4 weeks
after the initial session.30 A conjunctival 360
peritomy is carried out and transillumination
and diathermy localize the tumor. A Peyman
basket is sutured to the globe. A partial thickness
flap is dissected around the lesion. Penetrating
diathermy is applied around the tumor in the
scleral bed. Pars plana sclerotomies are made
for later vitrectomy and sealed with scleral plugs.
The lesion is excised using curved Vannas
scissors. The scleral flap is sutured back in place
and pars plana vitrectomy is performed to remove
any vitreous blood and incarcerated vitreous from
vitrectomy site. Surgery can also be performed
under systemic hypotensive anesthesia to reduce
the risk of hemorrhage.29
Endoretinal biopsy (Internal approach): Endoretinal
biopsy is done in patients with uncertain retinal
inflammation. A pars plana vitrectomy is
performed before the retina is biopsied. After the
vitrectomy, the retinal site is demarcated and
surrounded by endodiathermy or a barrage of
endolaser. A shallow retinal detachment is
induced by injection of a minute amount of
balanced salt solution under the retina to slightly
elevate it. The internal part of demarcation zone
is cut out using fine intraocular scissors. The
underlying tissue is sampled which can be
removed by gently aspirating it into a draining

flute. At times, additional material for examination can be collected from the subretinal space
using a soft tipped flute needle connected to a
tuberculin syringe. Additional endodiathermy
and endolaser burns may be added, if necessary,
in order to prevent fluid seepage under the cut
edges of the non-biopsied retina which can cause
a retinal detachment. This is followed by internal
tamponade using expansile gases.
In some instances, a biopsy of the retina may
be necessary to establish the diagnosis, particularly when both eyes are involved or there is a
great potential for loss of vision, as in cases of
acute retinal necrosis (Herpes and CMV). 32
Retinal biopsy is needed in patients if retinal
lesions have atypical presentations. A case
was reported, where an HIV-positive patient
presented with a clinical picture similar to
CMV retinitis. As the retinitis was found to be
ganciclovir resistant, retinal biopsy was carried
out which showed it to be toxoplasmic
chorioretinitis33 highlighting the importance of
retinal biopsy in establishing the diagnosis.
Fine-Needle Aspiration Biopsy

Fine-needle aspiration biopsy (FNAB) offers a
histologic correlation to the clinical diagnosis
in cases of atypical presentation of intraocular
lesions. It aids in effective planning and
management and enables histopathological
diagnosis without having to sacrifice the eye or
having to resort to open biopsy methods.
FNAB has been recommended in following
conditions:
1. Cases of suspected infectious subretinal
lesions (abscess or tuberculoma) mimicking as
choroidal tumors. Gregor and coworkers 34
diagnosed a Nocardia asteroides subretinal
abscess following a trans-vitreal FNAB.
2. Cases where diagnosis is difficult, distinction
between benign and malignant is not clear,
all ancillary tests are inconclusive, and where
therapeutic decisions have to be made on the

basis of cytological findings.35
3. Patients with metastatic disease of the choroid
but with no primary.
4. Cases where patient refuses recommended
therapy until histopathological confirmation
is obtained.
Techniques of Fine-Needle
Aspiration Biopsy
The method of choice of FNAB is contingent on
the existing anatomic state of the eye, the location
of the lesion, size of the lesion, and the presence
or the absence of a retinal detachment.
Approach 22,36,37
Limbal, pars plana, corneolimbal-zonule and
subretinal approaches are used for taking FNAB.
Limbal approach: This approach is used for iris
lesions (Fig. 20.3) or posterior ciliary body lesions
in aphakia.
Pars plana approach: In this approach, the needle
is passed from the pars plana region (3.5 mm
from the limbus) in the quadrant opposite the
lesion, through the vitreous gel (Fig. 20.4).
For some of the eyes with tumors located
posteriorly, a vitrectomy has to be performed
Fig. 20.3: Shows the technique of FNAB of an iris

mass lesion using a limbal approach
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342

a trochar and cannula, although the excess
movement caused by removing the trochar and
attaching the syringe and flexible connector may
lead to increased complications.
Complications of FNAB22,36,37
Fig. 20.4: Technique of FNAB of a subretinal mass

lesion using a pars plana approach
before aspiration. The purpose of vitrectomy is

to maintain the clear visualization of the lesions
and the needle path, to remove the vitreous that
could potentially adhere to the needle (reducing
unnecessary retinal traction), to eliminate
adherence of the vitreous to the tumor cells in
the needle as the needle is withdrawn (mitigate
potential of tumor cells tracking in the wound),
and to control bleeding after aspiration.
Corneolimbal-zonular approach: It prevents
dissemination of the tumor mass through the
needle track. This approach is used in patients
with retinoblastoma, a highly friable tumor, as
the chance of needle track dissemination is
extremely high. Through a corneolimbal
approach the needle passes through multiple
planes, thus wiping out the tumor cells as the
needle is removed from the eye. In addition the
absence of blood vessels theoretically decreases
the chances of dissemination.
Subretinal approach: It is adopted in cases of
subretinal abscess and tuberculoma, considering
the site is approachable.
Most surgeons prefer to use a 25-gauge needle
with a flexible connector to a 2 ml syringe to
minimize the movement and surgical trauma
during biopsy. Others prefer a spinal needle with
The most common complication of FNAB is

bleeding from the site of the needle track. Virtually
all intraocular FNABs are associated with a
small degree of hemorrhage, which can be
subretinal, retinal or intravitreal.
Orbital dissemination of tumor cells and distant metastatic spread caused by tumor
implantation along the needle track has been
reported. It is reduced with the use of smaller
25-gauge needle. Theoretically, the procedure can
also disseminate a subretinal focus of infection.38
Iatrogenic retinal perforations are unavoidable by the indirect needle approach to the
choroidal lesions and may cause a retinal
detachment after FNAB. The number of cases
developing the retinal detachment following
FNAB is few, possibly because the blood clot
closes the site of perforation.
Test and Handling of Biopsy Material

For obtaining maximal information from
retinal and chorioretinal biopsy, a close
cooperation amongst the clinician, the surgeon,
the microbiologist and the pathologist is of utmost
value. The differential diagnosis should be
communicated to the laboratory personnel and
a plan of handling the tiny biopsy specimen
should be worked out. As soon as the biopsy
specimen is removed, it should be divided into
four parts based on the clinical suspicion. One
part should be snap frozen for immunostaining,
one for light and electron microscopy, one for
in situ hybridization and the remaining for
microbiological cultures and PCR detection of
infective agents.

Microbiological Cultures
A small piece of tissue is seeded onto the agar
plate or preferably onto the agar medium. After
incubation for 24-48 hours, initial indications
for the type of infective microbial agent can be
obtained.
Light and Electron Microscopy

These two techniques are complimentary and
should be used in parallel. The specimen to be
used for these tests should be fixed in 10%
formaldehyde or preferably glutaraldehyde
solution.
Immunohistochemistry
The material should be snap frozen. Frozen
sections can be studied with appropriate
antibody to identify infectious agents like viruses
and autoimmune diseases. Immunohistochemistry can also be done from sections of formalin
fixed tissues.
In situ Hybridization39
In situ hybridization test can be done in cryo
preserved tissue as well as sections from formalin
or glutaraldehyde fixed tissues. Radiolabelled
probes are used specially for infectious organisms
like viruses. Localization of such infectious
agents within a cell is possible.40
Polymerase Chain Reaction

Polymerase chain reaction (PCR) is a new
molecular biological technique, which involves
enzymic application of specific sequence of DNA
or RNA (Fig. 20.5). This technique was first
described by Mullis and coworkers in 1985. PCR
is based on the principle of three steps namely:
(i) denaturation, (ii) annealing, and (iii) amplification (Fig. 20.6). Since its introduction in 1995,
PCR has been widely used in both research and
Fig. 20.5: Photograph of the PCR machine
clinical medicine. Its application in ophthalmology and medical sciences as a whole has increased exponentially over the last few years.41,42
The ocular tissues which can be submitted
for PCR include: intraocular fluid (aqueous and
vitreous), fresh retinal and choroidal tissues,
formalin fixed or paraffin embedded tissues, and
DNA material extracted from a stained or
unstained cytology slide.
PCR is a reliable test for detection of
adenoviruses from the conjunctiva and
Propionibacterium acne and other bacterial
endophthalmitis.43 It is also employed in the
diagnosis of tuberculous uveitis,44 presumed
ocular tuberculosis45 and also to emphasize the
role of tuberculosis in the etiology of Eales
disease46,47 and toxoplasmosis.
Some general precautions are needed to
minimize the risk of contamination, which
include performing the initial processing in a
biologic safety hood not used for any other PCR
related procedure. All reagents should be
prepared in another biologic safety cabinet using
materials dedicated solely to the PCR and should
be aliquoted in sterile tubes.
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344

Polymerase Chart Reaction
Fig. 20.6: Diagrammatic representation of the three steps of PCR: Denaturation, Annealing and Amplification
Lastly, PCR can detect agents for which the

primers exist. There are limited numbers of
primers available. It also does not provide cellular
morphology. In contrast, the in situ DNA
hybridization can show the hybridized DNA
within the infected cell. PCR detects only the
amplified DNA and not necessarily reflect the
etiological agents.
syphilis and coccidiomycosis.22 Stains used

include hematoxylin and eosin supplemented
by Gomoris methamine silver, Warthin-Starry
stain and acid-fast stains, as well as immunohistochemical stains using antibodies.
Occasionally, a gallium scan will demonstrate
lacrimal gland uptake and support the need for
lacrimal gland biopsy.
Conjunctival and Lacrimal Gland

Biopsy
Mucosal Biopsy
Conjunctival and lacrimal gland biopsy should

be reserved for those patients with visible
conjunctival masses or lacrimal gland enlargement, as can occur with sarcoidosis, tuberculosis,
The commonest indication of oral mucosal

biopsy in a uveitic scenario is for the diagnosis
of Behets syndrome, which shows evidence of
an occlusive vasculitis. Similarly, characteristic
inflammation of one of the minor salivary glands

on scanning can confirm a clinical suspicion
of Sjogrens syndrome, whereas inflammation
of the intestinal mucosa can support the diagnosis
of ulcerative colitis, Crohns disease or Whipples
disease.22
Lymph Node Biopsy

In patients with uveitis and enlarged lymph
nodes, FNAB or excision biopsy of the affected
nodes can be performed to rule out tuberculosis
or sarcoidosis2.
Ancillary Tests
Fundus Fluorescein Angiography
Fundus fluorescein angiography (FFA) is a
helpful adjunct test in inflammatory diseases
involving the fundus of the eye. The main
advantage of this technique is its ability to better
visualize the retinal vessels and delineate their
walls. FFA is most often used to diagnose cystoid
macular edema, retinal or choroidal neovascularization, areas of retinal non-perfusion and active
retinal vasculitis. FFA is also useful in patients
with neurosensory retinal detachment and other
outer retinal inflammations, particularly those
involving the RPE. The major drawback of FFA
is its inability to image the choroid and to detect
inflammatory events affecting the choroid and
choriocapillaris especially in areas where the
lesion is deep.20 Furthermore, one has to remember
that although FFA findings are helpful in illustrating the inflammatory processes and anatomic
changes within the retina and the vessels,
generally the FFA patterns are not diagnostic
or pathognomonic for any particular intraocular
inflammatory disease.
Posterior uveitic entities where FFA is particularly indicated are birdshot retinochoroidopathy, geographic helicoid peripapillary
choroiditis, acute posterior multifocal placoid
pigment epitheliopathy, multiple evanescent

white dot syndromes, multifocal choroiditis,
sympathetic ophthalmia and VKH syndrome
(early stage).
FFA can also distinguish a macular retinitis
or choroiditis from central serous choroidopathy
or choroidal neovascular membrane.
Indocyanine Green Angiography48

The choroid is composed of vascular elements
and is involved in majority of chorioretinal
vascular disorders. FFA provides information
regarding the alterations in the blood-aqueous
barrier at the level of the retinal vessels and the
retinal pigment epithelium in intraocular
inflammatory conditions. However, it is unable
to describe the choroid, as the absorption and
emission of photonic fluorescein energy in the
blue-green wavelength range is impaired by the
retinal pigment epithelium. Indocyanine green
angiography (ICGA) uses the ICG molecule,
which absorbs and emits photonic fluorescein
energy in the near infrared wavelength range,
which penetrates melanin pigment, hemorrhage,
macular xanthophyll pigment and other obstacles
such as turbid fluids.20 These characteristics
allow imaging of the normal and disturbed
choroidal and retinal circulations as well as the
normal and disturbed fluid distribution in the
choroid.
ICGA can aid in the diagnosis of Behets
disease, sarcoidosis, tuberculosis, birdshot
retinochoroidopathy toxoplasmic retinochoroiditis, acute posterior multifocal placoid pigment
epitheliopathy, multiple evanescent white dot
syndromes, multifocal choroiditis, VKH syndrome and sympathetic ophthalmia.. Different
patterns of ICG fluorescence have been identified
during examinations of patients with similar
disorders. Fardeau and coworkers 49 established
a precise ICGA semiology in 52 patients with
Birdshot retinochoroidopathy. In another
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346

landmark article by Oshima et al, 50 ICGA was
performed in 20 eyes with VKH syndrome and
the findings suggested a transient choroidal
circulatory disturbance during the acute stage.
A standardized procedure for combining FFA
and ICGA has been found to be more useful.
Ultrasound
B-scan ultrasonography is used most commonly
in patients with uveitis to investigate inflammatory choroidal and scleral thickening that can
occur with VKH syndrome (Fig. 20.7), posterior
scleritis and sympathetic ophthalmia20and to
evaluate the posterior segment in patients with
dense cataracts or other media opacities. It is
also useful in detecting exudative retinal
detachment, detachment of choroid, evaluation
of the ONH and thickening of macula (edema).
It is useful in detection of panophthalmitis and
scleritis where classically T-sign is present.
Ultrasound has a very important role in the
management of endophthalmitis to determine its
severity and extent of infection.
USG is also useful in diagnosis of granuloma
and abscess in tuberculosis, cysts with scolex
in cysticercosis and nematode infection.
Fig. 20.7: Ultrasound B-scan with vector A-scan

showing gross choroidal thickening in a patient with VKH
syndrome
Ultrasound Biomicroscopy51,52
Conventional ultrasound use frequencies in
10 MHz range. The use of ultrasound frequencies
in the 50-100 MHz range is a relatively new
development in the ultrasound imaging of the
eye. Ultrasound biomicroscopy (UBM) is a new
tool available for evaluation inflammation in
areas, which are not visualized clinically. It can
be used to study up to the anterior 4-mm of the
globe. In conditions like small undilating pupil
due to posterior synechiae with or without
complicated cataract this modality is extremely
useful in identifying the presence of inflammation
in the area of the pars plana (Fig. 20.8). It has
also been used in ciliary body metastatic tumors,
which can masquerade as uveitic entities,12 (Figs.
20.9 and 20.10) and for the diagnosis and
management of pars planitis caused by caterpillar
hair.53

Optical Coherence Tomography (OCT) is a
noncontact, non-invasive imaging technique
used to obtain high-resolution cross-sectional
Fig. 20.8: UBM photograph showing a membrane (m)

over the pars plana region (arrows denoting the extent
of membrane) with vitreous exudates suggestive of pars
planitis in a patient with complicated cataract obscuring
retinal view
Fig. 20.9: Metastatic Lesion: Slit-lamp photograph showing

anterior chamber reaction and fluffy exudates on the
superior iris
Fig. 20.10: UBM image showing cystic metastatic lesions

in the ciliary body region
images of the retina. It is analogous to ultrasound

B-scan imaging except that light rather than
sound waves are used in order to obtain a much
higher longitudinal resolution of approximately
10 m (axial) and 20 microns (transverse) in the
retina.54 Its resolution is 8-25 times greater than
any sonic modality. Newer fourth generation

OCT uses a femtosecond laser light source and
has achieved an axial resolution of 3 microns.
Spectral OCT and the en-face OCT are newer
developments. Among the newer modalities of
investigations OCT has come to stay and is a
very useful supplement to conventional
techniques.
Macular changes can occur in various forms
of uveitis and can be studied clinically by slitlamp biomicroscopy, indirect ophthalmoscopy
or by fundus flourescein angiography. Macular
edema and its sequelae are among the leading
causes of decreased vision in patients with
uveitis. Other changes that can occur in the
macula due to uveitis include: serous retinal
detachment at the macula, epiretinal membrane,
macular hole, vitreomacular traction (tractional
retinal detachment), and choroidal neovascular
membrane.
Uveitic conditions are by nature recurrent
and hence the patients have to be followed-up
at frequent intervals. OCT being a non-invasive
technique has the advantage of repeatability. OCT
thus is helpful in not only diagnosing but in
follow-up of patients at regular intervals with
treatment. It is helpful in the management of
intraocular inflammation as it is able to define
the extent, depth and thickness of the inflammatory lesion. It is also helpful in localizing the
layer of retina and choroid harboring lesion.
This localization is helpful in not only
diagnosing the disease but also in monitoring
the response to treatment for example cystoid
macular edema is a classical complication of
ocular inflammation. It results from either a
rupture of the inner or outer blood ocular barrier.
OCT can detect precisely even very minimal
amount of fluid in particular layers of retina.
OCT can be more helpful in detecting subtle
macular edema which may not be detected on
FFA.55-57 Macular edema is an important cause
347
348
A
A
B
B
Figs 20.11A and B: A Pretreatment OCT picture showing
large cystoid spaces at the macula. B Posttreatment OCT
picture of the same patient showing resolution of macular
edema with restoration of foveal contour
of defective vision due to various uveitic

conditions especially intermediate uveitis. Early
detection and treatment is important (Figs 20.11A
and B) because it can lead to complications
and vision loss. We have found intermediate
uveitis to be the commonest cause of macular
edema.
OCT is extremely sensitive in identifying
neurosensory retinal elevation because of the
distinct difference in optical reflectivity between
photoreceptors and underlying RPE/choriocapillaris. It can detect the presence of shallow
subretinal fluid or macula involvement in retinal
detachment. OCT is helpful in the early diagnosis
as well as resolution of shallow retinal
detachment (Figs 20.12A and B). It can also be
used to distinguish true retinal detachment from
retinoschisis.
OCT appearance of CNVM is described as
a bump with moderate slope extending upward
or as a fusiform thickening with disruption of
the reflective band. OCT is useful before planning
Figs 20.12A and B: A OCT picture showing neurosensory

detachment at the macula, B OCT picture showing
posttreatment resolution
macular surgery for removal of subfoveal CNV

especially in patients with presumed ocular
histoplasmosis syndrome and multi-focal
choroiditis. Following patterns of subfoveal
CNVM can be made out with the help of OCT:
Reflective band anterior to and clearly
separated from the RPE.
Highly reflective red band anterior to and
adherent to the RPE, similar to the bump
Highly reflective band indistinguishable from
the RPE.
Submacular surgery results have shown that
eyes for which OCT reveals the triad of hyperreflective tissue with anterior location, a
separation zone and an underlying optically
clear zone, surgical removal may represent a
reasonable alternative.
Color Vision Testing

Color vision testing serves as an objective measure
of optic nerve dysfunction. In addition, patients
with birdshot choroidoretinopathy can develop
color vision loss disproportionate to the visual

acuity or fundus finding, presumably reflecting
the widespread outer retinal dysfunction.
Visual Field Testing

Visual field testing (VFT) is an important ancillary investigation in uveitic entities, especially
in posterior uveitis like serpiginous choroiditis,
multifocal choroiditis, birdshot retinochoroidopathy, Behets disease, sarcoidosis, toxoplasmic
retinochoroiditis, acute posterior multifocal
placoid pigment epitheliopathy and multiple
evanescent white dot syndromes. It can document
the progression of a disease process involving
the retina which manifests as well-demarcated
scotomas. De Courten and co-workers58 discussed
the potential role of computerized visual field
testing for appraisal and follow-up of patients
with birdshot retinochoroidopathy. VFT can also
categorize the patients developing field loss
secondary to steroid induced glaucoma.
Audiometry
Audiometry can record the extent of hearing loss
seen in VKH syndrome and syphilis.
Radiological Studies
The sacroiliac joint is inflamed in 60% to 90%
of patients with HLA-B27 related uveitis. Plain
radiographs are quite useful in demonstrating
the inflammatory narrowing of the sacroiliac
joint. CT-scan and MRI offer increased sensitivity
for documenting sacroiliitis, but are more
expensive and indicated in selected cases. Chest
X-ray is indicated in sarcoidosis and tuberculosis
while cases with ankylosing spondylitis need
radiograph of sacroiliac joint.
Radionucleotide Studies
Intravenously injected gallium-67 localizes to
normal liver, spleen and bone, as well as areas
of active inflammation, such as inflamed lymph

nodes, parotid and lacrimal glands, and joints.
Although any cause of inflammation can produce
a positive test, the gallium scan is used frequency
to identify pulmonary hilar gland or lacrimal,
parotid and submandibular gland inflammation,
as in the case of sarcoidosis.
Lumbar Puncture
Lumbar puncture (LP) is most often used in
patients with suspected intraocular lymphoma.
LP should be done after a complete neurological
evaluation and imaging procedure like CT and/
or MRI-scan to avoid unexpected shifting of
intracranial contents. LP is also used in selected
cases to test suspected meningitis due to syphilis,
tuberculosis, toxoplasmosis, cryptococcal
infection and coccidiomycosis.
Skin Testing
Purified protein derivative of tuberculin (Mantoux
test): Mantoux test is a non-specific test. Skin
testing involves intradermal injection of
0.1 ml of antigen to elicit a delayed type
hypersensitivity response indicative of prior
exposure. Normally all patients with panuveitis
are tested for tuberculosis (TB) with 0.1 ml of
5 units of purified protein derivative (PPD). This
includes patient with a prior Bacillus CalmetteGuerin (BCG) vaccination or a distant history
of tuberculosis. Although a positive test does
not reflect tubercular activity, a negative test often
rules out a tubercular focus in the body. Due
to the prior exposure to TB, a large number
(60 to 90%) of healthy adults have a positive
PPD skin test in India. Therefore, there are high
possibilities of false positive results. Hence, all
patients of suspected ocular tuberculosis should
be evaluated by associated findings like X-ray
chest showing pulmonary tuberculosis. A
positive Mantoux test in a case of granulomatous
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350

anterior uveitis with poor general health or in
a nonresponder to systemic steroids is of greater
significance. Aqueous samples should be
subjected to PCR study for Mycobacterial
tubercular genome in such cases.
Patients with active Behets syndrome
occasionally show increased dermal sensitivity,
termed pathergy, which is manifestated by formation of local pustule in response to intradermal
injection. This test is of limited sensitivity even
in the active phase of the disease.
References
1. Baarsma GS, La Hey E, Glasius E, et al. The
predictive value of serum-angiotensin
converting enzyme and lysozyme levels in the
diagnosis of ocular sarcoidosis. Am J Ophthalmol
1987;104:211-17.
2. Power WJ, Rodriquez A, Perroze-Seres M, et
al. The value of combined serum-angiotensin
converting enzyme and gallium scan in
diagnosing ocular sarcoidosis. Ophthalmology
1995;101:2007-11.
3. Weinreb RN, Sandman R, Ryder MI, et al.
Serum-angiotensin converting enzyme activity
in human aqueous humor. Arch Ophthalmol
1985;103:34-36.
4. Allansmith MR, Skaggs C, Kimmuras SJ. Anterior
chamber paracentesis: Diagnostic value in
postoperative endophthalmitis. Arch Ophthalmol
1970;84:745-48.
5. Foster RK. Etiology and diagnosis of bacterial
postoperative endophthalmitis. Ophthalmology
1978;85:320-24.
6. Witmer R. Clinical implications of aqueous
humor studies in uveitis. Am J Ophthalmol
1978;86:39-42.
7. Benitez del Castillo JM, Herreros G, Guillen JL et
al. Bilateral ocular toxocariasis demonstrated by
aqueous humor enzyme linked immunosorbent
assay. Am J Ophthalmol 1996;119:51-54.
8. OConnor GR. Precipitating antibody to
toxoplasmosis in blood and aqueous humor.
9. Michelson JB, Chisari FV, Kansu J. Antibodies
to oral mucosa in patients with ocular Behcets
disease. Ophthalmology 1985;92:1277-34.
10. Michels RG, Green WR, Engel HM, et al.

Intraocular reticular cell sarcoma:diagnosis by
pars plana vitrectomy. Arch Ophthalmol
1975;93:1331-35.
11. Takahashi T, Oda Y, Chiba T, et al. Metastatic
tumour of iris and ciliary body simulating as
iridocyclitis. Br J Ophthalmol 1984;188:266-69.
12. Woog JJ, Chess J, Albert DM, et al. Metastatic
tumour of iris simulating as iridocyclitis. Br J
Ophthalmol 1984;188:167-69.
13. Freeman LN, Schachat AP, Knox DL, et al.
Clinical features, laboratory investigations and
survival in ocular reticulum cell sarcoma.
14. Michelson JB, Whitaker JP, Wilson S, et al.
Invisible foreign body granuloma of the retina
associated with intravenous cocaine addition.
15. Scholda CD, Egger SF, Lakits A, et al. A system
for obtaining undiluted intraoperative vitreous
biopsy specimen. Arch Ophthalmol 1996;114:127172.
16. Peyman GA. A Pneumovitrector for the
diagnostic biopsy of the vitreous. Ophthalmol
Surg Laser 1996;27:246-47.
17. Doft BK, Donelly K. A single sclerotomy vitreous
biopsy in endophthalmitis. Arch Ophthalmol
1991;109:465.
18. Tamai M, Nakazawa M. A collection system
of obtaining vitreous humor in clinical cases.
19. Smiddy WE, Michels RG, de Bustros, de la Cruz
Z, Green WR. Histopathology of tissue removed
during vitrectomy for impending macular holes.
20. Ben Erza D. Diagnostic intraocular interventions.
In: Ben Erza D (Ed). Ocular inflammation: Basic
and clinical concepts. Martin Dunitz,1999;83-89.
21. Crofty TB, Campbell RJ. Flow cytometry.
Ophthalmol Clinic North Am 1995;8:37-46.
22. Ma PE, Peyman GA. Uveal biopsy. In: William
T, Jaeger EA (Eds). Duannes Clinical
Ophthalmology. Lippincott Williams and
Wilkins, 1998.Vol 4,Ch 36,1-13.
23. Moorthy RA, Rao NA, Sidikaro Y, et al.
Coccidioidomycosis iridocyclitis. Ophthalmology
1994;101:1923-28.
24. Kirmani MH, Thomas EL, Rao NA, et al.
Intraocular reticular cell sarcoma: diagnosis by
choroidal biopsy. Br J Ophthalmol 1987;71:74852.

25. Peyman GA, Charles H. Internal eye wall
resection in the management of uveal
melanoma. Can J Ophthalmol 1988;23:219-24.
26. Peyman GA, Juarez CP, Raichand M. Fullthickness eye wall biopsy: Long-term results
in 9 patients. Br J Ophthalmol 1981;65:722-25.
27. Peyman GA, Axelrod AJ, Graham RO. Fullthickness eye wall resection: An experimental
approach for treatment of choroidal melanoma:
Evaluation of cryotherapy, diathermy and
photocoagulation. Arch Ophthalmol 1974;91: 21930.
28. Constable IJ, Chester GH, Horne R, et al. Human
chorioretinal biopsy under controlled systemic
hypotensive anaesthesia. Br J Ophthalmol
1980;64:559-63.
29. Peyman GA, Diamond JG, Axelrod AJ. Sclerochorio-retinal (SCR) resection in humans. Ann
Ophthalmol 1974;6:1347-49.
30. Peyman GA, Nelson PT, Axelrod AJ. Fullthickness eye wall resection: Evaluation of
preoperative photocoagulation. Invest
Ophthalmol 1973;12:262-66.
31. Peyman GA, Mary DR, Ericson ES, et al. Fullthickness eye wall resection: An experimental
approach for the management of choroidal
melanoma II. Homo- and heterograft. Invest
Ophthalmol 1973;11:668-72.
32. Culbertson WW, Blumenkranz, Pepose JS, et
al. Varicella zoster virus is a cause of acute
retinal necrosis. Ophthalmology 1986;93:559-69.
33. Cote MA, Rao NA. The role of histopathology
in the diagnosis and management of uveitis.
Int Ophthalmol 1990;14:309-16.
34. Gregor RJ, Chong CA, Augsburger JJ, et al.
Endogenous Nocardia asteroides subretinal
abscess diagnosed by transvitreal fine needle
aspiration biopsy. Retina 1989;9:118-21.
35. Shanmugam MP, Biswas J. Fine needle
aspiration biopsy in the diagnosis of intraocular
lesions. Indian J Ophthalmol 1997;45:105-08.
36. Glasgow BJ, Straatsma BR, Kreiger AE. Fineneedle aspiration of the posterior segment
intraocular tumors. Ophthalmol Clinic North Am
1995;8:59-72.
37. Glasgow BJ, Brown HH, Zargoza AZ, et al.
Quantification of tumor seeding from the needle
aspiration of ocular melanomas. Am J Ophthalmol
1988;105:538-56.
38. Freeman WR, Wiley CA. In situ nucleic acid
hybridization. Surv Ophthalmol 1989;34:187-92.
39. Henderly DE, Atalla LR, Freeman WR, Rao NA.

Demonstration of cytomegalovirus retinitis by
in situ DNA hybridization. Retina 1988;8:17781.
40. Della G. Molecular biology in ophthalmology:
review of principles and recent advances. Arch
Ophthalmol 1996;114:457-63.
41. Adleberg JM, Wittwer C. Use of the polymerase
chain reaction in the diagnosis of ocular disease.
Current Opinion in Ophthalmology 1995;6:III:8085.
42. Chan CC, Palestine AG, Li Q, Nussenblatt RB.
Diagnosis of Ocular toxoplasmosis by the use of
immunocytology and the polymerase chain
reaction. Am J Ophthalmol 1994;117:803-05.
43. Therese KL, Anand AR, Madhavan HN:
Polymerase chain reaction in the diagnosis of
bacterial endophthalmitis. Br J Ophthalmol
1998;82:1078-82.
44. Biswas J, Therese L, Madhavan HN. Use of
polymerase chain reaction (PCR) in the detection
of Mycobacterium tuberculosis complex DNA
from aqueous sample of suspected tubercular
uveitis. Uveitis Today. Proceedings of the
Fourth International Symposium on Uveitis,
Yokohama, Japan, 10-14th October 1997, pp.
227-230, 1998.
45. Gupta V, Arora S, Gupta A, Ram J, Bambery
P, Shegal S: Management of presumed
intraocular tuberculosis: possible role of the polymerase chain reaction. Acta Ophthalmologica
Scandinavica 1998;47:679-82.
46. Madhavan HN, Therese KL, Gunisha P, Biswas
J. Polymerase chain reaction for the detection
of Mycobacterium tuberculosis in epiretinal
membrane in Eales' disease. Invest Ophthalmol
Vis Sci 2000;41:822-25.
47. Biswas J, Therese L, Madhavan HN: Use of
polymerase chain reaction in detection of
Mycobacterium tuberculosis complex DNA from
vitreous sample of Eales disease. Br J Ophthalmol
1999;83:994.
48. Ruiz-Moreno JM, Ben Erza D. Indocyanine green
angiography in uveitis. In: Ben Erza D (Ed).
Ocular inflammation: Basic and clinical Concepts.
Martin Dunitz, 1999;91-102.
49. Fardeau C, Herbert CP, Kullmann N, et al.
Indocyanine green angiography in Birdshot
choroidoretinopathy. Ophthalmology 1999;106:
1928-34.
351
352

50. Oshima Y, Harino S, Hara Y, et al. Indocyanine
green angiography in Vogt-Koyanagi-Harada
disease. Am J Ophthalmol 1996;122:58-66.
51. Pavin CJ, Sherar MD, Foster FS. Subsurface
ultrasound microscopic imaging of the intact
eye. Ophthalmology 1990;97:224-50.
52. Pavin CJ, Harasiewicz K, Sherar MD. Clinical
use of ultrasound biomicroscopy. Ophthalmology
1991;98:287-95.
53. Bhende M, Biswas J, Sharma T, et al. Ultrasound
Biomicroscopy in the diagnosis and management of pars planitis caused by caterpillar hairs.
54. Zolf R, Glacet Bernard A, Benhamou N, Mimoun
G, Coscas G, Soubrane G. Imaging analysis with
optical coherence tomography; Retina 2002;22(2):
192-201.
55. Reinthal EK, Volker M, Freudenthaler N, Grub
M, Zierhut M, Schlote T. Optical coherence
tomography in the diagnosis and follow up
of patients with uveitic macular edema.

Ophthalmology 2004;101(12):1181-88.
56. Antcliff RJ, Stanford MR, Chauhan DS, Graham
EM, Spalton DJ, Shilling JS, Ffytche TJ, Marshal
J. Comparison between optical coherence
tomography and fundus fluorescein angiography for the detection of cystoid macular
edema in patients with uveitis. Ophthalmology
2000; 107(3):593-99.
57. Markomichelakis NN, Halkiadakis I, Pantelia
E, Peponis V, Patelis A, Theodossiadis P,
Theodossiadis G. Patterns of macular edema
in patients with uveitis: qualitative and
quantitative assessment using optical coherence
tomography: Ophthalmology 2004;111(5): 94653.
58. De Courten C, Herbort CP. Potential role of
computerized visual field testing for the appraisal
and followup of Birdshot choroidoretinopathy.
Retinopathy of Prematurity: Diagnostic Procedures and Management
YOG RAJ SHARMA, DEEPENDRA VIKRAM SINGH, NIKHIL PAL, RAJANI SHARMA
21
Retinopathy of
Prematurity:
Diagnostic Procedures
and Management
The improved survival rate of extremely

premature infants has indirectly led to increase
in the incidence of retinopathy of prematurity.
Ophthalmologists are now being required to
examine these premature babies with greater
frequency. The understanding of pathogenesis,
screening and management of retinopathy of
prematurity (ROP) has markedly changed since
Terry first described it.1 The Multicenter Trial of
Cryotherapy for Retinopathy of Prematurity
(Cryo-ROP) 2-5 and lately, Early Treatment
Retinopathy of Prematurity (ETROP) study6
have influenced the management of ROP.
Etiology
Retinopathy of Prematurity is the result of abnormal development of immature retinal vessels
capable of progressing to a vasoproliferative
retinal disorder. ROP can result in severe visual
impairment and has been reported to attribute
to as much as 40% of the perinatal blindness.
reach nasal ora serrata by 36 weeks of gestation

and the temporal ora serrata by 39 to 41 weeks of
gestation. The interruption of this normal vasculogenesis leads to development of retinal ischemia
and ROP. The location of this interruption
which is related to time of premature birth determines the development of various stages of ROP.
Risk Factors
The multiple factors that are associated with the
severity of ROP are: low birth weight, young
gestational age, non-black race, multiple birth,
prolonged elevation of arterial oxygen levels,
hypoxemia, hypercarbia, hypocarbia, respiratory
distress syndrome, apnea, erythrocyte transfusions, sepsis, intraventricular hemorrhage (IVH),
prolonged parentral nutrition, methylxanthine
administration, and treatment with indomethacin.7-12
Classification and Staging
Arrested Vasculogenesis
Zones
During normal retinal development, the vessels

start at optic disk at approximately 16 weeks of
gestation and migrate towards ora serrata. They
The coordinated developmental sequence

permits the retina to be subdivided in to 3
concentric zones.
353
354

Zone-I, the innermost zone, consists of a circle,
the radius of which subtends an angle of 30
and extends from the disk to twice the distance
from the disk to the center of the macula.
of vascularized and avascular retina. The

demarcation line can develop in any zone
depending upon the level of prematurity and
very premature babies can have it nasally only.
Zones II and III are circular extensions to the area

encompassed by Zone-I, while the zone-III being
the residual crescent of the retina anterior to
zone-II. The periphery of zone-II in the nasal
portion of the retina is the ora serrata, but in
the temporal portion, the junction of zones II
and III cannot be accurately defined clinically.
Thus, all 3 retinal zones are derived from a spatial
coordinate system centered on the optic disk
(Fig. 21.1).
Stage 2: Demarcation ridge

The demarcation line progresses to ridge which
is pink or white elevation of the thickened tissue.
Some neovascular tufts can be seen posterior to
this ridge.
Stage 3: Extraretinal fibrovascular proliferation
Neovascular growth occurs into and above the
ridge. The vessels also grow into the vitreous
and can lead to vitreous hemorrhage (Fig. 21.2).
Fig. 21.1: Standardized zones of retina used for

classification and documentation of ROP
Documentation
International Classification of ROP
The International Classification of Retinopathy
of Prematurity (ICROP) was a consensus statement of an international group of retinopathy
of prematurity experts.13 The original classification has facilitated the development of large
multicenter clinical treatment trials and furthered
our understanding of this potentially blinding
disorder. The different stages described by ICROP
are as follows:
Stage 1: Demarcation line

Earliest feature of ROP in a premature baby is
the development of a flat white line at the junction
Fig. 21.2: Stage 3 ROP: 6 clock hours of extraretinal

neovascularization with demarcation ridge inferiorly
Stage 4: Partial retinal detachment

With progressive growth into the vitreous,
contraction of the fibrovascular proliferation
exerts traction on the retina, leading to partial
retinal detachment (Stage 4 ROP), either without
foveal involvement (Stage 4A) (Figs 21.3 and 21.4)
or with foveal involvement (Stage 4B).
Stage 5: Total retinal detachment
These retinal detachments are always funnelshaped and their configuration can further be
described as open and closed anteriorly and open
or closed posteriorly (Fig. 21.5).
Fig. 21.3: Early Stage 4A ROP: Traction along the

ridge with peripheral retinal detachment
Fig. 21.6: Zone-I ROP with plus disease
Plus Disease and Rush Disease
Fig. 21.4: Stage 4A ROP: Tractional retinal

detachment not involving macula
Plus disease is defined as dilated and tortuous

blood vessels at posterior pole along with
pupillary rigidity and media haziness (Fig. 21.6).
Rush disease is defined as rapid progression
through the three stages of ROP, with plus disease
and retinal detachment occurring within a few
weeks.14 It often occurs in the zone-I and the
smallest babies are frequently affected. Failures of
treatment are highest in this group and hence such
eyes need prompt and aggressive management.
Recently, an international group of pediatric
ophthalmologists and retinal specialists has
developed a consensus document that revises
some aspects of ICROP.15 The aspects that differ
from the original classification include
introduction of (1) the concept of a more virulent
form of retinopathy observed in the tiniest babies
(aggressive, posterior ROP), (2) a description of
an intermediate level of plus disease (pre-plus)
between normal posterior pole vessels and frank
plus disease, and (3) a practical clinical tool for
estimating the extent of zone-I.
Threshold ROP (Figs 21.7A and B)

Fig. 21.5: Stage 5 ROP: Total retinal detachment
with white reflex
Threshold ROP is defined as Stage 3 + ROP in

zone-I or -II occupying at least 5 contiguous clock
355
356
Figs 21.7A and B: Threshold ROP. A prelaser and B postlaser ablation
hours or 8 noncontiguous clock hours of retina.

The Cryo-ROP trial found that 62% of the
untreated eyes as compared to 44% of the treated
eyes with threshold ROP progressed to
unfavorable outcome5 (Table 21.1).
Prethreshold ROP
Prethreshold ROP is defined as any stage of ROP
in zone-I with plus disease and ROP stage 3
plus with 3 contiguous or 5 noncontiguous clock
hours of involvement of retina in zone-II, but

less than threshold stage.
ROP may not progress through all these
stages sequentially. ROP in zone-I frequently
progresses to stage 3 without an intervening
demarcation line or ridge. With advancements
in neonatal support and intensive care units and
increasing availability of screening modules more
and more prematures are being diagnosed ROP
in zone-I, which progresses at a faster rate and
almost always to threshold stage. Therefore,
TABLE 21.1: CATEGORIES OF STRUCTURAL OUTCOME5

Favorable
Unfavorable
(1) Essentially normal posterior pole (near periphery

and zone-I), including angle of vessels
(2) Abnormal angle of major temporal vascular arcade
in the posterior pole
(3) Macular ectopia
(4A) Stage 4A partial retinal detachment, also including
retinoschisis, or fold in the posterior pole (fovea spared)
(4B) Stage 4B partial retinal detachment, also including

retinoschisis, or fold, all with foveal involvement
(4C) View of macula (and presumably patients central
vision) blocked owing to partial cataract, partial retrolental
membrane, or partial corneal opacity due to retinopathy
of prematurity (ROP)
(5) Stage 5 total retinal detachment, or total retinoschisis,
or retrolental membrane (blocking all view of fundus)
(5A) Entire view of posterior pole and near periphery
blocked by total cataract or total corneal opacity from
ROP.
(6) Enucleation for any reason
Unable to grade (UG)

Unable to determine (e.g. view impossible because of corneal opacity unrelated to ROP or because of miotic
pupil)
None of the above (e.g. extreme vascular attenuation and optic atrophy)

zone-I eyes and high risk zone- II eyes should
be treated earlier. This issue was addressed in
the multicenter study of Early Treatment for
Retinopathy of Prematurity (ETROP). 6
Comparison between untreated eyes, high risk
pre-threshold eyes treated early, and high-risk
eyes treated at threshold demonstrated that
retinal ablative therapy is beneficial for
preventing unfavorable outcome.
The ETROP concluded that the early
treatment can be considered for Type 1 ROP
defined as; (a) Any eye that has any stage of
ROP in zone-I with plus disease, (b) Stage 3 ROP
in zone-I with or without plus disease and (c)
Stage 2 or 3 ROP in zone-II with plus disease.
Screening for ROP

The natural history data from the CRYO-ROP
and other studies were combined to answer the
question of when to begin and conclude
screening for acute ROP (Table 21.2).
Screening Procedure
Screening is best done at Neonatal ICU along
with trained neonatology staff to monitor vital
parameters during examination.
Mydriasis can be achieved by 2.5% phenylephrine and 0.5% tropicamide instilled thrice
at an interval of 15 mins.
Instruments required include: 28 D/20 D lens,
pediatric scleral depressor, pediatric lid speculum (Fig. 21.8) and indirect ophthalmoscope.
Since examination with lid speculum and
scleral depressor is often distressing to the
infant, presence of a pediatrician is extremely
useful.
Examination should be carried out with
utmost gentleness and minimal possible
illumination. A quick examination of the
posterior pole gives impression whether the
plus disease is present or not. Screening all
along the 4 major blood vessels in four
quadrants up to the retinal periphery should
be carried out.
TABLE 21.2: GUIDELINES FOR SCREENING AND FOLLOW-UP EXAMINATION

Screening criterion
First examination
By 32 weeks postmenstrual age or 4 weeks chronological age whichever

is earlier
Follow-up
Final examination
All infants with a birth weight < 1500 gm

All infants born at postmenstrual age of 32 weeks or earlier
All infants weighing between 1500 and 2000 gm requiring supplemental
oxygen, or with an unstable clinical course
48-72 hours
(a) After treating threshold ROP

(b) High risk prethreshold ROP (consider treatment if in zone-I)
Weekly
(a) Retinal vessels immaturity with vessels ending in zone-I but no ROP
in that zone
(b) Low risk prethreshold ROP
Fortnightly
(a) Retinal vessels immaturity with vessels

zone-III but no ROP in that zone
(b) Less than prethreshold ROP in zone-I
ending
in
zone-II
or
(a) Attainment of 45 weeks post-menstrual age without development

of ROP
(b) Progression of retinal vascularization into zone-II without previous
zone-II ROP
(c) Full vascularization within 1 disk diameter of the ora serrata on two
occasions
357
358
A
C
B
Figs 21.8A to C: The instruments required for screening: A scleral depressor, B speculum,
C condensing lens for indirect ophthalmoscope
Retcam
The Retcam (Fig. 21.9) is a real time wide-angle
(120-130 degrees) digital imaging system for
viewing pediatric eyes manufactured by Massie

Research Laboratories, Dublin CA. Retcam fills
the need for wide-field imaging and is fully digital
enabling efficient assessment and monitoring.
Nearly the entire retina is documented with only
five images. Real-time imaging display provides
immediate feedback. Inexpensive digital image
storage eliminates film. One is able to retrieve
and manage patient information with built-in
image database and also transmit images to
colleagues. Retcam II is the latest addition to
the series with newer benefits like flat LCD color
display, frame by frame video review and 20
second video capture especially useful for
fluorescein angiography.
Intervention for ROP

Cryotherapy
Fig. 21.9: Retcam
The most detailed and comprehensive data

regarding the safety and efficacy of ROP was
made available by the multicenter trial of
Cryotherapy for Retinopathy of Prematurity
(CRYO-ROP) study.2-5 The study was carried out
in 23 centers across USA. CRYO ROP results
indicated an unfavorable outcome in 25.7% of
the eyes that received cryotherapy compared with
47.4 % of the control eyes. Though the data signify
a definite advantage of treatment over no
treatment but the rate of 25% blindness is still
very high.

Laser Ablation
Laser treatment applied through laser indirect
ophthalmoscope (LIO) has become the method
of choice for treatment of threshold and high
risk prethreshold ROP.16-19The cryotherapy is also
effective in decreasing the incidence of
unfavorable outcome, but laser has following
advantages:
1. The laser is more precise than cryo in treating
the retina, especially for the areas near the
ridge and thus reduces the risk of vitreous
hemorrhage.20
2. Laser is less painful and allows treatment
under a topical anesthesia with sedation and
monitoring.
3. Laser leads to lesser dispersion of the retinal
pigment epithelial cells and less or no
breakdown of blood-retinal barrier.21
4. Laser photoablation seems to be particularly
effective for zone-I disease.20 The diode laser
(810 nm) has the advantage of being portable
so that it can be easily transported to the
neonatal intensive care unit.22
The treatment is carried out in presence of
a trained neonatologist, who monitors the infant.
An intravenous infusion maintains the hydration
of the infant. Adequate sedation is achieved by
administration of oral sedative one hour prior
to the surgery.
The treatment is applied in a near confluent
pattern with moderate intensity burns placed
half burn apart covering the whole avascular
area.16 However, new vessels are not to be treated.
The combination of 20 D and 28 D lenses with
scleral indentation is utilized to approach
different areas. Continuous monitoring by a
trained neonatologist is essential during laser
ablation. Any suspicion of severe apneic episode
should lead to curtailment of the treatment, which
can be planned at a later date. It is not infrequent
to find large skip areas in the eyes treated by
beginners, so all attempts should be made to
do maximum laser photocoagulation in the entire

avascular area. Reevaluation after 48 hours to
assess the disease progression and the adequacy
of the photocoagulation is most vital. Presence
of plus disease and of skip areas usually guides
the advisability of the supplementary treatment.
The infants showing definite signs of regression
like disappearance of plus disease can safely
be followed-up after a week. Other infants should
be reexamined after 3 days. It is to be stressed
that while more than 90% of cases with ROP
will regress, a significant percentage of cases
will keep progressing despite laser therapy.23
Complications of laser treatment are few. Besides
systemic problems like apneic episodes, ocular
side effects include iris atrophy, posterior
synechiae and cataract.24
Surgical Intervention
Scleral Buckling
The buckling is done for stage 4A ROP. After
performing 360-degree limbal peritomy, a band
is passed under the four recti and tied. Indirect
ophthalmoscopic examination is done to ensure
adequate retinal and choroidal perfusion and
position of the buckle. Care should be taken to
avoid pulling the band too tight. Within a year
of surgery, the scleral band is divided or removed
to permit growth of the globe and orbit. Buckling
does reduce the progression of stage 4 to stage
5 ROP.25, 26
Vitrectomy
Pars plana vitrectomy is being increasingly
utilized to manage advanced ROP cases.27-31
Although recent reports describe encouraging
anatomical results, the functional results have
been disappointing so far.28, 30 The vitrectomy
is usually performed for stage 5 ROP.27 The lens
sparing vitrectomy for stage 4a and 4b has also
359
360

been reported to result in better outcomes as
compared to scleral buckling.28-31
The entry sites are usually made at the limbus.
Most cases require removal of the crystalline lens.
A 20-gauge knife is used to make a slit incision
in the dense retrolental membrane and the tissue
is dissected away from the retina with scissors
and forceps. Removal of the transvitreal extraretinal fibrovascular proliferative membrane,
which is in the plane of the anterior hyaloid
surface, is effected from the center to peripheral.
Retinal troughs and folds are opened.
Viscodissection is extremely helpful for this
purpose. At the conclusion, air-fluid exchange
is performed to push the retina further back.
The timing of the intervention is important
for both anatomical and functional results. Early
intervention is desirable in terms of visual
function, but anatomical results were not more
favorable in very young infants. The membrane
in older infants is thinner, adhesion to the retina
is weaker, and active neovascularization is
absent. Membrane removal from the retina is
easier, but visual recovery is poor.
Visual Rehabilitation and Parental

Counseling
Management of ROP involves not only a proper
follow-up of neonates with prompt laser ablation
at the required stage and/or vitreoretinal surgery,
but also a proper refraction including low vision
aid assessment. As well, parents need to be
educated about the severity of the disease and
to cope with psychosocial issues in children
disabled due to ROP.
Conclusion
ROP is becoming a major cause of blindness
among children worldwide because of the
introduction of the neonatal intensive care
services for preterm and low-birth-weight babies.

The future challenge is to make accessible to
these infants laser, cryo or surgical treatment.
To conclude, recent surgical advances have made
ROP from untreatable to manageable in most
cases. The investigators need to focus on
improving the surgical techniques for stage 4
and stage 5 ROP, preventing the prematurity
and preventing the development of ROP.
References
1. Terry TL. Extreme prematurity and fibroblastic
overgrowth of persistent vascular sheath behind
each crystalline lens. Am J Ophthalmol 1942;25:20304.
2. Cryotherapy for Retinopathy of Prematurity
Cooperative Group. Multicenter Trial of
Cryotherapy for Retinopathy of Prematurity:
preliminary results. Arch Ophthalmol 1988;
106:471-79.
one-year outcomestructure and function. Arch
Ophthalmol 1990;108:1408-16.
Snellen visual acuity and structural outcome
at 5 years after randomization. Arch Ophthalmol
1996;114:417-24.
Cooperative Group. Ophthalmological
outcomes at 10 years. Arch Ophthalmol 2001;
119:1110-18.
6. Early Treatment for Retinopathy of Prematurity
Cooperative Group. Revised indications for the
treatment of retinopathy of prematurity: results
of the Early Treatment for Retinopathy of
Prematurity Randomized Trial. Arch Ophthalmol
121:1684-96.
7. Darlow BA, Horwood LJ. Retinopathy of
prematurity: risk factors in a prospective
population-based study. Paediatr Perinat
Epidemiol 1992,6:62-80.

8. Flynn JT, Bancalari E, Snyder ES, et al. A cohort
study of transcutaneous oxygen tension and
the incidence and severity of retinopathy of
prematurity. N Engl J Med 1992;326:1050-54.
9. Hammer ME, Mullen PW. Logistic analysis of
risk factors in acute retinopathy of prematurity.
10. Palmer EA, Flynn JT, Hardy RJ, et al. Incidence
and early course of retinopathy of prematurity.
11. Schaffer DB, Palmer EA, Plotsky DF, et al.
Prognostic factors in the natural course of
retinopathy of prematurity. Ophthalmology
1993;100:230-37.
12. Shohat M, Reisner SH, Krikler R, et al.
Retinopathy of prematurity: incidence and risk
factors. Pediatrics 1983;72:159-63.
13. The Committee for the Classification of
Retinopathy of Prematurity. An International
Classification of Retinopathy of Prematurity.
14. Pierce E, Peterson R, Smith L. Retinopathy of
prematurity. In: Principles and Practice of
Ophthalmology. Jakobiec A. (Ed). WB Saunders,
Philadelphia, PA 2000;4443-59.
15. An International Committee for the
Classification of Retinopathy of Prematurity.
The International Classification of Retinopathy
of Prematurity Revisited. Arch Ophthalmol
2005;123:991-99.
16. Fallaha N, Lynn MJ, Aaberg TM Jr, Lambert
SR, Clinical Outcome of Confluent Laser
Photoablation for Retinopathy of Prematurity.
J AAPOS 2002;6:81-85.
17. Paysse EA, Lindsey JL, Coats DK, Contant CF,
Steinkuller PG. Therapeutic outcomes of
cryotherapy versus transpupillary diode laser
photocoagulation for threshold retinopathy of
prematurity. J AAPOS 1999;3:234-40.
18. Connolly BP, McNamara A, Regillo CD, Tasman
W, Sharma S. Visual outcomes after laser
prematurity. Ophthalmology 1999;106:1734-8.
19. Connolly BP, McNamara A, Sharma S, Regillo
CD, Tasman W. A comparison of laser
photocoagulation with trans-scleral cryotherapy
in the treatment of threshold retinopathy of
20. Hammer ME, Pusateri TJ, Hess JB, Sosa R,

Stromquist C. Threshold retinopathy of
prematurity.Transition from cryotherapy to laser
treatment. Retina 1995;15:486-89.
21. Hunter DG, Repka MX. Diode laser
22. McNamara JA. Laser treatment for retinopathy
of prematurity. Curr Opin Ophthalmol 1993,4:7680.
23. Hartnett ME, McColm JR. Retinal features
predictive of progressive stage 4 retinopathy
of prematurity. Retina 2004;24(2):237-41.
24. Ibarra MS, Capone A Jr. Retinopathy of prematurity and anterior segment complications.
Ophthalmol Clin North Am 2004;17(4):577-82.
25. Chuang YC, Yang CM. Scleral buckling for stage
4 retinopathy of prematurity. Ophthalmic Surg
Lasers 2000;31(5):374-79.
26. Noorily SW, Small K, de Juan E Jr, Machemer
R. Scleral buckling surgery for stage 4B
retinopathy of prematurity. Ophthalmology 1992;
99(2):263-68.
27. Gopal L, Sharma T, Shanmugam M, Badrinath
SS, Sharma A, Agraharam SG, Choudhary A.
Surgery for stage 5 retinopathy of prematurity:
the learning curve and evolving technique. Indian
J Ophthalmol 2000;48(2):101-06.
28. Seaber JH, Machemer R, Eliott D, Buckley EG,
deJuan E, Martin DF. Long-term visual results
of children after initially successful vitrectomy
for stage V retinopathy of prematurity.
Ophthalmology 1995;102(2):199-204.
29. Hartnett ME, Maguluri S, Thompson HW,
McColm JR. Comparison of retinal outcomes
after scleral buckle or lens-sparing vitrectomy
for stage 4 retinopathy of prematurity. Retina
2004;24(5):753-57.
30. Prenner JL, Capone A Jr, Trese MT. Visual
outcomes after lens-sparing vitrectomy for stage
4A retinopathy of prematurity. Ophthalmology
2004;111(12):2271-73.
31. Hubbard GB, Cherwick DH, Burian G. Lenssparing vitrectomy for stage 4 retinopathy of
prematurity. Ophthalmology 2004; 111(12): 227477.
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362
AMIT NAGPAL, LINGAM GOPAL
22
Localization of
Intraocular
Foreign Body
Intraocular foreign body (IOFB) is defined as an

intraocular retained unintentional projectile. Of
all open globe injuries, 18-41% harbor IOFB.1
Most of such injuries occur in the 20-40 years
age group. 2 This being the most productive age,
the effect on the economy is significant. The most
common type of injury associated with IOFB is
metal on metal injury exemplified by hammering
activity (60-80%). 3-5 Power machine tools
contribute to 18-25% of IOFBs and weapon
related injuries contribute to about 19%.3-5
Seventy to 90% of IOFBs are metallic and 80%
of these are magnetic which has a significant
bearing on the management and the ease with
which the FB can be extracted from the eye.
Types of Intraocular Foreign

Bodies
As alluded to, IOFBs can be broadly grouped
under metallic and non-metallic. Metallic foreign
bodies can be magnetic such as iron and some
of its alloys and nonmagnetic. Among the nonmagnetic foreign bodies the most important are
lead foreign bodies seen in bullet injuries. Brass
and other metal pieces can be seen in explosive
injuries such as bomb blasts. Glass forms the
most frequently encountered non-metallic foreign

body. Other non-metallic foreign bodies include
wooden pieces classically seen with broomstick,
and caterpillar hair.
History of Injury
History can guide the clinician as to the possibility
of the IOFB being present in a given eye and
as well as the type of IOFB. From the management
perspective, it is important to note the type of
instrument or tool being used at time of the injury.
In cases of metal on metal, the identity of the
IOFB is fairly certain. Injuries in a rural set up
are likely to be due to thorn and plant twigs
and could be associated with high incidence of
fungal infection. The findings of the surgeon who
examines the patient immediately after the injury
would be very important because subsequently
visualization of the fundus becomes difficult due
to hazy media.
Thorough slit-lamp examination can provide very
useful information.
Localization of Intraocular Foreign Body

Cornea
Caveats
Corneal entry wound can often be made out

easily. However, fine linear corneal scars can
be missed unless one looks for them carefully.
The size of the corneal wound is usually smaller
than the foreign body since the foreign body
traveling at a high velocity is able to stretch the
elastic tissues. Presence of localized corneal
edema especially inferiorly can be indicative of
foreign body lying at 6 oclock angle.
1. Glass IOFB in anterior chamber can be

particularly difficult to see even on slit-lamp
examination.
2. Gonioscopy may be the only way to identify
a small foreign body in the angle.
3. Foreign body located in the ciliary body area
is difficult to identify by both slit-lamp
evaluation and fundus examination.
Iris
Fundus Examination
Presence of iris hole is a very important clue

to the presence of the IOFB. The relationship
between the location of the iris hole and the
corneal scar also indicates the direction in which
the foreign body was traveling. Iris hole can be
hidden under a dense arcus senilis. Presence
of siderosis bulbi may be evident on slit-lamp
examination of the iris and lens. The rusty
brownish hue is striking.
Evaluation of fundus using indirect ophthalmoscopy cannot be over emphasized. Since the
injury is likely to produce vitreous hemorrhage
and vitritis, the visualization of fundus details
may deteriorate very rapidly. Therefore, the initial
fundus examination should be as thorough as
possible. The documentation of fundus findings
made by the first examiner is often valuable for
the subsequent ophthalmologist who may be
called upon to manage the case.
Binocular indirect ophthalmoscopy with
scleral indentation may detect IOFB (Fig. 22.1),
Lens
Presence of a track of foreign body in the lens
can be seen occasionally. However, in most cases
lens opacity rapidly becomes total. Intactness
of posterior capsule can be assessed sometime
clinically and if not possible by slit-lamp
examination, then the ultrasound evaluation is
recommended. If the vitreous is perceived to be
clear and posterior capsule is intact despite lens
injury, one can presume that the FB is located
in the anterior segment. On occasions, foreign
body can traverse across the zonule of the lens
without disrupting the lens. Hence corneal
wound with presence of intact posterior capsule
does not necessarily exclude the possibility of
posterior segment foreign body. Intralenticular
foreign body can be obvious on slit-lamp
examination.
Fig. 22.1: Showing a large metal foreign body on

the retina
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364

if the media are clear enough. In delayed cases,
the IOFB may be surrounded by fibrous capsule
and could be missed. In case of iron foreign
bodies present on the retina for significant period
of time, one may find tell tale signs of localized
siderosis bulbi. Large glass pieces may evade
clinical detection with ophthalmoscopy if they
are embedded in the peripheral opaque vitreous
following vitreous hemorrhage.
Signs in the fundus that may facilitate
localization of foreign body:
1. Vitreous track formed by blood may point
to the location of foreign body
2. Intra-retinal hemorrhage may indicate the site
of impaction of foreign body. On occasion,
the foreign body may hit the retina and
ricochet to another location or fall down to
the inferior periphery. Therefore, inferior
periphery should be inspected carefully if
foreign body is not located elsewhere.
3. Signs of double perforation of globe indicate
the presence of foreign body in the ocular
coats posteriorly or even behind the eye in
the orbit.
two probes that can be used intraoperatively by

covering them with sterile sleeves. One probe
has higher penetrance and is used to grossly
locate the foreign body to a quadrant. The second
probe is more sensitive for precise localization.6
Ultrasonography
A combined B- and vector A-scan is the easiest
way of evaluating the eye for presence of IOFB7
(Figs 22.2 and 22.3). A 10 Mega hertz (MHz)
probe is routinely employed. A 20 MHz probe
Electrical Induction Methods for

Localization of IOFB
Fig. 22.2: Ultrasound B-scan showing metallic IOFB

near the retinal surface
The Berman and Roper-Hall localizers are purely

of historic importance. Induction is a physical
phenomenon wherein an alternating current
passed through a primary coil will induce current
in a secondary circuit. If the voltage in the
secondary circuit is equalized, no current flows
between them. If such an instrument approaches
a metallic foreign body, a difference in potential
is created in the secondary circuit resulting in
a flow of current. Roper-Hall localizer gives audio
signal if foreign body is metallic. A continuous
sound is heard for an iron foreign body and
a discontinuous sound for a nonferrous metal
foreign body. The instrument is provided with
Fig. 22.3: Ultrasound B-Scan showing large piece of

metallic IOFB with orbital shadowing

can give higher resolution. For anteriorly located
IOFB, one may have to use immersion scan or
stand off or use ultrasound biomicroscopy.
Since the injured eye could potentially have
a wound that can open on pressure, the
ultrasonography should be done very gently. For
the same reason, ultrasonography is done over
closed lids.
Features
Foreign bodies are characterized by a high
echogenecity. They are seen as dense white spots
on gray scale display and persist even at low
gain. Depending on the size, reverberating echoes
may also be seen. Metal and stone have a high
echogenecity, more than any other normal
structure except bone. Wood and vegetable
matters reflect only intermediate amplitude
echoes. Glass gives a high amplitude echoes only
when the ultrasound beam strikes the surface
of the glass with perpendicular incidence.
Caveats
Very large foreign bodies can cause shadowing.
Linear glass foreign bodies can sometimes
produce misleadingly low amplitude echoes due
to the ultrasound beam not being perpendicular
to the surface of the foreign body. With regards
to foreign bodies in the eye wall, it may be difficult
to be certain whether the foreign body is closer
to the vitreous cavity or scleral surface. The
shadowing caused by the foreign body will make
it difficult to assess the integrity of the coats of
eyeball. Very anteriorly located foreign bodies
and small foreign bodies entrapped in dense
vitreous hemorrhage can be missed by routine
ultrasonography. Air bubble in the vitreous cavity
can mimic IOFB due to the high reflectivity.
However, air tends to float in the vitreous cavity
and hence is located in the nondependent
position irrespective of the position of the head.
Multiple foreign bodies can present bizarre echo

patterns. Foreign body with irregular surface can
give the impression of multiple foreign bodies.
Organic matter degrades with time and the IOFB
could be difficult to detect.
The injury related damage to the retina,
choroid and the vitreous can be detected on
ultrasonography. One should look for the
presence or absence of choroidal detachment
(hemorrhagic or serous), retinal detachment and
vitreous detachment. Vitreous incarceration in
the posterior coat of the eye indicates possible
site of double perforation. In general, echography
tends to overestimate the size of an IOFB.
Ultrasound Biomicroscopy
Ultrasound biomicroscopy (UBM) is a relatively
new investigational modality. Using a 50 MHz
probe, the resolution is increased multifold at
the expense of penetrance. Foreign bodies located
in the anterior segment can be well imaged with
this modality. Foreign bodies located beyond the
posterior capsule of the lens cannot be reached
because of the low penetrance. Since the
investigation can only be done in contact with
the globe, it is obviously contraindicated in eyes
with open globes or precariously approximated
wounds. IOFB such as caterpillar hair can only
be picked up with UBM.8
Radiological Methods
Computerized tomography has replaced most
of the other radiological methods in the
investigation of injured eye with suspected IOFB.
However, from the historical perspective, these
methods are reviewed.9
Direct Methods
a. Plain X-ray, true lateral view: The affected
side is towards the film with infraorbital line
at right angles to the film.
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366

b. Plain X-ray, posteroanterior view (PA-Waters
view): The nose-chin position allows good
view of maxillary region since the bony
shadow of petrous temporal bone is excluded.
The face is placed against the film with the
orbito-mental line tilted at an angle of 15
degrees to the horizontal.
Methods Based on Rotational

Movements of the Eye
a. Movement of the eye in lateral position:
Three exposures are made on the same film
arranged for a true lateral view. With the
head steadily placed, exposures are made
with the eye looking straight, up and down.
If the foreign body moves with the eye, three
images of the foreign body will be seen. This
is indicative of the presence of foreign body
in the eye.
b. Use of limbal ring: A metallic ring made of
either silver or steel of suitable diameter is
sutured to the limbus. The same procedure
as described above is followed for the lateral
view. In addition, a posteroanterior view Xray is also taken. In a perfect true lateral view,
the limbal ring is imaged as a straight line
corresponding to the limbus. Three such lines
will be seen corresponding to the three
positions of the eyeball. An outline of the eye
can be drawn using the limbal ring as guide.
The location of the foreign body can be
identified with respect to the outline drawn.
Movement of the foreign body with respect
to the ring movement also gives a clue as to
the location of the foreign body. The
posteroanterior view gives the clock meridian
location of the foreign body while the lateral
view gives the anteroposterior location.
Movement of the foreign body with the ring
indicates that the FB is within the eyeball
while if it does not move it is likely to be extraocular. There are obviously a lot of fallacies
in the interpretation. A foreign body stuck to

the eye wall is likely to move to the same extent
as the ring while one in the vitreous cavity
is likely to move more or less than the limbal
ring. Foreign body in the center of rotation
of the eye will not move while a foreign body
in the extra ocular muscle, although outside
the eyeball will move with the contraction of
the extra ocular muscle. Suturing a ring to a
recently traumatized eye is not a pleasant
procedure and could be associated with risk
of further damage if the globe has precariously
approximated wound.
c. Radio opaque markers: Other radio opaque
markers that have been used are contact lens
with 4 radio opaque dots incorporated in it.
Method Based on Different Angle of

Exposure to X-rays
a. Sweets method: Using two reference
markers, one located just in front of the cornea,
and the other temporal to it, two exposures
of X-ray are taken from two different directions on the same plate. The superimposition
of the markers on the plate along with the
foreign body permits the localization of the
foreign body. However, the calculations are
cumbersome.
b. Other methods: Similar to Sweets method
there are others methods such as Mac
Kenzies method, Dixons method, Bromleys
method, and Mc Rigors method. None of
them are in vogue now.
Use of Contrast Material to

Delineate the Globe
This method envisages injection of radio opaque
dye into the subTenons space with a view to
delineate the globe surface and use it as a
reference to locate the FB. This technique for
obvious reasons is obsolete.

Computerized Tomographic Scan
Computerized tomographic scan (CT-scan) has
replaced all other radiological methods for
localization of IOFB. It is noninvasive and does
not need placement of any radio opaque marker
on or near the injured eye. It images the orbit
equally well and hence superior to ultrasonography from that perspective. It enables the
localization of the foreign body easily in vitreous
(Figs 22.4 and 22.5) and very precisely in the
coats of eyeball (Fig. 22.6). Associated damage
Fig. 22.6: CT-scan showing a metallic IOFB within
the ocular coats with retinal detachment
to the orbital bones and brain can also be

evaluated. Multiple foreign bodies can be easily
identified. For foreign bodies of more than 0.06
cu mm in size, the sensitivity is 100%.10 However,
soft tissue details inside the eye cannot be seen
well. For detecting small IOFBs, high-resolution
scans with overlapping slices are needed.
Wooden foreign bodies are not easily imaged
by CT scan.
Magnetic Resonance Imaging (MRI)

Fig. 22.4: CT scan showing a piece of metallic wire
within the vitreous cavity.
In general, magnetic resonance imaging (MRI)

is not indicated in detection of IOFBs. In the
presence of magnetic IOFB it can be positively
harmful. The application of powerful magnetic
field can move the magnetic IOFB and damage
the intraocular structures.11 However, wooden
IOFBs are best picked up on MRI.
References
Fig. 22.5: CT-scan showing metallic IOFB within mid

vitreous cavity
1. Shock JP, Adams D. Long-term visual acuity

results after penetrating and perforating injuries.
2. Punnonen E, Laatikainen L. Prognosis of
perforating eye injuries with foreign bodies.
Acta Ophthalmol 1989;66:483-91.
3. Roper-Hall MJ. Review of 555 cases of intraocular
foreign bodies with special reference to the
prognosis. Br J Ophthalmol 1954;38:65-99.
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368

4. Williams DF, Mieler WF, Abrams GW, Lewis
H. Results and prognostic factors in penetrating
ocular injuries with retained intraocular foreign
bodies. Ophthalmology 1988;95:911-16.
5. Percival SPB. A decade of intraocular foreign
bodies. Br J Ophthalmol 1972;56:454-61.
6. Duke-Elder S. System of ophthalmology vol
14 Part I- Mechanical injuries. Intraocular foreign
bodies. Henry Kimpton. London 1972;570-72.
7. Bhende M , Gopal S, Gogi A, Sharma T, Gopal
L, Lekha G, Sen P, Menon S. In The Sankara
Nethralaya Atlas of Ophthalmic Ultrasound.
New Delhi: Jaypee Brothers Medical Publishers,
2006;61-68.
8. Bhende M, Biswas J, Sharma T, Chopra SK,
Gopal L. Ultrasound biomicroscopy in the

diagnosis and management of pars planitis
caused by cater pillar hairs. Am J Ophthalmol
2000;130:125-26.
9. Duke-Elder S. System of ophthalmology vol
14 Part I- Mechanical injuries. Intraocular foreign
bodies. Henry Kimpton. London 1972;579-611.
10. Chacko JG, Figueroa RE, Johnson MH, Marcus
DM, Brooks SE. Detection and localization of
steel intraocular foreign bodies using computed
tomography. Ophthalmology 1997;104:319-23.
11. Ta CN, Bowman RW. Hyphema caused by a
metallic intraocular foreign body during
magnetic resonance imaging. Am J Ophthalmol
2000;129:533-34.
Comitant Strabismus: Diagnostic Methods
HARINDER SINGH SETHI, PRADEEP SHARMA
23
Comitant
Strabismus:
Diagnostic Methods
Introduction
A strabismus or squint is a misalignment of the
two eyes when they do not point together towards
the same object. This may take the form of one
or other eye turning in (convergent strabismus)
or out (divergent strabismus). Occasionally, one
eye may be higher than the other (vertical
strabismus). The strabismus may be constant
(present at all times) or occur only intermittently.
In a comitant strabismus there is a full range
of movement of each eye.
Incidence
It is estimated that a strabismus occurs in about 5%
of the population. Most strabismus develops in the
first few years of life with the majority appearing
either in the first or the third year of life.
Etiology
Both eyes are moved by six muscles and the
movements of the two eyes are linked by reflexes
which are normally fully developed within six
months of birth. A strabismus occurs because
of the failure of these reflexes to develop fully
in early life. In most cases the reason for this
failure of the reflexes to develop is unclear. In
some cases the development of the strabismus
is related to uncorrected refractive error, trauma

and general ill health.
Comitant Strabismus
Comitant strabismus is usually congenital. It is
not associated with diplopia. Extra-ocular
muscles and nerves are often normal. The angle
between the longitudinal axes of the eyes remains
constant on testing eye movements. Both eyes
have full movement if tested separately. There
is excess tone in one muscle compared with its
antagonist resulting in deviation of the eye.
Types of Comitant Strabismus

Convergent strabismus termed esotropia
Divergent strabismus termed exotropia
A and V syndromes
The examination of strabismus requires a few
equipments, a list of essential and desirable
equipments is given in the Table 23.1.
Examination of a Case of Strabismus

The examination of a case of strabismus requires
assessment of:
1. The motor status
2. The sensory status
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370

TABLE 23.1: ESSENTIAL AND DESIRABLE EQUIPMENTS FOR EXAMINATION OF STRABISMUS
Essential equipments
Desirable equipments
Prism bars: horizontal and vertical prism bars and loose

prisms set, at least 30 and 45 prism diopter prisms
Occluder
Fixation targets for distance and near to control the
accommodation as desired,
trial set with prisms of
1 to 8 pd
Bagolinis striated glasses
Red and green goggles.
Double Maddox rod set
Snellen chart with letters and E in rows and a single
letter E chart
Protractor with a foot ruler
Direct ophthalmoscope
Randot stereotest
Synoptophore
Hess chart or Lees screen
Perimeter
Indirect ophthalmoscope
Teller acuity cards with screen
Haidinger brushes and after images
attachment for synoptophore
Spielmann occluder, translucent or one way reflecting
Optico Kinetic Nystagmus (OKN) drum
VER
Digital camera
Electronystagmography and videonystagmography
system
Examination of Motor Status

The examination of the motor status includes:
1. Head posture
2. Ocular deviation
3. Limitation of movements or the extent of the
versions
4. Fusional vergences.
Head Posture
Observation of head posture starts at the first
glance of the patient, as he enters the clinic. He
must not be made conscious of keen observation.
Much of information is lost after the patient
becomes conscious of being examined. Head
posture has three components:
(a) Chin elevation or depression (vertical),
(b) Face turn to right or left side (horizontal) and
(c) Head tilt to right or left shoulder (torsional).
These three components at three different
joints between head and neck may correct the
motility disturbances in the three directions. The
patient prefers a head posture at which the ocular
deviation is the least, and image can be fused.
Rarely, a head posture which causes the maximal
deviation is chosen so that the peripheral image
can be easily suppressed or ignored.
Common causes of abnormal head posture

are tabulated in Table 23.2.
TABLE 23.2: CAUSES OF ABNORMAL HEAD
POSTURE
1. Incomitant strabismus either paralytic, restrictive, or
musculofascial anomalies
2. Comitant strabismus with A and V phenomenon; chin
up in a V-exotropia or A-esotropia and chin down
in V-esotropia and A-exotropia
3. Nystagmus cases with a null position
4. Under corrected glasses with the peripheral stronger
power or a wrong cylinder axis
5. One eyed persons
6. Homonymous hemianopia
Ocular torticollis is a classic example of an

abnormal head posture seen in a patient with
congenital superior oblique palsy who maintains
a binocular vision in spite of the congenital defect.
Such cases may present later with their head
posture forcibly corrected. An old photograph
of the patient helps in diagnosing the condition
and rule out a supposedly acute onset. The head
posture in a case of left superior oblique (LSO)
palsy will present chin depression, face turn to
the right, and head tilt to the right shoulder.
For comprehension it is told that LSO being a
depressor, chin depression occurs, it being an
intorter, a head tilt towards the opposite shoulder

occurs, and a face turn to the right brings the
eyes in abduction so that the vertical movements
can be executed by the vertical recti. Head posture
ensures that the eye is out of the field of action
of the paralytic muscle.
An asymmetric face requires an asymmetric

adjustment of the optical centers of the spectacle.
The IPD should also be similarly measured with
the patient looking at the distant target (6 m).
There may be slight (2-3 mm) difference between
the near and distance measurements.
Measurement of Interpupillary Distance
Using the Pulzone-Hardy rule

Pulzone-Hardy rule is a special device for
measuring the pupillary distance of each eye.
It has a slot for the nose and the central line
is aligned with the midline of the patient. With
the patient and examiner seated as in the above
method, with the left eye occluded the patient
fixates with his right eye at the examiners left
eye. The vertical wire is moved till it bisects the
pupil. The reading is taken (half IPD). Similarly
the left half IPD is taken. Add the two which
gives the interpupillary distance. Difference
between the two readings indicates asymmetry.
Interpupillary distance (IPD) is the distance

between pupils of the two eyes. The interpupillary
distance is a very important parameter that can
give information about the craniofacial disorders,
a true hypertelorism versus telecanthus and
vergence requirement. It is helpful in proper
centering of the spectacles. Decentered lenses
have prismatic effect and can increase or decrease
an existing deviation, or induce a strabismus
causing eye strain. A narrow interpupillary
distance may predispose, simulates and
accentuates esotropia. A wide IPD gives an
impression of exotropia.
Interpupillary distance can be measured by
following methods:
By an ordinary millimeter scale: A 15 mm rule is
required to measure the IPD. The patient is seated
with the examiner positioned about 33 cm in
front, both in the same vertical plane. The
millimeter rule is placed on the nasal bridge of
the patient in the spectacle plane. The examiner
closes his right eye and asks the patient to look
at his left eye with his right eye (left eye may
be closed). The scale reading bisecting the pupil
is aligned to one. Next the right eye of the patient
is covered and the patient asked to look at the
examiners right eye with his left eye. Again the
scale reading bisecting the pupil of left eye of
the patient is taken. The difference between the
two readings gives the IPD.
It is better to note the scale reading aligned
with the midline of the patient. This gives the
pupillary distance of each eye from the midline
and helps in detecting asymmetry of the face.
Using the synoptophore

The IPD can be simply determined on the
synoptophore. It is considered a first step before
the synoptophore can be used for any measurement. This is done by adjusting the distance
between the two eye pieces each of which can
be separately adjusted and the distance between
the two read on a millimeter scale.
The arms of the synoptophore are kept at
zero and the patient is asked to look at the center
of the slide in the right picture tube with his
right eye. The examiner with his right eye closed,
aligns the central white line on the top of mirror
unit of the tube with the reflection of the light
in the center of patients pupil. The procedure
is repeated with the left eye of the patient similarly
and the IPD read from the millimeter scale. Once
set, it is locked for the different procedures for
the patient.
Ocular Deviation
The examination of ocular deviation is the most
important aspect of strabismus examination as
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it not only establishes strabismus but also
quantifies it. Further it is very important to
differentiate the true strabismus from the apparent
strabismus, i.e. pseudostrabismus which
needs only reassurance to the patient. A cover
test is required to establish the existence of a
strabismus.
Pseudostrabismus
A true strabismus is a misalignment of the two
visual axes, so that both do not meet at the point
of regard. An apparent strabismus is just an
appearance of strabismus in spite of the alignment
of the two visual axes. Apparent strabismus or
pseudostrabismus can be due to an abnormality
of adnexal structures like the lids, canthi or orbits,
or due to abnormal relationship between the visual
axis and optical axis of the eyes. A telecanthus
or a broad nasal bridge covers the nasal bulbar
conjunctiva and gives the appearance of a
convergent strabismus (pseudoesotropia). This
becomes more prominent whenever a lateral gaze
is attempted, the adducting eye getting covered
by the telecanthal fold. Similarly the epicanthus
covers the nasal bulbar conjunctiva to cause a
pseudoesotropia. Neonates and young infants
are commonly suspected to have such a
strabismus. A proper examination can exclude
this and reassure the mothers. A greater interorbital separation (hypertelorism) gives the
appearance of a divergent strabismus (pseudoexotropia). On the other hand, euryblepharon,
a condition with horizontally large palpebral
apertures gives a look of pseudoesotropia.
Similarly, a ptosis or lid retraction can masquerade
as a pseudohypotropia and hypertropia,
respectively. A ptosis may mask an existing
hypotropia or aggravate hypertropia. And a
telecanthus may mask an exotropia and highlight
an esotropia. These appearances, therefore,
assume importance even in a case of strabismus
posted for surgery. The patient should be explained
of the consequence of a surgery in advance to

avoid any discontentment later.
Angle kappa: Angle kappa is the difference between
visual and the optical axis. The visual axis (the
line joining the fovea and the target) is not the
same as the optical or geometric axis (the line
passing through the center of the pupil or cornea).
They differ normally by about + 5, that is the
eye would appear to be looking 5 out (exotropic)
when it looks at any object. This is the natures
mechanism to offset some optical aberrations.
The angle kappa gives a look of exotropia in
spite of perfect alignment, but it is within our
limits of acceptance. When it is more than 5,
as in some hyperopes, it causes pseudoexotropia.
On the other hand, an angle less than 5 or a
negative angle kappa, as in some myopes, causes
pseudoesotropia. Occasionally, displacement of
the macula (heterotopia) can occur in some
conditions like retinopathy of prematurity, leading
to displacement of the corneal reflection. If only
one eye is affected, the squinting appearance is
accentuated. Angle kappa can be measured on
the synoptophore with a special slide.
Detection of a strabismus: A cover-uncover test is
required to confirm the diagnosis of strabismus
and to differentiate it from pseudostrabismus.
It is necessary to perform this test when the
corneal reflections are unequal, or if the history
suggests a strabismus. It is an objective test which
is a cornerstone of the diagnosis and management
of strabismus. It has two components:
1. Observations to be made during covering
(Cover test, Fig. 23.1A) and
2. Observations to be made during uncovering
(Cover-uncover test, Fig. 23.1B).
Cover Test
It is important to have a proper fixation target.
It should be a figure or letter of size 6/9 of Snellen
chart. This is to control the accommodation. A
Figs 23.1A and B: Cover/uncover test: A cover test, B uncover test
fixation achieved by a torch light is not desirable.

Lang fixation stick which has very small figures
is very useful for young children and reduced
Snellen letters or numbers are ideal for the adults
and older children. The fixation distance should
be 33 cm for near and 6 meters for distance. It
is important that target for near should be held
slightly below eye level and for distance it should
be at eye level to avoid a false impression of
strabismus. Thirdly an occluder is required and
in case of children it is the hand or a thumb
which can be used to avoid scarring him.
The subject is asked to fixate on the target
at the requisite distance and an observation is
made whether both eyes appear to fixate (no
apparent strabismus) and one appears to fixate
as the other deviates (apparent strabismus).
Cover test (Observation made during cover test)
The next step is to cover the apparently fixating
eye and observe what happens to the other
(apparently deviating) eye. If that moves to take
up fixation, it confirms the presence of a manifest
or true squint (heterotropia). If one had used a
Spielmann translucent occluder (Fig. 23.2) one
would have observed the eye behind the cover,
deviating. However, if both the eyes appear to
fixate in the first instance, the examiner attempts
to cover either of the eyes to observe the behavior
Fig. 23.2: Spielmann occluder
of the eyes. If it moves to confirm a heterotropia

it would imply a true squint masked by
appearance.
Uncover test (Observations made during
uncovering)
The second part, uncover test is helpful in
unmasking the latent strabismus (heterophoria)
which presents with both eyes appearing to fixate
the target. One of the eyes is covered, which breaks
the fusion, and if there is any heterophoria
(tendency for strabismus) the eye behind cover
deviates (in/out/up/down). The examiner then
observes the behavior of this eye as he removes
the cover. If it remains deviated it confirms a
latent strabismus with poor fusion (poor recovery)
and if it recovers, the examiner observes the speed
of recovery. The speed of recovery indicates the
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strength of fusion and is an important prognostic
sign.
Another observation can be that on uncovering the eye, the uncovered eye reassumed fixation
as the other eye deviates. This indicates the
presence of a strabismus with the uncovered
eye being dominant. This also indicates that the
visual acuity is unequal in the two eyes. A free
alternation of fixation between the two eyes
indicates equal vision in the two eyes.
Alternate Cover Test

In the alternate cover test, the eyes are rapidly
and alternately occludedfrom one eye to the
other and then back again (Fig. 23.3). This
procedure causes breakdown of the binocular
fusion mechanism and reveals re-fixation
movements of each eye at the moment of
uncovering. The cover/uncover test is less
dissociating than alternate cover test. In the
absence of a manifest strabismus, such a
strabismus in fixation implies a latent strabismus.
Prerequisites of Cover-Uncover Test

The cover-uncover test requires the following prerequisites:
1. Ability of both eyes to fixate the target
2. Ability of both eyes to have central fixation and
3. Ability of both eyes to have no gross / severe

motility defect.
The cover-uncover test may be fallacious if
the eye is blind, have markedly subnormal vision
or eccentric fixation and limitation of moments.
For infants who would not allow an occluder
or a hand close to their face, the examiner can
use indirect occlusion test or distant cover test.
Here the fixation light or target is obstructed for
one eye by an occluder at some distance away
from the child
The cover-uncover test helps to confirm a true
manifest or latent strabismus along with its type:
exodeviation, esodeviation or vertical deviations.
It also indicates the visual dominance or the
presence of amblyopia. It also tells about
comitance of the strabismus by comparing the
primary and secondary deviations. The
characteristics of strabismus like unilateral or
bilateral, constant or alternating can be noted.
The variability in strabismus for near and
distance, the effect of accommodation and
patients refractive error can also be studied. The
test can uncover the associated latent nystagmus
if any. A cover-uncover test needs to be done
in all the nine cardinal positions of gaze, as also
for near and distance fixation. With experience
the examiner can detect even small angle
strabismus except microtropia of less than 5 prism
diopter deviation.
Fig. 23.3: Alternate cover test

Measurement of Ocular Deviation
Deviations can be measured by two methods:
objective and subjective. Both require the
cooperation of the patient. The objective tests
depend on the observations by the examiner of
the patients fixation pattern. This is based on
neutralizing the movement of the deviating eye
as it takes up the fixation. Methods based on
this principle requires patient to have foveal or
steady parafoveal fixation. Inherently the
subjective tests are more precise and reveal status
of the sensory system. Tests cannot be done if
the patient lacks binocular vision, or the ability
to comprehend the directions or express the
response. The subjective measurement is based
on dissociation of two eyes to induce the maximal
angle of deviation or observe the position of the
images on a calibrated scale. Both the tests would
have to be used judiciously by the examiner in
order to understand the sensorimotor aspects
of strabismus.
Prism Bar Cover Test

The deviations can be measured whether
subjectively or objectively by various methods.
The simple and best way to measure deviation
is by using prisms or prism bar (Fig. 23.4) along
with the cover test known as prism bar cover test
(PBCT). In fact it is the cover-uncover with the
addition of neutralization of deviation by the
prisms (Fig. 23.5).
For neutralizing esodeviations, prisms are
placed base out and for exodeviations they are
placed base in. A simple rule to remember is
Fig. 23.4: Prism bar and loose prisms
Fig. 23.5: Prism bar cover test
that apex of the prism should point towards

deviation. Therefore, in a vertical deviation, base
up prism is used in front of right eye if there
is right hypotropia and base down if there is
hypertropia. If there is combination of horizontal
and vertical deviations, the prisms are placed
horizontally in front of one eye and vertically
in front of the other eye. For large deviations,
a combination of loose prism of 30 or 45 prism
diopter in front of one eye and prism bar in front
of the other eye is used. The plastic prisms are
placed in the frontal position, that is, parallel
to the infraorbital margin. But the glass prisms
are placed in the Prentice position, that is, the
posterior face of the prism is perpendicular to
the line of sight.
It may be reiterated that the fixation distance
(both for near and distance), fixation targets (Fig.
23.6) and proper dissociation of the two eyes
should be ensured. A hurriedly done test can
be fallacious. An accommodative or fusional
convergence should be relaxed. The latter by
making the subject wear occlusion for at least
4 hours (even extended up to 24 hours in cases
of intermittent exotropia of simulated divergence
excess type). The accommodative convergence
should be controlled by making the subject wear
his proper refractive correction for the test
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Fig. 23.6: Fixation targets
distance. For near fixation additional reading

correction may have to be added in cases of
accommodative esotropia of convergence excess
type.
Following precautions should be taken for
prism bar cover test:
a. It is essential to prevent fusion by continuous
use of alternate cover test.
b. It is essential to control accommodation by
use of an accommodating target.
c. Since a high powered prism reduces the
clarity of vision, often impairs fixation if placed
in front of an ambylopic eye, therefore, it
should preferably be placed in front of better
eye.
d. Children can cooperate for short time only
so it is preferable to start with approximately
the correct prism rather than to work up from
lower strength.
e. In cases with combined vertical and
horizontal strabismus, it is preferable to use
square prisms as they can be easily held
together between thumb and the finger.
It is important to understand that the
deviation to be measured is to be static deviation
and should be free of the aforementioned dynamic
factors of accommodation and fusion. It is the
static angle which requires surgical correction
whereas the dynamic deviation of accommodation should be corrected by glasses.
Prism Bar Under Cover test: Measurement of

Dissociated Vertical Deviations
In patients with dissociated vertical deviations
(DVD) the alternate cover test reveals that each
eye turns upward under cover in contrast to the
situation in vertical heterophoria. After removal
of the cover, the eye makes a slow downward
movement to reach the midline, at times even
going below it, accompanied by incycloduction.
The translucent occluder of Spielmann is
especially useful in the diagnosis of this condition
as well as demonstrating it to the patients parents.
A precise measurement of the vertical excursions
of each eye during DVD is nearly impossible
because of its variable nature. An accurate
quantitative assessment of DVD may be obtained
provided visual acuity in each eye is sufficient
to visualize the fixation target, using a
modification of the prism and cover test. As the
patient focuses on the fixation target at 6 m
distance, the occluder is quickly shifted to the
fixating eye, allowing the previously dissociated
and elevated eye to take up fixation. The cover
is then returned to the nonfixating eye. As the
alternate cover test is continued, increasing
amounts of base-down prisms are held under
the occluder infront of the nonfixating eye until
the downward fixation movement of that eye
is neutralized. The procedure is then repeated
with the fellow eye fixating.
Effect of high plus or minus glasses on measuring
strabismus deviations
Plus lenses always measure less deviation than
actual, both in esodeviation and exodeviation
(base-out effect in eso and base in effect in exo).
Minus lenses always measure more deviation
than actual, both in esodeviation and exodeviation (base in effect in eso and base out effect
in exo).
Measurements
To determine the different aspects of strabismus,
deviations can be measured in various ways:

1. Deviation with distance and near fixation
to determine its nature as to whether esotropia
is: basic/convergence excess divergence
insufficiency, and exotropia is: basic/ convergence insufficiency /divergence excess.
2. Deviation in nine different cardinal positions
of gaze to determine any incomitance
(paralytic, restrictive or spastic).
3. Deviation in up gaze of 25 degree and down
gaze of 35 degree for determining A-V patterns.
4. Deviations with right and left eye fixating
alternatively to determine primary and
secondary deviation in case of incomitant
strabismus.
5. Deviations with subjective method and objective method to determine the type of retinal
correspondence (normal or anomalous).
6. Deviations after prolonged cover to differentiate a true divergence excess type from the
simulated divergence excess exotropia as also
to determine the fully undissociated
deviation.
Examination of Eyes in Nine Gaze

Positions
It is important to measure the ocular deviations
in different gaze positions for diagnosing motility
defects. Although, except for the down gaze, one
does not use 35 degree gaze positions physiologically, these are helpful for diagnosis. These
are, therefore, called diagnostic positions. Just
like the measurements in the primary position,
measurements in these peripheral eight positions
are also best done by prism bar cover test, with
an accommodative target. Some clinicians prefer
to use deviometers, which are devices that can
give different fixed/repeatable fixation target
positions. For near measurements any Listers
perimeter (Fig. 23.7) or a simple vertical stand
with a vertically rotatable arm around a pivot,
with the free end carrying the fixation target,
Fig. 23.7: Lister perimeter
can be used. For distance measurements one may

use multiple fixed points on the opposite wall.
Alternatively a single fixed target may be used
with the head being turned to bring the eyes
in the desired positions. The deviation of head
can be read on a protactor along with scale. A
cephalodeviometer, a calibrated mirror can also
be used.
Synoptophore
Synoptophore (Fig. 23.8) is a basic orthoptic
instrument based on the haploscopic principle.
It is also known as amblyoscope (Major,
CurpaxMajor types), and troposcope. It
consists of a chin rest and forehead rest with
two tubes carrying the targets seen through an
angled eye piece. The tubes are placed horizontally and are movable in the horizontal and
vertical planes. The distance between the two
tubes can also be adjusted with the subjects
interpupillary distance (IPD). The targets in the
tubes are illuminated slides which can be raised
up or down and also be tilted to test for vertical
and torsional deviations. All these adjustments
can be read on the scales in degrees and prism
diopters. The tube can be locked individually
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378

allows the subject to view a distant object
superimposed on the targets in slide holders.
Another synoptometer Oculus is a modification
which allows measurement of deviations in peripheral positions with the help of mirrors.
Corneal Reflection Tests
Fig. 23.8: Synoptophore
or both with respect to each other. The

illumination of each target can be increased or
decreased and flashes can be given if desired.
Additional devices like Haidinger brushes can
be attached. The targets are placed at a fixed
distance from the eye piece which are of + 6.0
D or +6.5 D, so that the targets are at optical
infinity. This should theoretically not stimulate
accommodation. However, in reality proximal
convergence does come into play distorting the
deviations. This factor has significantly reduced
the applicability of the synoptophore as a reliable
instrument to measure deviations, especially
horizontal ones.
Uses of Synoptophore
In cyclovertical strabismus the synoptophore is
a useful instrument to measure torsion. It is also
useful for studying accommodative convergence
and for imparting orthoptic exercises.
The synoptiscope of Curpax-Major is a modification which uses semi-transparent mirrors in
place of opaque mirrors in front of eyes. This
Hirschbergs test: The test estimates the deviation

of corneal light reflex from the center of the pupil
and provides a rough measurement of degree of
strabismus. The corneal reflections, even
normally are not exactly centered, because of
angle kappa, but are symmetrical in the absence
of a strabismus. In case of esodeviation, the
corneal reflection falls more temporally and in
exodeviation, reflection falls nasally. Roughly a
1 mm shift signifies a 5 deviation (earlier thought
to be 7). Thus if the reflex falls on the nasal
limbus, the exodeviation is 30 (approximately
60 prism diopters). This test can be used in
infants, who are not very cooperative or in cases
of eccentric fixation or non-fixation (blind eyes).
Krimsky test: In Krimsky test (or prism reflex test),
a prism bar is utilized to quantify the deviation
using the corneal reflection. It is preferable to
place the prism bar on the fixating eye and to
neutralize the amount by observing the corneal
reflex in the deviating eye (nonfixating).
Synoptophore: A foveal sized slide is placed in
front of the fixing eye and the position of the
corneal reflections is noted while the amblyoscope tubes are both at zero. The tube in front
of the fixing eye is moved along the eye in such
a way that reflection in the squinting eye moves
into the normal position (comparable with that
in other eye). The angle can be recorded in degree
or prism diopter.
Methods using corneal reflections give
approximate values but are useful when PBCT
cannot be done, for e.g. young children,
uncooperative patients, patients with poor

fixation, etc. Deviations measuring less than 10
prism diopters cannot be measured.
Subjective Tests of Deviation

These tests utilize the subjects perception of the
deviation. When there is misalignment, the subject
perceives diplopia and the separation between
the two images indicates the subjective deviation.
This is the diplopia principle. Here the single
physical location is perceived by the subject as
two perceptual localizations. Diplopia testing
with the red green goggles is based on this
principle. Measurement of deviation on Maddox
tangent scale with the help of Maddox rod is
also based on it, Subjective tests can also be
done on the haploscopic principle, where two
physical locations are used to have one
perceptual localization. The examples are as
done on synoptophore when tested subjectively
or the Hess or Lees screen.
Diplopia testing: When red and green glasses are
placed before the right and left eye respectively;
they dissociate the two images and are seen
double in cases of strabismus. Esodeviations
cause uncrossed diplopia (homonymous diplopia) and exodeviations cause crossed diplopia
(heteronymous diplopia). In the former the image
falls on the nasal half of the retina and is projected
on the temporal half of the field, and so is seen
uncrossed (same side as the eye). In exodeviations the image falls on the temporal retina to
produce crossed diplopia. It is preferable to use
an illuminated slit target and to use the slit
vertically for charting horizontal deviations and
to use it horizontally to chart vertical deviations.
A tilt of the image is also better appreciated with
a slit target. The test can be done both for near
and distance. For distance one may utilize the
Maddox tangent scale or cross, to quantify the
deviation otherwise prisms for deviation are used.
The separation between the two images is
recorded for each eye in the nine diagnostic gaze

positions. A red filter alone can also be used
but the dissociation is then not complete as with
red and green glasses. The test is very useful
for diagnosis and follows-up of incomitant
strabismus.
Hess and Lees screen: Here two test objects (two
locations) are shown to the patient but seen by
him as one. The dissociation may be done by
red-green glasses as in the Hess screen test (Fig.
23.9A) or a mirror septum as in the Lees screen
(Fig. 23.9B). The Lancaster red-green test with
the two Foster torches use red-green filters in
the torches and green glasses. Polaroid dissociation can also used in order to have a more
physiological dissociation. These haploscopic
tests are very good for documentation of ocular
muscle paralysis and restrictive conditions.
The Hess chart has a grid pattern where each
square represents 5 degree excursion for the
fixating eye. Thus the inner square tests for 15
Fig. 23.9A: Hess screen
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380
Fig. 23.9B: Lees chart
Fig. 23.10: Maddox rod
degree eye movements from the primary position.

The outer square (each side is curved inwards)
represents 30 degree excursion for the fixing eye.
The outer square is usually charted to mild
underaction. The Hess chart is a very good test
which can document the under or over action
of the extraocular muscles.
the torsion in the slides. The slides used should

have vertical features or one can use the after
image slides.
For objective evaluation of the cyclodeviations, the indirect ophthalmoscopy and fundus
photography are useful methods. These are good
to semi-quantify the cyclodeviations. Normally
the fovea is located between the two horizontal
lines, one passing through the center of the disk
and the other cutting the lower pole of the disk
tangentially. The usual location is in the middle
of these two horizontal lines, that is, 0.3 disk
diameters below the horizontal line through the
center of the disk. A difference of 0.25 disk
diameter or more between the two eyes is
considered abnormal.
Measurement of cyclodeviations: While the objective

tests are difficult, the subjective tests are very
good for measuring cyclodeviations. Diplopia
charting with a slit target is used to make the
patient appreciate the tilt. A horizontal slit
appears to be tilted in the opposite direction to
the cyclodeviation in the eye. In case of
excyclodeviation of the right eye, the tilt is
anticlock-wise and in case of incyclodeviation
it will be clock-wise.
By using two Maddox rods (Fig. 23.10),
preferably one white and the other red, the tilt
is neutralized by rotating the Maddox rods in
the requisite direction. The change of axis on
the trial frame can be read to give the actual
cyclodeviation. It is known as the double Maddox
rod test. A vertical prism of 5 prism diopter can
be added to create a separation between the two
horizontal lines seen through the Maddox rods.
The synoptophore is a good instrument to
measure cyclodeviations, the slides can be tilted
to make the patient appreciate straightening of
Limitations of movements: In addition to measuring

the ocular deviations, it is valuable to note the
limitations of movements. In restrictive
strabismus, the limitation of movements is
marked compared to the ocular deviation which
is small. In contrast, in the incomitant strabismus
the limitation of movement and ocular deviation
collaborate each other. Both the ductions and
the versions should be noted and documented.
Usually a subjective assessment is made on a
scale of 7 points (+3 to -3) or 9 points (+4 to
-4). This is usually helpful in follow-up of cases

of incomitant strabismus. It should be noted that
due to variations in the adnexal structures, these
cannot be fool proof method of assessing such
deviations. Normally adduction is considered
normal when the nasal one-third cornea crosses
the lower punctum. Less than this is considered
to be limited. For abduction to be considered
normal, temporal limbus should touch the lateral
canthus. Vertical movements are difficult to assess
due to palpebral aperture. The overaction of the
obliques can be assessed. Mild over action is
appreciated only in sursum adduction and
moderate overaction in adduction. If there is a
hyper or hypotropia in primary position it
signifies severe overaction.
Grading oblique overactions: Another useful clinical
test to grade the inferior oblique overaction is
by observing the angle the adducting eye makes
with the horizontal line as it elevates and abducts
( if overacting ) on lateral version to the opposite
side. It may be noted that in the absence of inferior
oblique overaction eye would remain in the
horizontal line. Analogous to this grading the
supererior oblique also can be graded. The angle
adducting eye makes with the horizontal as it
depresses and abducts on a lateral version, is
noted (Table 23.3).
Measurement of Vergences
In actual practice the manifestation of a
strabismus (heterotropia) only occurs if the latent
tendency for the strabismus (heterophoria) is not
overcome by the fusional vergences. The
measurement of vergences is very important, as
it determines the capability of the motor system
to cope with an induced misalignment of visual
axes. If these vergence amplitudes are large, even
a large angle strabismus remains asymptomatic,
and if they are small, or intermittent, even a
small angle strabismus manifests remains
symptomatic.
Vergences are usually tested in the three
planes:
(a) Horizontal vergences: convergence and
divergence
(b) Vertical vergences: sursumvergence and
deorsumvergence and
(c) Torsional vergences: incyclovergence and
excyclovergence.
In principle, to measure the vergences, the
axes are misaligned artificially; and this may
be done with prisms or on the synoptophore.
The horizontal and vertical vergences can be
measured only by prisms in this manner, as the
prisms cannot induce a torsional misalignment.
TABLE 23.3: GRADING OF OBLIQUE OVERACTIONS

Inferior oblique overaction
Superior oblique overaction
Grade 1+*
Up to 20 degree angle with

the horizontal line
Grade 1+
Up to 15 degree angle with the

horizontal line
Grade 2+

the horizontal line
Grade 2+

horizontal line
Grade 3+

the horizontal line
Grade 3+

horizontal line
Grade 4+

the horizontal line
Grade 4+

horizontal line
* Grade 1 + inferior oblique overaction may not be easily detectable on lateral version and is better appreciated
by only in tertiary position, e.g. levoelevation for right inferior oblique
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Horizontal Vergences
Near point of convergence: The simplest way to
measure the convergence is to bring a line drawn
on a paper closer to the eyes, till the point, it
becomes double. This determines the near point
of convergence (NPC). It is important to note that
the line should appear to be double, not blurred.
The point at which it is blurred would determine
the near point of accommodation (NPA). The
test is done with each eye separately (monocular)
and also with both eyes together (binocular). For
testing NPC in presbyopes or ametropes, suitable
glasses should be used by the subject. The point
at which the line becomes double is called the
break point convergence. If the line is gradually
withdrawn away, at some point the line becomes
single again which is the recovery point
convergence. The two differ from each other. The
measurements are made from the bony margin
of the lateral canthus. Normally it is 8-10 cm.
NPC is more than 10 cm is considered defective.
Apart from the patient describing the diplopia,
an objective assessment is made by the examiner
by seeing one of the eyes deviating out. Near
point ruler, Royal Air Force binocular gauge and
Livingstone gauge are instruments based on this
principle.
Convergence sustenance: A further assessment
needs to be made to assess the ability of the eyes
to hold the convergence at the near point. This
is convergence sustenance. It gives a good
parameter to assess the strength of fusional
convergence. Normally one should be able to
hold it for 45 seconds to one minute. Less than
30 seconds is definitely poor and indicates
symptomatic exodeviation.
Measurement of Vergences with Prisms

Convergence and divergence can be measured
both for distance (6 m) and near (33 cm) fixation
with the help of a prism bar or a rotary prism.
With the patient properly seated and made to

fixate at a fixation target at distance or near as
desired, the prism bar is moved with its prism
strength increasing. The end point is noted as
break point, when one eye deviates out or diplopia
is reported. The prism strength is then gradually
reduced till the object is seen single again this
is noted as the recovery point. The break point
is usually more than the recovery point but within
3 to 5 diopter. A larger difference would indicate
poor recovery as in cases of intermittent exotropia
who are symptomatic. Using base out prisms
the convergence amplitudes are measured and
using base in prisms the divergence amplitudes
are measured. The vertical vergences are similarly
measured using prisms base up for deorsumvergence and prisms base down for sursumvergence.
The order of testing the vergences should be
convergence, deorsumvergence, divergence and
sursumvergence. This is to avoid any artificial
changes. The normal values of these vergences
are shown in Table 23.4.
TABLE 23.4: SHOWS NORMAL VALUES OF
VERGENCE FOR NEAR AND DISTANCE
Vergence with
prisms
Distance
(6 m) in pd
Near (33 cm)

in pd
Convergence
Divergence
Vertical vergence
Incyclovergence*
Excyclovergence*
14-20
5-8
2-4
10-12
10-12
35-40
15-20
2-4
10-12
10-12
*Though cyclovergences (in degrees) are as good

as above on synoptophore the tolerance in practice
is up to 4 only.
Examination of the Sensory Status

The evaluation of sensory status of a patient
with strabismus is aimed to find the following
facts:
1. Presence of binocularity
2. The presence of confusion and diplopia
3. Presence of suppression and its depth

4. Presence of ambylopia and its degree
5. Type of correspondence and
6. Presence of stereopsis and its grade.
Binocularity and Diplopia

If binocular diplopia is present, it indicates
binocularity. The presence of true diplopia
should be established by differentiating it from
false impression of diplopia due to blurring or
elongation of an image due to astigmatism. It
is necessary to establish binocular nature of
diplopia by closing one eye. If, it disappears,
it is suggestive of binocular diplopia. In longstanding cases of strabismus even of adult onset,
patient may learn to ignore the other image. In
such cases use of dissociating mechanisms like
red-green goggles, Bagolinis glasses, single or
double Maddox rod are helpful in visualization
of diplopia. In cases of strabismus without diplopia or in cases without strabismus, dissociation
test are helpful in detecting the presence of
binocular perception.
Suppression
Suppression is a sensory adaptation to
strabismus in children, which only occurs when
the eyes are open. It is a temporary phenomenon.
As soon as the fixating eye is covered, deviated
eye takes up the fixation. It occurs from the active
cortical inhibition of disparate and confusing
retinal images originating from the retina of the
deviating eye. The stimulus for suppression is
diplopia, confusion or a blurred image resulting
from astigmatism or anisometropia.
Clinically, suppression can be classified into
three types:
1. Central or peripheral: In central suppression
the image from the fovea of the deviating eye
is inhibited to avoid confusion, while in
peripheral suppression image forming on the
peripheral retina is inhibited.
2. Facultative or obligatory: Facultative suppression occurs only during binocular conditions

and obligatory during monocular conditions.
3. Unilateral or alternating: Unilateral suppression is present in one eye only (unilateral)
while in alternating suppression both the
eyes are involved or it may alternate between
two eyes (alternating).
The extent (area) and depth (intensity) of
suppression should be noted. The sensitive
period during which suppression may develop
ends after the age of 8-9 years. Once developed,
suppression may persist throughout life. If due
to any reason, patient loses the ability to suppress
during adult age, it can never be regained and
diplopia prevails. Such a thing can happen due
to head trauma, spontaneous change of angle
of strabismus or due to iatrogenic causes like
strabismus surgery or improper orthoptic
treatment.
Tests for Suppression

Bagolini striated glasses: Bagolini striated glasses
tests is the most physiological test for dissociation
of eyes. A pair of striated glasses is used (Figs
23.11 and 23.12). The axis of striations of the
two eyes is kept at right angle to each other,
i.e. 45o and 135o. When viewed through the
glasses, a point source of light is seen as a line
which is at right angle to striation. In suppression
two types of response can be seen:
a. Single line response: If only one line is seen,
it is suggestive of other eye scotoma, i.e.
suppression response.
Fig. 23.11: Bagolini striated glasses
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384
Fig. 23.12: Bagolini glasses test: A Crossed response

(NRC with no strabismus or harmonious ARC with
strabismus), B Left suppression, C Right suppression,
D Crossed response with central scotoma in Right eye
E Esotropic diplopia, F Exotropic diplopia (With right and
left eye lenses at 135 and 45 degrees, respectively)
b. Cross response with central gap in one: It

is suggestive of central suppression scotoma
in that line, i.e. eye.
Interpretation of responses:
1. Symmetrical cross response: If the patient has
no strabismus, it is suggestive of normal bifoveal correspondence. But if a manifest
strabismus is present, it is indicative of harmonious anomalous retinal correspondence.
2. Asymmetrical cross response: Two lines
intersecting each others at some other point
than midline, indicates an incomitant
strabismus with normal retinal correspondence, i.e. diplopia response.
Worth four dot test: In the Worth four dot test
(WFDT) eyes are dissociated with red-green
goggles. It is more dissociating and hence less
physiological as compared to Bagolini glass. This
test is performed with patient wearing red lens
in front of right eye which filters all color except
red, and green lens in front of left eye which
filters all colors except green. The patient then
views a box with four lights which has one red,
two green and one white light (Fig. 23.13). The
result is interpreted as follows:
1. Four dots are suggestive of normal retinal
correspondence (NRC) if manifest strabismus
is not present. In presence of manifest
deviation it suggests harmonious anomalous
retinal correspondence.
Fig. 23.13: Worth four dot test: A Four dots: NRC with
no strabismus or ARC with strabismus, B Left suppression,
C Right suppression, D Binocular diplopia (With red and
green glasses in front of right and left eye)
2. Five dots (2 vertical red, 3 green in inverted

triangle form) are suggestive of normal retinal
correspondence with manifest deviation.
These five dots are separated differently
depending on the type of deviation. The
uncrossed pattern with red on right is
suggestive of esodeviation, crossed pattern,
i.e. red on left side is suggestive of exodeviation and if they are vertically displaced, it
is suggestive of vertical anomalous retinal
correspondence.
3. Three dots (green) indicate right suppression.
4. Two dots (red) indicate left suppression.
It is performed at 6 meter distance and it
subtends an angle of 1.2 degree. In case of central
scotoma larger than this size, WFDT will not be
visualized. The patient can be brought nearer to
WFDT test to increase angle subtended by it.
Synoptophore: The suppression scotoma can be
mapped with synoptophore, at least in the
horizontal meridian. One arm is rotated, and the
points are noted at which the target carried by the
moving arm disappears and reappear. Slides
which present paramacular targets are used.
After image test: After image test demonstrates
the visual direction of the fovea or eccentric
fixation point. It is highly dissociating orthoptic
test. The right eye is flashed with a vertical bright
flash of light and left by a horizontal flash. As
each eye is stimulated separately, fovea of each
eye or fixation point in eccentric fixation are at
Fig. 23.14: After image test: A Crossed response (NRC

with no strabismus), B Asymmetric cross (ARC with
strabismus, left suppression), C Esotropia, D Exotropia,
E Right suppression, F Left suppression diplopia (With
vertical and horizontal flash before right and left eyes,
respectively)
the center of the after images. The patient is then

asked to draw the relative positions of the after
images (Fig. 23.14). Interpretation of the test is
as follows:
a. Cross response: If the two after images are
seen as a cross, the patient has normal retinal
correspondence. This is irrespective of the
deviation of two eyes.
b. Asymmetrical crossing: In this vertical and
horizontal lines have their centers separated.
The amount of separation is proportional to
angle of anomaly. In case of esotropia with
ARC, vertical after image (belonging to right
eye) will be seen to the left of the horizontal
after image. These findings are reversed in
exotropia. A single vertical after image is
suggestive of left suppression and a horizontal after image is suggestive of right
suppression.
Measurement of Suppression Scotoma

Suppression scotoma can be charted under
binocular conditions (fixating with one eye, while
the field of other eye is charted). This can be
done by following methods:
Use of prisms: This is a simple method based
on the patient recognizing diplopia when the
image falls outside the limits of scotoma. Prisms
are used to displace the central object peripherally
till it can be visualized in different directions.
Binocular perimetry: The testing apparatus is

arranged in such a manner that fixation target
is common to both eyes but the test object is seen
only by the eye under examination. This can
be achieved in following way:
a. Lees screen or Hess screen: When one eye
is charted the other eye fixates through mirror
in Lees and red green dissociation in Hess
charting.
b. Two Bjerrum screens at 90o to each other.
c. Polaroid scotometer: Using polaroid dissociation while one eye fixates, the field of other
eye is charted.
Depending upon the test different responses
are observed.
i. With more dissociating tests like prisms and
Lees screen single large coarse scotoma is
seen, extending from fovea to the diplopia
joint. Some authors have demonstrated
hemiretinal scotoma in exodeviations,
whereas esodeviations showed more
discreate scotoma.
ii. With less dissociating test like phase difference haploscope and Polaroid scotometer
two discrete scotomas are seen. These are
foveal scotoma about 2o3o in size and
diplopia point scotoma. This is seen in both
esodeviation and exodeviation; in exodeviation the foveal scotoma showed a vertical
step-like hemiretinal scotoma of Jampolsky.
Depth of Scotoma
Depth of scotoma is measured by using differential stimulation of the two eyes. This can be done
with red filters of increasing density arranged
in ladder pattern (Bagolinis graded density filter
bar). The patient fixates a small target and filters
of increasing density are placed in front of the
fixating eye until patient perceives diplopia.
Greater the density of filter required to induce
diplopia, greater the depth of suppression.
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Retinal Correspondence
Investigation of state of retinal correspondence
is indicated in all cases of constant strabismus.
A bifoveal correspondence is called normal retinal
correspondence (NRC). A correspondence between
fovea of one eye and extrafoveal point of the
other eye (deviating eye) is called anomalous retinal
correspondence (ARC). It is an acquired binocular
functional sensory adaptation to strabismus at
the cortical level. Suppression precedes the
development of ARC. At the cortical level there
is a change in synoptic connections from the
foveo-foveal to the foveo-extrafoveal. The
extrafoveal point should have good visual
potential in order to have an association with
the fovea of the fixing eye.
Following conditions facilitate the development of ARC:
1. Early onset strabismus: a good neural
plasticity is required for the new connections,
2. Constant angle of deviation: Constancy of
the stimuli favors development of new
connections and
3. Small angle of deviation especially esodeviations and rarely exodeviations: It is rarely
found in exotropias as they are generally
intermittent or variable due to good fusional
vergence. ARC allows some binocular vision
with limited fusion to be maintained in the
presence of heterotropia.
Diagnosis of ARC
It is necessary to measure the angle of deviation
by subjective and objective methods to diagnose
ARC. ARC is present when there is difference
in the subjective and objective deviations. In NRC
objective and subjective angles are equal. If the
subjective angle is zero, there is no subjective
strabismus. In the presence of objective angle
showing a strabismus, ARC is termed as
harmonious ARC. If the subjective angle is not
zero but less than the objective angle of deviation,

it is unharmonious ARC. The difference between
objective and subjective angle is the angle of
anomaly. Hence in harmonious ARC, subjective
angle is zero and objective angle is equal to angle
of anomaly. In unharmonious ARC, objective
angle is greater than subjective angle and hence
angle of anomaly. In NRC, objective and subjective
angles are same and angle of anomaly is zero.
The objective angle of deviation can be
measured by prism bar cover test (PBCT) or by
cover-uncover test, and on the synoptophore
with alternate on-off method. The subjective angle
of deviation can be measured by following
methods:
1. After image test
2. Synoptophore
3. Worth four dot test
4. Maddox rod or red filter test
5. Polaroid dissociation
6. Phase difference haploscope and
7. Bagolinis striated glasses.
Bagolinis Striated Glasses

The patient with strabismus is first evaluated
with cover-uncover test and objective angle is
measured with PBCT. Next with the strabismus
manifested, the patient looks through the
Bagolinis striated glasses. If he sees a cross
response (as seen by person with NRC with no
strabismus) in the presence of manifest strabismus it implies a harmonious ARC. If the patient
does not see a cross response, i.e. X, the prisms
are added to get a X cross response. The prism
power required is the subjective angle of deviation
and it is termed non-harmonious ARC. In
presence of strabismus with NRC, patient sees
two oblique lines crossing asymmetrically to form
a V or A instead of X response. In the presence
of suppression, patient sees only one line, line
of the other eye which is suppressed is not seen.
In case of central scotoma, the eye with the

scotoma sees a line with a break in the center
(Fig. 23.12).
Worths Four Dot Test

The objective angle is first measured by PBCT.
After wearing red green glasses, patient is asked
to look at the dots. The prisms are added till
the patient shows a normal response that is four
dots in a normal rhombic pattern. The strength
of prism indicates subjective angle.
Synoptophore
The objective angle is measured by patient
alternately fixing till there is no movement of
eyes on alternate on-off. The subjective angle is
measured by the patient aligning the two images
by his perception of simultaneous perception
slides.
After Image Test

After image test is used to measure subjective
angle. Each eye is monocularity flashed with
a self flash to create a horizontal after image
in right eye and vertical after image in left eye
(Fig. 23.14). Each after image is centered at fovea
(even in cases of ARC due to central fixation).
In case of ARC, patient sees an asymmetric cross.
The displacement between the centers of the two
after images is proportional to the angle of
anomaly (tan =displacement/distance of
testing). The angle of anomaly can thus be
calculated.
The strabismus can be corrected surgically
if the appearance warrants it. More extensive
surgery can be performed if there is established
ARC with sensory and motor fusion, the
correspondence should adapt to the new eye
position, reducing the risk of consecutive
strabismus. Treatment may not be needed on
many cases of ARC because it may cause
intractable diplopia, bifoveal binocular single

vision cannot be restored and many patients with
ARC may have useful and symptom-free
binocular single fusion.
Amblyopia
Amblyopia is a condition with unilateral or
bilateral decrease of visual functions caused by
form vision deprivation and/or abnormal
binocular interaction. It cannot be explained by
a disorder of ocular media or visual pathway.
It is a condition caused by abnormal visual
experience during early childhood, the critical
period of visual development. In appropriate
cases it is reversible by therapeutic measures.
Classification of Amblyopia
1. Strabismic amblyopia
2. Anisometropic amblyopia (unilateral or
asymmetric)
a. Anisohyperopic
b. Anisomyopic
3. Form vision deprivation amblyopia (unilateral or bilateral)
a. Stimulus deprivation amblyopia or
amblyopia ex-anopsia, ptosis (covering
pupil), opacities in cornea, lens or vitreous,
unilateral occlusion or penalization
b. Ametropic amblyopia (uncorrected
bilateral high refractive error)
i. Hyperopia
ii. Myopia
iii. Astigmatism (meridional amblyopia)
4. Nystagmus related amblyopia
5. Organic amblyopia
a. Subclinical macular damage
b. Malorientation of cones
c. Cone deficiency syndrome
Amblyopia is a disorder of visual perception,
only one of which is the visual acuity on the
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standard vision charts (Snellen acuity); but there
are other visual functions too that are affected.
The amblyopia syndrome shows the following
abnormalities:
1. Decreased visual acuity (Snellen)
2. Decreased grating acuity (Teller)
3. Decreased vernier acuity
4. Decreased or lost stereoacuity
5. Decreased contrast sensitivity
6. Decreased brightness perception
7. Abnormal contour interaction
8. Increased perception and reaction times
9. Nasotemporal asymmetries in resolution of
vertical gratings and
10. Motility defects in pursuit, saccades and
fixation.
While the hallmark of amblyopia is decreased
visual acuity, it is important to understand that
recognition acuity (Snellen or similar charts) is
more affected than either resolution acuity
(Teller acuity, Fig. 23.15) or detection acuity
(Catford drum or Bailey-Hall cereal test).
Secondly the anisometropic and strabismic
amblyopes behave differently. The Snellen letter
or recognition acuity is affected more in strabismic
or mixed (strabismic + anisometropic) amblyopes
Fig. 23.15: Teller acuity cards
compared to anisometropic amblyopes. Both

Snellen acuity and grating acuity are affected
equally in anisometropic amblyopes, whereas
in strabismic amblyopes the grating acuity is
affected to half the extent of Snellen acuity. Thus
strabismic amblyopia is underestimated on
grating tests.
Diagnosis of Amblyopia
For diagnosis of unilateral amblyopia difference
of vision between two eyes or in case bilateral
amblyopia , difference from the age-related norm
is taken into consideration. Clinically, a difference
of two-line on Snellen chart (one octave difference)
is considered significant.
Yet another well recognized feature of strabismic amblyopic vision is that it is not degraded
by neutral density filters, it may even show some
improvement. However, in anisometropic
amblyopes, an equal deterioration is seen in
amblyopic and normal eyes. Other organic retinal
pathologies causing diminution of vision are
susceptible to deterioration by neutral density
filters. This test can thus distinguish functional
amblyopia from organic ones.
Abnormal contour interaction is seen in the
form of degradation of visual acuity for objects
placed in a row or line (linear acuity), compared
to the acuity of the same object viewed separately
(single letter acuity). This phenomenon has been
described as the crowding phenomenon. Crowding
phenomenon is present to some extent even in
normal subjects (critical area of separation=1.9
to 3.8 min of arc). In amblyopes this is more
pronounced, similar to the critical area of
separation of peripheral retina of normal human
subjects (8.4 to 23.3 min of arc).The crowding
phenomenon has also been attributed to the poor
visual acuity present in amblyopes. But its
importance in prognosticating progress in
amblyopia therapy should be remembered. The
single letter acuity improves more rapidly during

the course of treatment. Finally both the single
letter and linear acuity should approach each
other, if it is not so there is always a risk of
recurrence of amblyopia. Children who cannot
be tested with linear charts, single letter,
optotypes with surrounds can be used to cause
contour interaction.
In the normal charting of Snellen vision, high
contrast (80%) letters are used. Abnormal contrast
functions have been recorded both in strabismic
and anisometropic amblyopes, particularly at
high spatial frequencies. At low spatial
frequencies the contrast sensitivity is normal in
amblyopes, but at high spatial frequencies the
contrast sensitivity is deteriorated, more so with
severe amblyopia. This is due to a neural loss
of foveal function and not due to optical factors,
or unsteady fixation movements or eccentric
fixation. Contrast sensitivity has been observed
to differ in strabismic and anisometropic amblyopes. It becomes normal in strabismic amblyopes
when the luminance levels are reduced, while
the deficit persists in anisometropic amblyopes.
Other psychophysical functions are also affected.
Besides the affection of form vision, brightness
perception is also affected in ambylopes. Dark
adaptation curves are essentially normal and
even if there is an effect on the light sense, there
is clearly dissociation between the effect on the
light sense and the acuity. While recovery time
after a glare stimulus to fovea is normal, the
perception time and reaction time is 6 times
longer. The critical flicker fusion frequency (rate
at which a flicker just disappears) is usually
normal compared to maculopathies. Pupils are
generally normal and briskly reacting though
afferent pupillary defect and raised edge light
pupil cycle time have been reported.
Stereoacuity
Stereopsis refers to our ability to appreciate depth
that is the ability to distinguish the relative
distance of objects with an apparent physical

displacement between the objects. It is possible
to appreciate the relative location of objects using
one eye (monocular clues). However, it is the
lateral displacement of the eyes that provides
two slightly different views of the same object
(disparate images) and allows acute stereoscopic
depth discrimination. Stereoacuity develops and
can be tested on the preferential looking tests
(PLT) at 6 months after birth. It has been used
as a screening test for binocular vision anomalies
in preschool children, but with difficulty.
Stereopsis is an important binocular clue to depth
perception. Stereopsis cannot occur monocularly
and is due to binocular retinal disparity within
Panums fusional space. Two objects stimulate
disparate (noncorresponding) retinal points
within Panums fusional area.
Stereoacuity tests: The real-depth tests are not used
as clinical tests. Most clinical tests are based
on the haploscopic principle, using two dimensional or vectographic pictures. Some elements
of the two pictures have a disparity which is
fused to create a 3-D image. There are two groups
of clinical tests used to measure stereopsis. These
are the contour stereotests and the random-dot
stereotest. Random-dot stereograms were first
used by Julesz to eliminate monocular clues.
As there are no contours, depth perception
(stereopsis) can only be appreciated when
binocular fusion occurs. Two process of
stereopsis are used and these are local and global
stereopsis. Local stereopsis exists to evaluate the
two horizontally disparate stimuli. This process
is sufficient for contour stereotests. Global
stereopsis is required in random-dot stereogram
when the evaluation and correlation of
corresponding points and disparate points are
needed over a large retinal area. An example
of a contour stereotest used in the clinic is Titmus
Fly stereotest. In the Titmus Fly stereotest,
horizontal disparity is presented via the
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390
Fig. 23.16: Titmus fly stereotest with polaroid glasses
Fig. 23.17: Lang stereotest
vectographic technique (Fricke and Siderov).

Examples of random-dot stereotests used in
the clinic are Frisby stereotest, Randot
stereotest, Random-dot E stereotest and Lang
stereotest.
Stereopsis can be tested by following methods:
(i) Synoptophore with stereopsis slides
(ii) Titmus fly stereotest with polaroid spectacles
(Figs 23.16).
(iii) Randot stereotest
(iv) TNO test with red-green goggles
(v) Frisby and Lang stereotest without using
glasses
(vi) Special 3-D pictures.
The last two are examples in which the
dissociation is not achieved by glasses which
are not liked by children.
The Lang test is based on the principle of
panography where two images are printed on
the same card each interrupting the other with
regular linear interruptions. A prismatic film
laminated over the picture ensures that one image
is visible to right eye only and the other to the
left eye only. The two, when fused in spite of
the disparity, create a 3-D vision (Fig. 23.17).
The newer special 3-D pictures, much in fashion;
recently have two pictures specially merged in
such a manner that if the two eyes are artificially
diverged but controlling accommodation (as if
looking for distance through the print), each
eye sees two different images creating a 3-D

image.
Randot Stereotest
Randot stereotest (Fig. 23.18) is the most popular
clinical test and has replaced the earlier popular
Titmus fly test. It uses Julesz random dot
background to mask the monocular clues which
are there with the animal tests and Wirts circle
test. Geometric figures like square circle, triangle
and star are also presented devoid of any
monocular clues. But the letter type figures,
though a better test, are usually not appreciated
by small children.
The test requires polaroid glasses to be worn
by the patient. It is used at a distance of 40 cm
Fig. 23.18: Randot stereotest
Fig. 23.19: TNO test with red-green glasses
and thus tests near binocular vision, therefore,

the myopes up to 3 diopters can be missed in
the screening test. The Wirt circles (1-10) test
has the stereoacuity from 400 arc seconds to 20
arc seconds.
TNO Test
TNO test (Fig. 23.19) is also based on the randomdot background but uses red-green glasses for
dissociation of the two images. It tests stereoacuity from 480 arc seconds to 15 arc seconds.
Fig. 23.20: Frisby stereotest
of the plate is closest to the observer. By altering

the thickness of the plate and the distance from
the subject different stereoacuities can be
assessed. For 30 cm viewing distance, the 6 mm,
3 mm and 1.5 mm plates represent 600, 300 and
150 arc seconds of stereoacuity, respectively. This
assumes the interpupillary distance of 60 mm,
but no significant change is caused by different
IPD.
Frisby Test
The Frisby stereotest (Fig. 23.20) consists of three
perspex plates of different thickness: 6 mm,
3 mm and 1.5 mm.
On one face of each plate are found squares,
three of which are filled with a random pattern
of blue triangles of various sizes and the fourth
of which has a central circular area that is not
patterned. On the opposite side of the plate
coincident with this area is a circular pattern
of similar blue triangles. The plate is held in
front of a white board and when viewed directly,
the squares are all filled with random patterns
although in one square a binocular viewer will
see a circle standing up from the plate (crossed
disparity) or lying below the rest of the design
(uncrossed disparity) depending on which side
Distance Stereopsis Tests

Stereoacuity should be tested for distance also.
A projection vectographic test or Oculus distance
stereotest can be used to test stereopsis for
distance. A diminished stereopsis for distance
may be an early sign of decompensating
exophoria.
Normal Stereoacuity
The adult individuals are capable of appreciating stereopsis with disparities as fine as 1520 arc seconds. The adult norm is 40 arc seconds.
For children, 3-5 years old the norm is 70 arc
seconds, and for 5-7 years it is 50 arc seconds.
Children above 8 years have the adult norm.
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Lang Two Pencil Test
In the absence of fine stereotests a gross estimation
of stereopsis can be made by a bedside test, two
pencil test popularized by Lang. A pencil is held
in the examiners hand horizontally and the child
is asked to touch the tip with the tip of another
pencil rapidly, coming from one side. Care should
be taken to avoid giving the end on view of the
pencil, as that can be accomplished even
monocularly, therefore, horizontal pencils are
better, as they do not allow an end-on view.
Always compare the binocular task with
monocular task. The test is a gross stereopsis
test of about 400 arc seconds disparity.
All the tests provide a measure of stereoacuity
by asking the patient to identify the correct target
that has stereoscoptic depth (target with
disparity). The working distance and interpupillary distance will need to be taken into
consideration when calculating stereoacuity.
Patients with disturbed binocular vision or
different refractive error in one eye will perform
poorly on depth discrimination tests. A rough
estimation of visual acuity has been made on
the basis of stereoacuity.
Fixation Disparity
The concept of fixation disparity is important
to understand the relationship of binocularity
and heterophoria. Ogle et al described the fusion
disparity as a physiological sensory phenomenon occurring in heterophoria, in which a
deviation of the visual axes of 6-10 minutes of
arc is compatible with bifoveal binocular single
vision The phoria that is measured after
disrupting fusion by cover- uncover test or similar
methods is dissociated phoria. Fixation disparity
is dependent upon the Panums fusional area.
Under binocular conditions there may be a
misalignment of the fixation points in the two
eyes within the limits of the Panums area of
fusion, which is fused and is seen as one. This
Fig. 23.21A: Fixation disparity
fusible misalignment is fixation disparity (Fig.

23.21A). This is quantified in minutes of arc.
Under binocular conditions of viewing a
vertical line is shown such that the upper half
is seen by right eye and the lower half by the
left eye, each viewed through polaroid
dissociation. If there is a misalignment, prisms
are used to align the two halves. This is called
associated phoria. The rest of the picture shown
apart from the vertical lines is seen by the two
eyes and function as a fusion lock. The associated
phoria is different from the phoria seen under
dissociation and is, therefore, named differently.
Fixation disparity curves: Under forced vergence
situations, using 3, 6, 9, 12 pd prisms base-in,
and base-out alternatively, the fixation disparity
and the associated phoria can be charted and
plotted. These plots are called fixation disparity
curves. There are four common types of fixation
disparity curves (Fig. 23.21B). Individuals with
Type I curves are frequently asymptomatic. Those
individuals having a steep slope, greater than
0.77 minute/prism diopter in esophoria and 1.06
minutes/prism diopter in exophoria are usually
symptomatic. Type II curves do not intersect the
Fig. 23.21B: The four fixation disparity curve types

developed by Ogle et al. The type of curve depends
upon the curve shape and not on the vertical or horizontal
position of the curve on the graph
fixation targets provides more natural

circumstances and a fusion lock and are visible
equally by both eyes. The central fixation target
for vertical associated phoria has half split
horizontal lines, each half visible to the right
or left eye. For horizontal associated phoria, the
split half lines are vertical. For measuring
associated phoria the adjustment knob (to move
one half line) is kept at zero and prisms are used
to correct the misalignment that is reported by
the patient. Both vertical and horizontal
associated phorias can be measured. For
measuring fixation disparity, the knob is shifted
to set 10 minutes of exofixation disparity. If the
patient reports misalignment the knob is taken
to the other end till the patient reports
misalignment in the reverse direction. Finally
the misalignment is decreased till the patient
reports alignment. The viewing time should be
limited to a few seconds.
Wesson Card
X-axis. Type IV curve is associated with unstable
binocularity. The individuals with types II, III
and IV are usually symptomatic. The flatter
portion of the curve represents the condition of
rapid adaptation to the vergence stimuli. Vision
therapy may be considered to successfully flatten
these curves and make the patient asymptomatic.
Forced fixation disparity curves can also be
plotted using different spherical lenses (in prepresbyopes) using lens power + 2.0 D to - 3.0 D in
0.5 D or 1.0 D steps. These forced fixation disparity
curves are also used to measure AC/A ratio.
Fixation disparity can be measured by Sheedy
disparometer, Mallet unit and Wesson card.
Disparometer
A close-up view of the fixation disparity targets
on the disparometer is shown in the Figure 23.22.
The fine reading print shown adjacent to the
Wesson card has to be viewed through polaroid

glasses (Fig. 23.23). It has vertical lines in the
upper half (seen by one eye) and an arrow in
the lower half (seen by the other eye). The rest
of the card is viewed binocularly.
Fig. 23.22: Disparometer for measuring angular amount

of fixation disparity, A Front or patient side, B Back or
clinician side
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394
10.
11.
12.
13.
Fig. 23.23: Wesson fixation disparity card
14.
Bibliography
1. Adelstein FE, Cuppers C. Analysis of the motor
situation in strabismus. In: Arruga A (Ed).
International strabismus symposium (university
of Giessen, 1966) New York, S. Karger A.G. 1968;
139-48.
2. Bagolini B. Tecnica par Lesame della visione
binoculare sensa introduzone di elimenti dissicianti
test del vetro striato. Boll Ocul 1958;37:195.
3. Bielschowsky A. Lectures on motor anomalies,
Hanover NH. 1943. (reprinted 1956) Dartmouth
College Publications.
4. Bixenmann WW, Noorden GK von. Apparent
foveal displacement in normal subjects and in
cyclotropia. Ophthalmologica 1982;89:58.
5. Brodie SE. Photographic calibration of the
Hirschberg test. Invest Ophthalmol Vis Sci 1987;28:
736.
6. Broniarczyk-Loba
A,
Nowakowska
O,
Laudanska-Olszewska I, Omulecki W. Advancements in diagnosis and surgical treatment of
strabismus in adolescent and adults. Klin Oczna
2003;105(6):410-3.
7. Bruckner R. Exakte strabismus diagnostik bei Yz
-3 jahrigen, Kindem mit einem einfachen Durch
leuch tungs test Ophthalmologica 1962;144:184.
8. Burian HM. Normal and anomalous correspondence in Allen JH (Ed). Strabismus Ophthalmic
symposium II. St. Louis, Mosby,1958.
9. Capobianco NM. The subjective measurement of
the near point of convergence and its significance
15.
16.
17.
18.
19
20.
21.
22.
23.
24.
in the diagnosis of convergence insufficiency. Am

Orthopt J 1952;2:40.
Fern KD, Manny RE. Visual acuity of the preschool
child: a review. Am J Optom Physiol Optics
1986;63:314-34.
Filipovic T, Grzetic R, Sviderek-Stalekar D. Earlier
detection of amblyopia and strabismus by
ophthalmologic screening card attached to the
vaccination card. Can J Ophthalmol 2003; 38(7):58792.
Holmes JM, Fawcett SL. Testing distance
stereoacuity with the Frisby-Davis 2 (FD2) test. Am
J Ophthalmol 2005;139(1):193-95.
Hussein MA, Coats DK, Muthialu A, Cohen E,
Paysse EA. Risk factors for treatment failure of
anisometropic amblyopia. J AAPOS 2004; 8(5):42934.
Kim DS, Coats DK, McCreery KM, Paysse EA,
Wilhelmus KR. Accuracy of clinical estimation of
abnormal head postures. Binocul Vis Strabismus Q
2004;19(1):21-24.
Leske DA, Holmes JM. Maximum angle of
horizontal strabismus consistent with true
stereopsis. J AAPOS 2004;8(1):28-34.
Parvataneni M, Christiansen SP, Jensen AA,
Summers CG. Referral patterns for common
amblyogenic conditions. J AAPOS 2005; 9(1):2225.
Sharma P. Strabismus Simplified. Modern
Publishers, New Delhi 1999.
Sokol S. Visually Evoked Potentials: theory
techniques and clinical applications. Surv
Ophthalmol 1976:21:18.
Spielmann A. A translucent occluder to study eye
position under unilateral or bilateral cover test. Am
Orthopt J 1986;36:65.
Teller DY, McDonald M, Preston K, Sebris SL.
Dobson V. Visual acuity in infants and children:
the acuity card procedure. Dev Med Child Neurol
1986:28:779.
Urist MJ Pseudostrabismus caused by abnormal
configuration of the upper eyelid margins. Am J
Veronneau-Troutman S. Prisms in the Medical and
Surgical Treatment of Strabismus. St. Louis: Mosby,
1994.
Von Noorden GK, Campos EC. Binocular Vision
and Ocular Motility: Theory and management of
strabismus. 6th edn, St Louis, Mosby, 2002.
Wright KW, Walonker F, Edelman P. 10 dioptre
fixation test for amblyopia. Arch Ophthalmol
1981;9:1242.
Incomitant Strabismus
S MEENAKSHI, T SURENDRAN
24
Incomitant
Strabismus
Incomitant strabismus comprises a large group

of disorders in which the amount of deviation
is different in different gaze positions. Broadly
these can be categorized in paralytic and
restrictive or mechanical.
Paralytic strabismus includes:
1. Third cranial nerve (Oculomotor nerve) palsy
2. Fourth cranial nerve (Trochlear nerve) palsy
3. Sixth cranial nerve (Abducens nerve) palsy
4. Paralysis of nerve supplying single muscle
5. Monocular elevation deficiency
6. Monocular depression deficiency and
7. Mbius syndrome.
Restrictive strabismus includes:
1. Duanes retraction syndrome
2. Orbital blow-out fractures with muscle
entrapment
3. Thyroid related strabismus
4. Congenital fibrosis and
5. Browns syndrome.
Following important points must be
considered while examining a case of incomitant
strabismus:
1. As most of the incomitant strabismus are
acquired a detailed history should be
obtained about:
(a) Trauma to the head and orbit
2.
3.
4.
5.
6.
7.
(b) Previous surgery such as cataract,

glaucoma implant and scleral buckle
(c) Treatment for thyroid eye disease.
Due to the incomitant nature of the strabismus patient may adopt an anomalous head
posture for fusion.
During duction and version testing, one
must be aware of restrictive and paretic
muscles giving the impression of an
overacting yoke muscle.
Primary and secondary deviations should
be measured meticulously. Primary
deviation is measured with the prism in
front of the affected eye and secondary
deviation, with the prism in front of the
normal eye.
Alternate prism cover testing should be
done in all cardinal positions of gaze.
Ability of the patient to proper fusion should
be ascertained with neutralizing prisms or
Fresnel prisms for both Snellen and free
space. It is important to ascertain fusion
for both primary and down gaze as these
are the important functional gazes for
activities of daily living.
Head tilt measurements are important to
assess cyclovertical muscle involvement.
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8. The presence of subjective torsion as
suspected by subjective complaints of tilting
or seen on diplopia charting may be
quantified by the Double Maddox Rod test.
The same can also be confirmed by on
fundus examination.
9. In office, forced duction and force generation
testing should be carried out when possible,
to assess the presence of restrictions and
degree of nerve function preserved.
10. Neuroimaging of the orbits and brain is
often required to make a complete diagnosis
and planning appropriate intervention.
11. It is also important to consider myasthenia
gravis and chronic progressive external
ophthalmoplegia in the differential
diagnosis.
Paralytic Strabismus
Third Cranial Nerve Palsy
The third cranial nerve supplies the levator
palpebrae superioris, superior rectus, medial
rectus, inferior rectus, and inferior oblique.
Therefore, the patient with third nerve palsy may
present with a combination of the following
symptoms and signs:
1. Diplopia: horizontal and vertical
2. Ptosis
3. Exotropia and hypotropia
4. Limited ocular motility in the direction of
action of affected muscles (Fig. 24.1), a partial
paresis involving only the superior or inferior
divisions or isolated muscle palsy may also
be a presentation.
Fig. 24.1: Third cranial nerve palsy
5. Paralysis of the pupillary sphincter with
resultant mydriasis or pupil sparing type
6. Long-standing palsy may have aberrant
regeneration in the form of ipsilateral
retraction of the upper lid on attempted
adduction and/or attempted infraduction, as
well as pupillary constriction.
If the pupil is spared the cause is most likely
vascular. When the pupil is involved, the cause
is likely to be an aneurysm. Patients with
vasculopathy and pupil sparing third nerve
palsy should be observed daily for one week,
then weekly for one month, and finally monthly
for six months.
To rule out concurrent superior oblique palsy,
patient is asked to attempt adduction and one
looks for incyclotorsion by observing the
conjunctival blood vessels.
Etiology
The etiology of third cranial nerve palsy differs
in pediatric and adult groups.
Causes of pediatric onset third nerve palsy are:
1. Congenital due to birth trauma
2. Trauma
3. Inflammation
4. Neoplasm and
5. Aneurysm.
Causes of adult onset third nerve palsy are:
1. Aneurysms
2. Vascular disease
3. Trauma
4. Neoplasm
5. Ideopathic.
Fourth Cranial Nerve Palsy

The fourth cranial nerve supplies the superior
oblique muscle. Fourth nerve palsy is the most
common cyclovertical muscle palsy. Patients may
present with a combination of the following
symptoms and signs:
1. Head tilt in both congenital and acquired

palsy
2. Facial asymmetry: The side of the face on
the side of the tilt is often less developed in
the congenital variety. This may be easily
evaluated by looking at old photographs.
3. Torsional diplopia can be assessed
subjectively and objectively.
4. The three-step test is the key to making the
diagnosis of isolated cyclovertical muscle
palsy. The test requires motility measurements
first in the primary position. This step incriminates the depressors of the hypertropic eye
and the elevators of the hypotropic eye. Next
measurements are performed in the side gazes
and an increase in hypertropia is noted (Fig.
24.2). This step eliminates the two muscles
that do not act in the field of gaze showing
the increased hypertropia. The third step,
which is the head tilt to either side, exposes
the weakened muscle that is unable to elevate
the eye.
5. Version testing may reveal an ipsilateral
inferior oblique overaction, ipsilateral superior oblique underaction and contralateral
superior oblique overaction due to failure of
the paretic eye to infraduct well in abduction
giving the impression of overaction.
6. Bilateral superior oblique palsy has some
unique features. These include history of
closed head trauma, subjective torsion,
objective torsion more than 10 degrees,
alternating hypertropia on head tilts, Vpattern esotropia and a chin-down posture.
Etiology
The etiology of fourth cranial nerve palsy may
be congenital and acquired.
1. Congenital is the commonest cause of fourth
cranial nerve palsy in many series.
2. Acquired fourth cranial nerve palsy may be
due to trauma, tumor, aneurysm and
iatrogenic.
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Fig. 24.2: Fourth cranial nerve palsy
Sixth Cranial Nerve or

Abducens Palsy
The sixth cranial nerve supplies the lateral rectus
muscle. The constellation of signs and symptoms,
which depend on the severity of the palsy are
as follows:
1. Horizontal diplopia
2. Face turn is present towards the side of the
paretic muscle. The face turn is present to
avoid diplopia and may be subtle.
3. Esophoria is present in primary gaze in
mild cases and esotropia with prominent
horizontal incomitance in more severe palsy
(Fig. 24.3). The esotropia is typically more
for distance and in bilateral cases there may
be a V-pattern.
4. Absence of vertical deviation.
Etiology
The sixth cranial nerve palsy occurs due to
infection, trauma, neoplasm, systemic vascular
disorders, systemic hematological disorders,
intracranial hypertension, raised intracranial
pressure, inflammatory disorders and idiopathic.
Principles of Management
1. If the cause is vascular or postinfectious, many
patients improve with time. It is prudent to
wait 3 to 6 months for recovery before
contemplating surgical intervention.
2. Conservative management options are
available to tide over during the waiting
period. Options include monocular occlusion,
prisms either ground in or Fresnel to help
patient fuse and carry on with activities of
daily living.
This can be achieved by:
a. Weakening the overacting antagonist
b. Strengthening the paretic muscle after
ascertaining the residual muscle function.
This may be obtained by shortening of
lateral rectus muscle in the sixth nerve
palsy, or tuck of the superior oblique.
c. If muscle function is very poor one must
consider transposition procedures such
as Jensens or Hummelsheims procedure.
Full tendon transposition for the lateral
rectus palsy and superior oblique
transposition procedures for the third
nerve palsy are recommended.
Monocular Elevation Deficiency
Fig. 24.3: Sixth cranial nerve palsy
3. Some patients are able to manage with a small

head posture especially patients with mild
sixth nerve palsy.
4. Botulinum toxin A injection into the antagonist muscle may prevent contracture and
help with the recovery of the paretic muscle.
5. Pre-surgical in-office testing includes:
a. To assess the amount of residual muscle
function in the paretic muscle. This is
done by assessment of saccades clinically
or through saccadic velocity testing. This
can also be done by the force generation
test.
b. To assess the presence of contracture of
the antagonist muscle. This is done by
the force duction test.
6. Surgical goals include fusion in primary gaze
or with a minimal head posture and cosmesis.
Formerly named double elevator palsy, the

terminology has been changed after studies
showed that many patients have only superior
rectus palsy without involvement of the inferior
oblique.
Etiology
Etiology may be congenital or acquired.
Congenital causes include supranuclear defects,
primary superior rectus paresis, primary inferior
rectus restriction and inferior rectus restriction
secondary to superior rectus paresis.
Acquired deficiency may occur due to
cerebrovascular disease, tumors, sarcoidosis and
infectious diseases.
Monocular elevation deficiency has following
clinical presentations:
1. Unilateral limitation of up gaze above midline
with accompanying ptosis
2. Hypotropia
3. Limitation of elevation in both abduction and
adduction
4. Abnormal head posture in the form of chin
elevation for fusion
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5. Pseudoptosis in addition to true ptosis
6. Acquired deficiency presents with acute onset
of diplopia in primary position and up gaze.
Diagnosis of the etiology is based on certain
clinical features. These include presence of Bells
phenomenon, saccadic testing below and above
midline and forced duction testing.
Bells phenomenon is present if the cause
is supranuclear and absent in the others. Upward
saccades are normal in inferior rectus restriction
and slowed in supranuclear monocular elevation
deficiency below midline and absent above
midline. In primary superior rectus paresis, the
saccades are slowed both above and below
midline. Forced duction testing is positive only
if inferior rectus is restricted.
A simple approach to management includes:
1. Forced duction testing on the table
2. If inferior rectus restriction is present then
the muscle is recessed.
3. If forced duction test is negative consider
transposition procedure such as Knapps
transposition where the medial and lateral rectus
are either split or in their entirety are transposed
adjacent to the superior rectus insertion
or muscle aplasia is the primary event has not

been established. Cranial nerves VI to XII may
be involved. This may present as dysphagia,
paralysis and hypoplasia of the tongue. The
cranial nerve VIII may be spared and III and
IV nerves are rarely involved. However, facial
nerves are always involved. The VI nerve is
involved in 75% of cases while the XII nerve
in only in minority of cases.
Mbius Syndrome
Duanes retraction syndrome (DRS) is a

congenital ocular motility disorder characterized
by limitation of abduction or/and adduction,
palpebral fissure narrowing on attempted
adduction (Fig. 24.4) due to retraction of globe
and upshoot or downshoot on adduction due
to leash effect of tight lateral rectus.
It is postulated that a disturbance in normal
embryogenic development causes Duane
syndrome. It is further substantiated by the
frequent associations of the syndrome with ocular
anomalies and congenital abnormalities of the
facial, skeletal, and CNS. Agenesis of the sixth
nerve or nucleus and innervation of the lateral
rectus muscle by the inferior division of third
nerve nucleus cause simultaneous cocontracture
A child with Mbius syndrome usually presents

in infancy. The child is brought by the caregiver
for the lack of facial movements while crying
and inability to smile. The child may be unable
to close his mouth, may have a prominent upper
lip and indistinct speech. No racial, sex predilection has been described, and the inheritance
pattern is variable.
Clinical Features
The clinical features include congenital facial
diplegia, bilateral abducens nerve palsies and
congenital bilateral incomplete facial palsy
resulting in a mask-like face. Nerve, brainstem,
Systemic Findings
Mbius syndrome is associated with congenital
deformities. The most common deformity is
clubfoot. Brachial deformities and pectoral
muscle hypoplasia (Poland anomaly) are
common. Brachydactyly and syndactyly are also
described. CT or MRI shows calcification in the
region of VI nerve.
Management involves a multidisciplinary
approach and is primarily cosmetic.
Restrictive Strabismus
Duanes Retraction Syndrome
Type 1: Duane is the most frequent classical form.
Apart from the defective abduction, retraction
of the globe, and palpebral fissure narrowing
on adduction, additional abnormalities like A
or V phenomenon, up drift or down drift of the
affected eye on adduction, or attempted
abduction may be present.
Type 2: Duane is characterized by limitation or
complete palsy of adduction with exotropia of
the paretic eye, abduction appears to be normal
or only slightly limited. As in Duane 1, distinct
narrowing of the palpebral fissure and retraction
of the globe on attempted adduction are also
present.
Fig. 24.4: Duanes retraction syndrome
of lateral rectus and medial rectus resulting in

globe retraction on attempted adduction. DRS
is more common in female, often unilateral and
left eye is more affected (75%). Both sporadic
and autosomal dominant inheritance have been
reported.
Duane' syndrome is traditionally classified
into 3 types:
Type 3: Duane is a combination of limitation or

absence of both abduction and adduction of the
affected eye. In this form, adduction and
abduction may be defective in the equal degree
(affected eye in parallel position), or adduction
more defective than abduction (affected eye in
divergent position). Globe retraction and
narrowing of the palpebral fissure on attempted
adduction are also present.
Duane' syndrome is associated with ocular
and systemic anomalies. Ocular anomalies
include optic nerve hypoplasia, morning glory
syndrome, congenital ptosis, dysplasia of the
iris stroma, cataracts, heterochromia, Marcus
Gunn jaw-winking, choroidal coloboma,
crocodile tears, and microphthalmos. Goldenhar
syndrome, Klippel-Feil anomaly and congenital
labyrinthine deafness are systemic anomalies.
Management
Usually surgical results in Duanes retraction
syndrome are disappointing. Surgery is done for
abnormal head posture, up shoot or down shoot
and enophthalmos. The most common indication
for surgical treatment is an unacceptable face
turn to permit fusion. Patients who have Duane's
syndrome with exotropia in primary position
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usually have a face turn away from the affected
eye. More commonly, an esodeviation in primary
position leads to a face turn toward the side
of the affected eye. A reduction of 50% or more
of the width of the palpebral fissure during
adduction compared with primary position has
been suggested as an indication for surgical
treatment of the syndrome.
The surgical procedures include medial
rectus muscle recession, vertical rectus muscle
transposition, lateral rectus muscle recession and
posterior fixation suture.
Medial rectus muscle recession: Recession of the
medial rectus muscle in the involved eye will
align the eye but will not improve abduction
beyond the primary position. Resection of the
lateral rectus muscle is avoided because it will
increase retraction and will not improve
abduction. Medial rectus recession alone also
may improve the enophthalmos and vertical
overshoots in adduction, in part by limiting
adduction of the eye. For adult patients adjustable
suture recession techniques are helpful.
Recession of the contralateral medial rectus
muscle in addition to the ipsilateral medial rectus
muscle may be performed in those cases in which
the patient has primary position esotropia greater
than 20 prism diopters.
Vertical rectus muscle transposition: Transposition
of the vertical rectus muscles to a position adjacent
to the lateral rectus, with or without recession
of the ipsilateral medial rectus, has been
suggested as a means of correcting the primary
position esotropia, improving abduction, and
enlarging the field of single binocular vision.
This procedure probably should be considered
only as primary treatment for patients with
marked limitation of abduction with minimal
retraction, and no up shoot or down shoot.
Lateral rectus muscle recession: Patients may present
with exodeviation in primary position with a
face turn away from the side of the affected eye.

The face turn is treated with recession of the
ipsilateral lateral rectus muscle. If primary
position exotropia is present with a marked up
shoot or down shoot, a lateral rectus recession
usually is combined with a Y-splitting procedure
or a posterior fixation suture. In up shoot or
down shoot, recession of the lateral rectus muscle
is effective.
Posterior fixation suture: A posterior fixation suture
on the lateral rectus muscle can effectively prevent
slippage of the muscle belly over the globe. It
may be used as an alternative procedure to treat
up shoots and down shoots. Simultaneous
recession of both lateral and medial rectus may
help with up shoot and down shoot.
Browns Syndrome
Browns syndrome is a restrictive strabismus
marked by limitation of elevation that is worse
when the eye is in adduction (Fig. 24.5). It is
characterized by following features:
1. Limitation of elevation in adduction. There
is some limitation of elevation in abduction
but the limitation is more marked in
adduction.
2. Minimal or no hypotropia in primary gaze
3. Minimal or no over action of ipsilateral
superior oblique
4. Divergence in upgaze causing Y-pattern
5. Limited elevation in abduction can produce
pseudo inferior oblique over action of the
fellow eye
6. Intorsion on attempted up gaze
7. Compensatory head posture chin elevation
and face turn to keep the affected eye in
abduction
8. Good fusion and stereopsis
9. In adduction, palpebral fissure widens and
there is a down shoot of the involved eye.
10. Forced duction test is positive
Fig. 24.5: Browns syndrome
Eustin and colleagues graded Browns

syndrome into 3 types:
1. Mild: Restriction of elevation in adduction,
no hypotropia in primary gaze and no down
shoot in adduction
2. Moderate: No hypotropia in primary gaze
and down shoot on adduction
3. Severe: Hyportropia in primary gaze, marked
down shoot on adduction and amblyopia,
usually patients develop compensatory head
posture and have fusion. If the patient
presents with a manifest hypotropia and no
compensatory head posture or have
associated horizontal strabismus, there is
increased risk of amblyopia.
Brown's syndrome is classified into
congenital and acquired forms. The congenital
form is subdivided into true and pseudo.
Cysticercosis is an important cause of acquired
Browns syndrome.
Differential diagnosis of the syndrome
include double elevator palsy, blow-out fracture,
inferior oblique palsy, superior oblique palsy and
Duanes retraction syndrome.
status should be closely monitored in young

children. Spontaneous resolution may occur in
some cases. Corticosteroids may be beneficial.
In the severe form of the syndrome with
hypotropia in primary gaze, surgery is indicated.
Other indications for surgery include anomalous
head posture, loss of binocularity in a child and
cosmetically unacceptable down shoot in
adduction. The surgery is based on the principle
of lengthening the superior oblique tendon.
Procedures such as tenotomy and tenectomy are
not controlled to achieve a controlled elongation
of superior oblique tendon a Wright superior
oblique tendon expander can be used.
Congenital Fibrosis of Extraocular

Muscles
It is an autosomal dominant disease affecting
the extraocular muscles. It is characterized by
blepharoptosis (Fig. 24.6) and chin elevation,
absence of elevation or depression of the globe
with eyes fixed 20 to 30 degrees below the
horizontal meridian, little or no horizontal
movement and absence of Bells phenomenon.
Fibrosis of extraocular muscles is seen on
histopathology. Ductions are very limited.
Amblyopia, refractive errors particularly
hyperopia and astigmatism are common. Patients
may also show esotropia in attempted elevation
probably due to the adductive action of superior
rectus muscle.
Treatment
The mild and moderate form of the syndrome
without strabismus in primary position should
be left untreated. Visual acuity and binocular
Fig. 24.6: Congenital fibrosis of the extraocular muscles
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Ocular associations and systemic associations are not common. Ocular associations such
as optic nerve hypoplasia, chorioretinal
coloboma, microphthalmos and albinism have
been described. Systemic associations such as
bilateral inguinal hernias and cryptorchidism
are reported.
movement testing can differentiate between

paretic and entrapped muscle. The associated
severe globe damage is often rare since blowout is a protective phenomenon. Plain X-ray
(Waters view) and CT-scan confirm diagnosis.
Management
Goals of management are: (a) clear the visual

axis, (b) alleviate chin-up posture, and (c) align
eyes in primary position. Large recessions after
careful dissection of intermuscular septal
attachments, with the use of preplaced sutures,
give good results. Frontalis sling is the mainstay
of ptosis repair. Absence of Bells phenomenon
often necessitates long-term generous use of
lubricants in these patients.
In initial phase of injury, surgery should be

withheld until two weeks till edema subsides.
Patient should be followed-up closely with serial
diplopia and Hess charting. Surgery should be
deferred if sufficient diplopia-free area is present
in primary and down gaze. Surgery can be
performed for significant enophthalmos.
Teflon plate can be placed subperiostially. For
troublesome diplopia, Fresnel prisms trial can
be considered. Initially inferior rectus recession
can be planned for surgical correction.
Orbital Blow-out Fracture
Bibliography
Management
Strabismus after blow-out fracture has been

estimated to occur in about 58% of patients.
Clinical Features
Immediately following injury with cricket or
tennis ball or road traffic accidents, the patient
presents with black eye and restriction of ocular
movement in all directions of gaze which usually
subsides by end of first week. It presents as specific
restrictive strabismus with diplopia in up and
down gaze due to entrapment of soft tissue in
fractured fragment, hypoesthesia along
infraorbital nerve and enophthalmos due to
herniation of orbital contents into the maxillary
sinus. The presence of muscle entrapment can
be confirmed on force duction test (FDT). Saccadic
1. Ahluwalia BK, Gupta NC, Goel SR, et al. Study

of Duanes retraction syndrome. Acta Ophthalmologica (Copen) 1988;66:77.
2. Brown HW. True and simulated superior oblique
sheath syndrome. Doc Ophthalmol 1973;34:123.
3. Kraft SP, Jacobson ME. Technique of adjustable
suture strabismus surgery. Ophthalmic Surg
1990;21:633.
4. Park MM, Eustis HS. Simultaneous superior
tenotomy and inferior oblique recession in
Brown syndrome. Ophthalmology 1987;94:1043.
5. Sharma P. Strabismus simplified. New Delhi,
Modern Publishers, 1999.
6. Smith RS, Damasat M. Acquired orbital
retraction syndrome after 6th nerve paralysis.
Neurology 1973;14:147.
7. von Noorden GK. Binocular Vision and Ocular
Motility. 4th ed. St Louis, Mosby, 1990.
8. Wilson WE, Eustis HS, Park MM. Brown
syndrome. Survey Ophthalmol 1989;34:153.
Diagnostic Procedures in Dry Eyes Syndrome
MS SRIDHAR
25
Diagnostic
Procedures in Dry
Eyes Syndrome
Dry eye (DE) is a disorder of tear film due to

tear deficiency or excessive tear evaporation
causing damage to the interpalpebral ocular
surface and associated with symptoms of ocular
discomfort.1
Presently, DE is classified into 2 major groups:
Tear deficient DE and evaporative DE. Tear
deficient DE (ATDAqueous tear deficiency) is
a disorder of lacrimal function causing decreased
secretion of aqueous or can result from failure
of transfer of lacrimal fluid into the conjunctival
sac. In evaporative or tear sufficient DE, lacrimal
function is normal and in most cases, the tear
abnormality is due to increased tear evaporation.
Meibomian gland (MG) dysfunction and
blinking disorders are common causes for
evaporative DE.
Clinical Features
The usual symptoms of a patient with dry eyes
caused by ATD include tearing, redness, burning,
blurring of vision, fluctuating vision, itching,
irritation, dryness, foreign body sensation, tired
eyes and heaviness of lids. Symptoms tend to
get aggravated in hot, arid climates and by certain
occupations like exposure to chemicals, dust,
smoke and prolonged use of computer video

terminals.
Signs include presence of greasy scales on
the lid margins suggestive of seborrheic
blepharitis or crusts on the lid margin, the removal
of which results in oozing of blood from the
surface which is common is staphylococcal
blepharitis. The tear film height is usually
reduced and mucus debris or stringy discharge
may be seen. The conjunctiva may appear
lusterless. It may be thickened, edematous,
hyperemic, or may show slight folding inferiorly.
In advanced cases, the conjunctiva may be
keratinized particularly in the exposed areas.2
Corneal examination may reveal fine punctate
staining with fluorescein which in severe cases
may appear as confluent patches. Epithelial
defects may develop which may be slow to heal
or may persist and predispose to rapid sterile
corneal ulceration or secondary bacterial
infection. Plaques or filaments on the surface
of the cornea may be formed.
Occasionally, clinical signs may be absent
in a patient with dry eyes and hence clinical
diagnostic tests are mandatory in the evaluation.
The clinical signs of meibomian gland
dysfunction include stenosed or pouting orifices,
squamous metaplasia of the orifices (white shafts
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406

of keratin in the orifices), reduced expressibility
of meibomian gland secretions and turbid or
thick toothpaste like secretions of the meibomian
glands. The presence of thickening of the lid
margins, telangiectatic blood vessels and cysts
on the lid margin may be noted. Transillumination
may also reveal drop out of the meibomian gland
ducts, which is a sign of obstructive meibomian
gland disease. In patients with acne rosacea with
inflammatory meibomitis, the gland architecture
is distorted. Video meibography, using one-chip
infrared video camera and a hand held
transilluminating light source along with a video
monitor, is useful for imaging the abnormal
structure of the meibomian glands in chronic
blepharitis.
Clinical Diagnostic Tests for Dry Eyes

Tear Film Break-Up Time (TBUT)
According to the diagnostic algorithm put forth
by Plugfelder3 for diagnosing dry eye, fluorescein
tear break-up time (TBUT) is the first diagnostic
test to be done which gives information regarding
tear film stability. A diagnosis of tear film instability is made when a fluorescein TBUT value of
<10 seconds is obtained. Even though Decker
in 1876 started research on tear film stability,
it was Norn4 in 1965 who evolved a simple and
convenient method to assess the tear film stability
by observing the tear film using a cobalt blue
filter on a slit-lamp, after instilling fluorescein
stain. The interval between the last blink and
the first appearance of a dry spot on the
fluorescein-stained tear film was then called the
corneal wetting time. Later term break-up time or
tear break up time (BUT or TBUT) was used.5-7
Although different methods now exist like the
invasive5 and non-invasive methods2, difference
in the method of instilling fluorescein, number
of readings taken4-6,8 and the type of slit-lamp
observation, with a narrow vertical slit, horizontal

slit or a full beam9, 10, this test is of importance
ever since it has been identified as the screening
test in determination of dry eyes in the potential
contact lens wearers.7
The clinical method of doing fluorescein tear
break-up time (TBUT) is as follows:
The subject is made to sit comfortably on a
slit-lamp with forehead firmly against the
forehead rest and chin resting comfortably on
the chin rest. The microscope is positioned
directly in front of the eye to be receiving the
stain. The fluorescein strip is wetted with a drop
of preservative-free saline. The strip is then
applied over the inferotemporal conjunctiva. The
subject is asked to blink for 3-5 times only and
then is asked to stop blinking. The fluorescein
staining is then viewed under a slit-lamp (full
beam) using a blue filter along with a wratten
filter with magnification. The time interval from
the last blink to the appearance of a randomly
seen dark spot is recorded with a stopwatch.
This is followed by taking another 2 readings
of TBUT with a gap of 3-5 blinks in between.
Non-invasive break-up time (NIBUT): In this
method, mire is projected using a keratometer,
topography, perimeter or tearoscope. The time
taken for the tear film to distort or break-up after
a blink is measured. The reading of break-up
time is less than that of invasive tear break-up
time using fluorescein, but it is more difficult
practically to do it in the clinic.
Schirmers Test 1 without Anesthesia

This test assesses the reflex secretion and tear
production potential. No anesthetic is used.
Whatman filter paper #41 measuring 35 mm in
length with a bend at 5 mm is used, and placed
at the junction of medial 2/3 and lateral 1/3
of the lower lid in the fornix (Fig. 25.1). The
patient is asked to look forward and blink

Schirmers Test with Nasal
Stimulation
Fig. 25.1: Schirmers test showing the Whatman filter

at the junction of medial 2/3rd and lateral 1/3rd of lower
lid in the fornix
normally. The test is carried out in dim

illumination and under standard conditions of
temperature and humidity. The length of wetting
is recorded after 5 minutes. Wetting of less than
5 mm is considered abnormal.
Schirmers Test with Anesthesia

Topical proparacaine is instilled into the
conjunctiva. After 5 minutes, the excess fluid is
wiped off with a Johnsons bud. The fluorescein
strip is then placed as mentioned above and the
length of wetting is read after 5 min. While taking
the reading when the front of the wetted area
was uneven, the millimeter it crosses is recorded
as the value.
Schirmers test though categorized by many
researchers as non-reliable11-14 is still widely used
to assess adequacy of tear production15-19 to help
in diagnosis of keratoconjunctivitis sicca,
screening for dry eye in contact lens wearers12,20
and for analysis of chemical components of tear
film.21-23 Lemp in the workshop on clinical trials
of dry eyes puts forth the use of Schirmers test
as the standard measure for diagnosing teardeficient dry eye. Validated by van Bijsterveld,24
this test is also recommended by the working
group on diagnostic tests, and available for
routine clinical practice.
After performing routine Schirmers test, a cotton

swab is inserted into the nasal cavity towards
the direction of ethmoid sinus. A 75 mm strip
of Whatman filter paper #41 is placed in the
conjunctival fornix and the length of wetting
measured after 5 minutes. Wetting of less than
10 mm is considered abnormal. It is advisable
to perform this test on a different occasion.
Patients, who do not respond to nasal stimulation
by an increase in the lacrimal secretion, are
thought to have an invasion of lymphocytes into
their lacrimal glands,5 resulting in anatomic
destruction of the gland. Such patients do not
show any response even on maximal stimulation.
Patients who respond, the lacrimal gland is
viable. When patient responds to nasal
stimulation but is less responsive to conjunctival
stimulation, it is postulated that the reflex circuit
between the lacrimal gland and the conjunctiva
is disturbed.
Diagnostic Dye Staining: Fluorescein

and Rose Bengal Stain
The instillation of dyes is a common method
to detect ocular surface epithelial pathology
associated with dry eyes. Rose bengal is a
fluorescein derivative that has been used for the
diagnosis of dry eye since Sjgren25 described
the presence of dye staining in patients with
keratoconjunctivitis sicca (KCS) in 1933. It was
thought to stain only devitalized epithelial cells
but it also stains healthy epithelial cells when
they are not protected by a healthy layer of
mucin.26 Therefore, it has the unique property
of evaluating the protective status of the preocular
tear film. Rose bengal also stains dead or
degenerating cells, lipid-contaminated mucous
strands, and corneal epithelial filaments (Fig.
25.2). Solution is preferred over impregnated
407
408
Fig. 25.2: Diffuse slit-lamp view showing rose bengal

staining (arrow) in a patient with aqueous tear deficiency
(ATD)
Fig. 25.3: Diffuse slit-lamp view showing fluorescein

staining with filaments in a dry eye patient
strips.27 A double vital staining technique was

described at the NEI Workshop.1 A 2 l mixture
of 1% rose bengal and 1% fluorescein (preservative-free) and non-preserved saline without
anesthetic, is instilled into the conjunctiva. The
areas of staining are graded on slit-lamp
examination.
The interpretation of rose bengal staining in
dry eyes is based on two factors, intensity and
location. Van Bijsterveld 28 reported a grading
scale that evaluates the intensity based on a scale
of 0 to 3 in three areas: nasal conjunctiva, temporal
conjunctiva and cornea, with a maximum
possible score of 9. The classic location for rose
bengal staining in aqueous tear deficiency is
interpalpebral conjunctiva, which appears in the
shape of two triangles whose bases are at the
limbus. The NEI workshop has recommended
division of nasal and temporal conjunctiva into
3 zones, each graded from 0-3, with a maximum
possible score of 18.
Rose bengal staining is considered more
sensitive and more specific in detecting patients
with dry eyes than either reduced tear breakup time or a low Schirmers test. Rose bengal
staining may help to differentiate between ATD
and lipid tear deficiency (LTD) by studying the
distribution of stain in the non-exposure zone.
Preferential staining has been observed in nonexposure zones in the LTD, whereas in ATD,
the staining is seen in the exposed interpalpebral
areas.29
Fluorescein is another diagnostic dye
commonly used for diagnosis of dry eye. The
dye penetrates intercellular spaces and indicates
increased epithelial permeability.26 Fluorescein
generally stains the cornea more than the
conjunctiva (Fig. 25.3).
Lissamine green B has been investigated as
a marker for ocular surface disease. It is found
to detect dead or degenerated cells and it produces less irritation after topical administration
than rose bengal.
Fluorescein Clearance Test

Schirmers Strip
Ten microlitre of 0.5% fluorescein and 0.4%
oxybuprocaine hydrochloride are instilled into
the conjunctival fornix. The eyes are kept open
for 5 minutes. 35 mm long strips of Whatman
filter paper #41 is placed in both the eyes. The
eyes are then closed for 5 minutes. The intensity
of color is compared to a standard scale. Each
grade shows a 12.5% increase in the basal tear
turnover and tear flow. This method may not

reflect the basic tear secretion since reflex tearing
may occur in response to the slit-lamp illumination or irritation by the strip. The length of
wetting may affect the intensity of fluorescein
color on the strip. In general the darker the
color of fluorescein, the less or poor is the
clearance.
Visual Scale
This is a safe and inexpensive method that
corroborates with irritation symptoms. Six

microlitre of 2% fluorescein is instilled into the
inferior cul-de-sac. Fifteen minutes later, the
color of the lower tear meniscus at the lateral
1/3 of lower lid is compared with the standardized scale (3 = Normal, >3 = disease, <3 =
equivocal).
A simple diagnostic algorithm is given below
to place a given patient in one of the categories
of dry eyes.
Diagnostic Algorithm for Dry Eyes
409
410
Laboratory Tests
Lysozyme and Lactoferrin Assays
Tear Film Osmolarity
Though lysozyme and lactoferrin are found to

be low in dry eye, the tests for their evaluation
are cumbersome and expensive and hence not
recommended for use in clinical practice.
Tear film (TF) osmolarity is said to represent the

gold standard in the diagnosis of DE because
of its greater sensitivity and specificity as a single
test or in combination with other tests. Though,
it is unable to distinguish between ATD DE and
Evaporative DE. The osmolarity of basal tears
is measured and thus reflex tearing has to be
avoided. There exists a need for an instrument
that is more reliable and freely available for testing
TF osmolarity. Technical errors resulting in falsely
abnormal values are reported.
Tear Ferning
Conjunctival mucus from a normal eye crystallizes in the form of ferns when placed on a dry
glass slide and observed under the microscope.
The scrapings are obtained from lower nasal
palpebral conjunctiva, 30 immediately following
drying; the slide is evaluated under a microscope
to find typical mucus arborization or ferning.
Ocular ferning test from conjunctival scrapings
is considered as a quantitative test for mucin
deficiency. The conjunctival mucus may be
reduced or absent in those patients with conditions like chemical burns, ocular cicatricial
pemphigoid and Stevens-Johnson syndrome.
Conjunctival Impression Cytology

The surface of the normal conjunctiva contains
goblet cells that produce mucin. In cases of
advanced dry eye, the epithelium undergoes
pathologic changes, termed squamous metaplasia, and the density of goblet cells decreases.
As a result, the tear film becomes unstable
secondary to a reduction in the mucin layer of
the tear film. Conjunctival impression cytology
allows the evaluation of epithelium and goblet
cells on the conjunctival surface.
Measurements of Immnoglobulins
and Antibodies
Measurements of IgA, IgG, IgM and viral
antibodies 31 in tears by ELISA have been tried
as laboratory tests in the diagnosis of dry eyes.
Since constitutive protein concentration in the
tears varies with flow rate, tear collection must
be standardized and it has to be assured that
only non-stimulated tears are obtained.32
Serum Autoantibodies
Detection of serum autoantibodies is used to
diagnose Sjgrens syndrome ATD. One or more
of the following autoantibodies may be found:
Antinuclear antibodies (ANA titer 1:160),
rheumatoid factors (RF titer 1:160) or Sjgrens
syndromespecific antibodies such as anti-Ro
(Sjgren-A) or anti-La (Sjgren-B). In one study33
antinuclear antibodies (ANA) were the most
frequently detected antibodies in ATD being
present in 80%. In contrast, positive RF was found
in 65% and positive SS-A in 30% of the same
group of patients.34
References
1. Lemp MA. Report of the National Eye Institute/
Industry Workshop on Clinical Trials in Dry
Eyes. CLAO 1995;21:221-32.
2. Tabbara KF, Wagoner MD. Diagnosis and
management of dry eye syndrome. Int
Ophthalmol Clin 1996;36:61-76.
3. Pflugfelder SC, Tseng SCG, Sanabin O, et al.
Evaluation of subjective assessment and
objective diagnostic tests for diagnosing tear
film disorders known to cause ocular irritation.
Cornea 1998;17:38-56.

4. Norn MS. Desiccation of precorneal film. I
Corneal wetting-time. Acta Ophthalmol (Kbh)
1969;47:865-80.
5. Lemp MA, Hamill JR. Factors affecting tear film
break up time in normal eyes. Arch Ophthalmol
1973;89:103-05.
6. Rengstorf RH. The precorneal tear film break
up time and the location in normal subjects.
Am J Optom Physiol Opt 1974;51:765-69.
7. Holly FJ. Tear film physiology and contact lens
wear. II. Contact lens tear film interaction. Am
J Optom Physiol Opt 1981;58:331-41
8. Vanley GT, Leopold IH, Gregg TH.
Interpretations of tear film break up. Arch
Ophthalmol 1977;95:445-48.
9. Cho P, Brown B. Review of TBUT technique
and a closer look at the TBUT of HK-Chinese.
Optom Vis Sci 1993;70:30-38.
10. Cho P, Brown B, Chan I, Conway R, Yap M.
Reliability of the tear film break up technique
of assessing tear stability and the locations of
tear break up in Hong Kong Chinese. Optom
Vis Sci 1992; 69:879-85.
11. Wright JC, Meger GE. A review of Schirmers
test for tear production. Arch Ophthalmol
1962;67:773-82.
12. Tabak S. A Short Schirmers test. Contacto
1972;16(2):38-42.
13. Hanson J, Fikentscher R, Rosenberg B.
Schirmers test of lacrimation. Arch Ophthalmol
1975;101:293-95.
14. Henderson JW, Prough WA. Influence of age
and sex on flow of tears. Arch Ophthalmol
1950;43:224-31.
15. Mishima S, Gasset A, Klyce SD, Baum JL.
Determination of tear volume and tear flow.
Invest Ophthalmol 1966;5(3):264-76.
16. Jones LT. Lacrimal secretory system and its
treatment. Am J Ophthalmol 1966;62:47-60.
17. Shapiro A, Merin S. Schirmer test and break
up time of tear film in normal subjects. Am
J Ophthalmol 1979;88:752-57.
18. Hamano H, Hori M, Hamano T, Mitsunaga S,
Maeshima J, Kojima S, Kawabe H, Hamano
T. A new method for measuring tears. CLAO
J 1983;9:281-89.
19. Rajiv, Mithal S, Sood AK. Pterygium and dry
eye a clinical correlation. Indian J Ophthalmol
1991;39:15-16.
20. Clinch TE, Benedetto DA, Feldberg NT, Laibson

PR. Schirmers test: a closer look. Arch Ophthalmol
1983;101:1383-86.
21. Prause JU. Immunoelectrophoretic determination of tear fluid proteins collected by the
Schirmer I test. Acta Ophthalmol (Kbh) 1979;
57:959-67.
22. Kiljstra A, Jeurissen SHM, Koning KM. Lactoferrin levels in human tears. Br J Ophthalmol
1983;67:199-202.
23. Stuchell RN, Feldman JJ, Farris RL, Mandel ID.
The effect of collection technique on tear
composition. Invest Ophthalmol Vis Sci 1984;
25:374-77.
24. Van Bijsterveld OP. Diagnostic tests in the sicca
syndrome. Ann Ophthalmol 1969;82:10-14.
25. Sjgren HS. Zur kenntnis der keratoconjunctivitis
sicca (keratitis folliformis ber hypofunktion der
ranendrasen). Acta Ophthalmol (Copen) 1933;
11:1-151.
26. Feenstra RPG. Tseng SCG. Comparison of
fluorescein and rose bengal staining.
27. Roberts DK. Keratoconjunctivitis sicca. J Am
Optom Assoc 1991;62:187-99.
28. Van Bijsterwald OP. Diagnostic tests in the sicca
syndrome. Ophthalmology 1969;82:10-14.
29. Lee SH, Tseng SCG. Rose Bengal staining and
cytologic changes associated with meibomian
gland dysfunction. Am J Ophthalmol 1997;124:
736-50.
30. Tabbara KF, Okumoto M. Ocular ferning test.
A qualitative test for mucus deficiency.
31. Coyle PK, Sibony PA. Viral antibodies in normal
tears. Invest Ophthalmol Vis Sci 1988;29:10.
32. Fullard RJ, Snyder C. Protein levels in non-stimulated and stimulated tears of normal human
subjects. Invest Ophthalmol Vis Sci 1990;32:8.
33. Pflugfelder SC, Whitcher JP, Daniels TE.
Sjgrens syndrome In: Pepose J, Holland G,
Whilhelmus K (Eds). Ocular infection and
immunity. St. Louis, Mosby, 1997.
34. Pflugfelder SC, et al. Chronic Epstein-Barr viral
infection and immunologic dysfunction in
patients with aqueous tear deficiency.
411
412
AK GROVER, RITURAJ BARUAH
26
Evaluation of
Epiphora
Applied Anatomy and Physiology

of the Lacrimal Apparatus
Lacrimal Gland
The lacrimal gland is an exocrine gland (20155
mm) that lies in the lacrimal fossa formed by
the frontal bone in the anterosuperior lateral
orbit. It is divided into a larger orbital lobe and
a smaller palpebral lobe by the fibrous extensions
from the Whitnall ligament, levator aponeurosis
and its lateral horn.1 It secretes tears through
a series of ducts (10-12) into the conjunctival
sac just in front of the superior fornix, 5 mm
above the lateral tarsal border. Two to six ducts
from the orbital portion run through and join
the ducts of the palpebral lobe. Removal or
damage to the palpebral lobe can thus lead to
significant decrease in tear secretion.
There are accessory exocrine glands of Krause
and Wolfring that are located in the superior
fornix and above the superior border of the tarsus,
respectively. These glands have got no apparent
nerve supply.
The blood supply of the lacrimal gland is
from the lacrimal branch of the ophthalmic artery.
Venous blood drainage is via the ophthalmic
vein.2
Nerve Supply
The lacrimal gland has got sensory, secretomotor
and, sympathetic supply. Sensory supply comes
through the lacrimal branch of the ophthalmic
division of the Vth cranial nerve. Secretomotor
supply is via the parasympathetic fibers.
Parasympathetic preganglionic fibers arise from
the lacrimal nucleus in the pons near the glossopharyngeal nucleus. Sympathetic postganglionic
fibers come from superior cervical ganglion and
reach the lacrimal gland via deep petrosal and
also along with the sympathetic fibers around
lacrimal artery and nerve.2
Lacrimal Excretory Apparatus

The lacrimal excretory apparatus consists of the
upper and the lower puncta, canaliculi, tear sac
and the nasolacrimal duct (Fig. 26.1).
Puncta: These are small, round to oval orifices
of about 0.2 mm in diameter on the summit of
an elevation, the papilla lacrimalis that lies near
the medial end of the eyelid margins at the
junction of its ciliated and the non-ciliated parts
in line with the openings of the meibomian
glands. The puncta, being relatively avascular
Evaluation of Epiphora
(0-5 mm long). It then enters a small diverticulum
of the sac, the lacrimal sinus of Maier at a point
on the posterolateral surface of the sac about
2.5 mm from the apex of the sac. The common
canaliculus is directed anteriorly forming an
acute angle of about 45o with the sac before
entering it. This acute entry into the lacrimal
sac creates a potential mucosal flap or valve
across the opening, the valve of Rosenmuller.2,3
The canaliculi are lined by stratified
squamous epithelium supported with elastic
tissue that can be dilated to three times the normal
diameter.2
Fig. 26.1. Lacrimal system
is paler than its surrounding, serving as a guide

in case of finding a stenosed punctum.
The upper punctum is slightly medial relative
to the lower but when the eyelids are closed they
appose each other. The medial ends of the lower
lid retractors also help stabilize the puncta and
prevent punctal eversion on blinking. The patency
of the puncta is maintained by the surrounding
dense fibrous tissue continuous with the adjacent
tarsal plate.
Canaliculi: The canaliculi are hollow tubes of
0.5 mm diameter connecting the puncta to the
lacrimal sac. Each canaliculus has a vertical part,
which is 2 mm in length and a horizontal part
of 8-10 mm, which follows the eyelid margin
converging towards the medial canthus. The
canaliculi are enveloped by the orbicularis muscle
fibers and elastic tissue, except on the posterior
walls, which are covered by conjunctiva through
which the probe can be easily seen. The upper
is slightly shorter than the lower. There is a
dilatation at the junction of these two parts, which
is the ampulla. The canaliculi pierce the periorbita
of the lacrimal sac separately, uniting at an angle
of 25o to form a short common canaliculus
Lacrimal sac: The lacrimal sac lies in the lacrimal

fossa formed by the lacrimal bone and the frontal
process of the maxilla in the anterior part of the
medial wall of the orbit which is continuous
below with the nasolacrimal duct. Vertical suture
line between the frontal process of the maxilla
and the lacrimal bone is slightly medial to the
middle of the floor of the fossa. This is of surgical
importance because in dacryocystorhinostomy
operation, the first bony opening is made through
this line.
The lacrimal sac is 12-15 mm tall, 4-6 mm
anteroposteriorly and 2-3 mm wide. The sac above
the junction of the common canalicular duct is
known as fundus. An imaginary line drawn from
the medial canthus to the first upper molar tooth
that slopes downward and backward at 15-25
indicates the long axis of the sac.
A portion of the periorbita, which splits at
the posterior lacrimal crest, encloses the lacrimal
sac and then joins at the anterior lacrimal crest
forming the anterior and the posterior lacrimal
fascia, respectively. Anterior ethmoidal air cells
and vessels are medial to the upper part of the
sac, the cribriform plate and the frontal sinus
floor lie superior to the sac. Between the posterior
surface of the sac and the posterior lacrimal fascia
there is a vascular plexus; injury to the plexus
cause troublesome bleeding. Anteriorly, the upper
413
414

part of the sac is in close contact with the medial
palpebral ligament so much that the ligament
may have to be divided near its attachment to
the anterior lacrimal crest for complete
mobilization of the sac. The angular vein crosses
the ligament subcutaneously 8 mm from the
medial canthus; however, the position of the vein
is not always constant. Incision for removal of
the sac should not be more that 2-3 mm medial
to the medial canthus.
Nerve supply of the lacrimal sac is by the
infratrochlear branch of the nasociliary nerve.
Blood supply of the lacrimal sac is via the
dorsalis nasi and medial superior palpebral, both
being branches of the ophthalmic artery, angular
branch of the facial artery, branch of the external
maxillary artery and the infraorbital branch of
the internal maxillary artery. Venous drainage
is through the rich venous plexus surrounding
the sac into the angular vein.
Hasner, which prevents air from entering the

lacrimal sac on sudden blowing the nose. The
duct opening varies in size, shape and also the
site of opening.
The duct is surrounded by a network of
venous plexus. The plexus of vessels when
engorged is sufficient to obstruct the duct.
Nerve supply to the duct is by the infratrochlear and the anterior superior alveolar nerves.
Blood supply of the nasolacrimal duct is from
the palpebral branches of the ophthalmic,
angular and infraorbital arteries and nasal
branch of the sphenopalatine. Venous drainage
is via the angular and the infraorbital vessels
above and below into the nasal veins. Lymphatics
of the nasolacrimal duct pass onto the
submandibular and deep cervical nodes.
Nasolacrimal duct: The nasolacrimal duct is a

continuation of the lacrimal sac. There is only
a slight constriction at the junction of the
nasolacrimal duct and the sac. The long axis
is along the line joining the medial canthus to
the first molar. It can be identified from outside
by the more numerous and prominent vein
surrounding the duct than the sac and from
inside by the focal narrowing (valve of Krause)
at the junction. The duct also has a thicker wall
which becomes apparent on incision.
The nasolacrimal duct can be divided into
two parts, an interosseous part (12 mm
approximately) and an intermeatal part (5 mm
approximately). It lies embedded in a bony canal
formed medially by the maxillary bone and
laterally by the lacrimal bone above and the
inferior conchea below. The nasolacrimal duct
opens on the lateral wall of the nasal cavity about
10 mm posterior to the anterior end of the inferior
conchea and 30 mm from the external nares. The
duct opening has a mucosal fold, the valve of
Orbicularis oculi is the muscle that acts as the

protector of the eyes through its blinking action.
It has got two main partsthe orbital and the
palpebral part. Our main concern here is the
latter. The palpebral part is again divided into
pretarsalthat part of orbicularis lying over the
tarsus and the preseptal part over the orbital
septum. The insertions of the orbicularis at the
medial canthus around the lacrimal sac are called
heads.
The preseptal part has its superficial head
inserted into the medial canthal tendon and the
deep head into the fascia on the dome of the
lacrimal sac and into the upper part of the
posterior lacrimal crest.
The pretarsal part has its circumferential fibers
oriented over the superior and inferior tarsal plate.
Laterally, it originates from the horizontal raphe
and also from the lateral orbital tubercle.
Medially, it is inserted into the anterior and
posterior lacrimal crest by its two headsthe
superficial and the deep head.
Orbicularis Oculi
Two other muscle strips, the marginal
preciliary and the retrociliary (muscle of Riolan)
exist that are part of the pretarsal part of the
orbicularis oculi.
Nerve supply to the orbicularis oculi muscle
is by the facial nerve.
Tear Secretion and Elimination4-6

Tear secretions are mainly by the two sets of
glandslacrimal and the accessory glands of
Wolfring and Krause. The accessory glands are
the basal secretory that give a constant supply
of tears as they lack any known innervations.
The lacrimal gland is the reflex secretor.
Autonomic stimulation; emotional stimulation;
conjunctival, corneal or uveal irritation or
irritative foci in the sinus, mouth, ear, or teeth
lead to reflex tearing. It can accompany yawning,
laughing, sneezing and coughing.
Tears are distributed along the conjunctival
fornices, precorneal tear film and the marginal
tear strips. Approximately 25% of the secreted
tears are lost by evaporation. Rest are drained
through the lacrimal drainage system via the
punctum, the canaliculi, the sac, the nasolacrimal
duct and ultimately into the inferior meatus of
the nose. About 60% of the tears are drained
via the lower punctum but in case of abnormalities the upper punctum can function
efficiently without overflow.6
The blinking action of the eyelids helps in
driving the tears forward into the drainage
system. Blinking displaces the upper as well as
the lower lid medially due to the firm attachment
of the orbicularis to the medial canthal tendon.
Moreover, with each blink the upper and lower
lid approximates at the lateral canthal area and
then proceeds towards the medial canthus
displacing the tear film towards the puncta.
Even in the absence of blinking, low flow
of tears occurs through the puncta due to the
Krehbiel phenomenon, capillary action and the
normal downhill slope of the eyelids but along

with a passive reflux into the lacrimal lake.
With the start of the blink the tears are
propelled towards the puncta. As the process
continues the open puncta move towards each
other and occlude. Due to the orientation of the
superficial and the deep heads of the orbicularis
around the canaliculi and their firm attachment
to the bone, the eyelid is pulled medially on
contraction, the canaliculi are shortened
squeezing the tear already in the ampulla and
the canaliculi into the sac. The attachment of
the deep head of the preseptal part of the
orbicularis into the fascia on the dome of the
lacrimal sac pulls the sac laterally on contraction
enabling the sac filling (negative pressure). The
valve of Rosenmuller reduces backflow, once the
tears are in the sac.
On opening the eyes, the muscle around the
canaliculi relaxes leading to the flow of tears
into canaliculi again due to the reduced intracanalicular pressure. Tears can also gravitate
down the nasolacrimal duct passively. But active
drainage into the nose is by the complex action
of the Horner muscle.
Tearing can broadly be grouped under two main
headings:
1. Lacrimation (Hypersecretion of tears)
2. Epiphora (Impairment of drainage)
It is essential to differentiate between two in
planning the management.
Epiphora is a condition where there is
excessive tearing due to reduced tear outflow,
i.e. defective tear drainage.
Obstruction at any point along the lacrimal
drainage pathway, from the punctum to the
nose can cause epiphora. This can lead to
epiphora varying in severity from intermittent
epiphora with a partial block to tears
415
416

overflowing to the cheek. It can be unilateral
or bilateral. It is worse in winter months and
windy weather. Vision can be affected more
on down gaze due to elevated tear meniscus
or tear splattered glasses. Chronic epiphora
can cause red, sore lower-lid skin, with
secondary anterior lamella (vertical)
shortening (mild cicatrical ectropion).
Excessive wiping away of tears can cause
or exacerbate a medial ectropion.
Functional epiphora is the term that is used
when there is epiphora with patent syringing,
in the absence of any causes of hypersecretion.
This may be due to a narrowing or stenosis
of the nasolacrimal duct, which increases the
resistance to the tear outflow but does not
cause a complete anatomical obstruction. The
term lacrimal pump dysfunction is used for
epiphora due to reduced tear drainage of
orbicularis causes. Common causes of
functional epiphora are punctal stenosis,
facial palsy with paralytic ectropion, single
functional canaliculus and common
canalicular stenosis.
Pseudoepiphora refers to the reflex
hypersecretion of aqueous tears from the main
lacrimal gland due to altered production by
the glands of Krause and Wolfring.7
Evaluating a case of epiphora needs a
systematic approach, so that the causes of
hypersecretion can also be ruled out.
History
A meticulous history taking is vital to the
evaluation. Patients symptoms, past ophthalmic,
nasal and medical history should be elicited.
A history of allergic diathesis and use of drugs
should be obtained.
In case of congenital tearing, parents may
complain of constant tearing with minimal or
no mucopurulent discharge suggesting upper
system block (punctal or canalicular dysgenesis).

Constant tearing with frequent mucopurulent
discharge and matting of the lashes suggest
nasolacrimal duct block. Intermittent tearing with
mucopurulence may suggest intermittent
obstruction of the nasolacrimal duct (impaction
of a swollen inferior nasal turbinate associated
with an upper respiratory tract infection).
Examination
The lacrimal examination can be divided under
three heading:
1. Periorbital, lid and lacrimal system
assessment
General examination of the face,
periorbital and medial canthal areas and
eyelids is essential. It includes:
Slit-lamp examination of the puncta,
external eye and tear meniscus,
Syringing,
Diagnostic probing and
Fluorescein dye test.
2. Examination of the nasal cavity
3. Radiological examination
4. Newer modalities
Periorbital, Lid and Lacrimal System

Assessment8
General examination of the face and periorbital region:
Examination of these parts with relevance to the
symptoms help in establishing a diagnosis.
Eyelid malposition, facial and periorbital
asymmetry should be looked for.
Lacrimal sac swelling: A lump over the medial
canthal area below the medial palpebral ligament
strongly indicates to a lacrimal sac swelling (Fig.
26.2).
Evidence of inflammation: Fistula (Fig. 26.3) and
inflammation over the sac area need to be further
evaluated.
Fig. 26.2: Swelling above the area of the lacrimal

sac in a child
Fig. 26.3: Acute dacryocystitis with fistula
Shortening of anterior lamella: Vertical eyelid

tightness should be checked by asking the patient
to look up at the ceiling. If there is short anterior
lamella, the ectropion will be exacerbated.
Assessment of puncta: All the four puncta should
be looked for the presence of any stenosis or
membrane blocking them. They should face
towards the lacrimal lake. The relative position
of the upper and the lower puncta to each other
and to the caruncle should also be assessed.
Eyelid laxity: The eyelid can in itself be a cause
of epiphora. Involutional ectropion often
progresses from punctal eversion to involve the
medial third, then the medial half of the lower
eyelid and eventually the entire lid. Examination
of the lid with utmost care is needed to diagnose

the condition.
Horizontal laxity of the eyelid can be estimated
by Pinch test and snap back test:
Pinch test: Using the thumb and the index
finger, the lid is pulled firmly away from the
globe, the distance between the lid and the
eye is measured and the laxity is documented
as:
None
5 mm
Minimal
5-7 mm
Mild
8-9 mm
Moderate
10-12 mm
Severe
>12 mm
Snap back test: The speed with which the lower
lid settles back against the globe after being
pulled down and released is to be observed,
as well as whether there is a short gap between
the lid and globe once settled and before the
first blink.
Medial canthal tendon laxity: It is always to
be assessed while evaluating a case of
epiphora. It is graded with the lateral
distraction test and by noting the position
of the lower punctum in relation to the upper.
These tests depend on the fact that the lower
puncta normally lies at the plica at rest and
also when pulled laterally.
The patient is made to sit in front of the
examiner at arm length distance with their
eyes at the same level. The patient is asked
to look at the bridge of the examiners nose
and without inducing accommodative
convergence by moving too close, the lower
punctum position is noted relative to the
upper.
-1 Punctal medialization
0 Normal
+1 Midway between the plica and the
medial limbus
+2 In line with the medial limbus
+3 - +6 Beyond the medial limbus
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Lateral distraction test: After noting the resting
position of the lower punctum, the lower lid
is pulled laterally and the position of the
punctum is noted again. The test is graded
as:
0
No distraction at all
+1
Punctum reaches midpoint of plica
and medial limbus
+2
Punctum reaches medial limbus
+3
Punctum reaches midpoint of medial
limbus and pupil line
+4
Punctum reaches pupil line
+5
Punctum reaches midpoint of pupil
line and limbus line
+6
Punctum reaches lateral limbus
Fig. 26.4: Involutional ectropion
The slit-lamp examination is an essential part
of evaluation.
Punctum should be evaluated for patency,
size, position and discharge.
Mild degrees of ectropion (Fig. 26.4) and
entropion (Fig. 26.5) that are not apparent
to gross external examination may be revealed
on the slit-lamp biomicroscopy. Small lesions
of eyelid margins like papillomas, molluscum
contagiosum, chalazia, nevi and carcinoma
are best detected with the slit-lamp.
Pressure over the lacrimal sac may cause
discharge from the punctum, suggesting
nasolacrimal duct obstruction.
Presence of inflammation on the area
overlying the canaliculus and discharge from
the punctum on pressure over the area may
suggest canaliculitis (Fig. 26.6).
Examination for the signs of blepharitis (Fig.
26.7) as well as dry eye syndrome which lead
to hypersecretion of tears should be looked
for. Conjunctival lesions particularly
pinguecula and pterygium may induce
tearing. The forniceal and palpebral
conjunctiva should be inspected for follicles
Fig. 26.5: Congenital entropion
and papillae of reactive inflammatory

disorders and allergic conjunctivitis.
Cornea should be examined for any
irregularities, features of dry eye syndrome
or epithelial dystrophies. These examinations
help to rule out causes of hyperlacrimation.
The vertical height of the tear meniscus is
to be measured prior to instillation of any
eyedrops. Staining the tear film with a small
amount of fluorescein aids in assessing the
volume of the tear lake.
Fig. 26.6: Canaliculitis
Fig. 26.7: Blepharitis
Schirmer Test
Schirmer test (Fig. 26.8) helps us to exclude
pseudoepiphora. For this test white filter paper
strips (41 Whatman) of 35 mm in length and
5 mm width are used. They are folded 5 mm
at one end and inserted into the inferior fornix
at the junction of the middle and lateral third
of the lid and allowed to remain in this position
for 5 minutes with the eyes open. The patient
should be comfortably sitting in a dimly lit room
away from direct air source as the fan. Moreover
there should not be any kind of verbal
stimulation. After the end of the 5 minutes, the
wetting of the filter paper is measured.
Fig. 26.8: Schirmer test
Schirmer test is basically of three types:

Schirmer I test, Basic secretion test and Schirmer
II test.
Schirmer I test is performed without topical
anesthetic. Ten mm or more wetting is taken as
normal. Excessive wetting can be due to
pseudoepiphora or hypersecretion.
Basic secretion test is done as the Schirmer I
test but after instillation of topical anesthetic into
the lower fornix. This anesthesia eliminates the
local source of irritation as by the Schirmer test
strips and gives an estimate of the basic tear
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secretion by the glands of Krause and
Wolfring.9,10 Wetting of less than 10 mm after
5 minutes indicates deficiency of basic tear
production. A tearing patient with patent
lacrimal drainage system with deficient basic
tear production indicates towards reflex
hypersecretion.
Schirmer II test measures the reflex tearing from
the main lacrimal gland after eliminating the
local causes of irritation. After anesthetizing the
conjunctival sac, the trigeminal nerve is
stimulated either with a cotton-tipped applicator
applied to the nasal mucosa or with ammonium
chloride on a cotton pledget held at the external
nares. The amount of excess wetting in addition
to that of the basic secretion test is the reflex
secretion.
Fig. 26.9: Instruments used for syringing and probing
Syringing
Syringing the canalicular system provides
information regarding the patency status. One
to two drops of topical anesthesia (proparacaine
or tetracaine) is instilled into the conjunctival
sac. The punctum is dilated gently by advancing
the Nettleship dilator (Figs 26.9 and 26.10), first
Fig. 26.10: Dilatation of punctum and syringing
vertically for about 2 mm and then horizontally
with a twisting movement. Simultaneously,
lateral traction is applied to the eyelid. With the
eyelid stretched, the dilator is withdrawn and
the lacrimal cannula attached with syringe filled
with normal saline is advanced horizontally
through the punctum and the canaliculus (Fig.
26.10). No resistance should be felt in its entire
path. Irrigation is then done and the patient is
asked to respond if fluid passes into the
oropharynx or nose.
If there is resistance to irrigation, obstruction
is present. Regurgitation of fluid from the same
punctum indicates that there is a canalicular
block. Regurgitation of fluid from the upper
punctum indicates blockage at the level of
common canalicular duct, lacrimal sac or
nasolacrimal duct. Immediate regurgitation of
clear fluid usually suggests a common canalicular
obstruction. Relatively delayed regurgitation of
fluid mixed with mucus or pus usually indicates
NLD blockage.
Diagnostic Probing
Probing the canaliculi provides information
regarding the site of obstruction, which is
necessary for decision-making. It is performed
only after obstruction is demonstrated by other
tests. After topical anesthesia of the conjunctival
sac, the canaliculi are also irrigated with
anesthetics. A probe of appropriate size is
inserted into the punctum after dilatation and
advanced till it meets obstruction. First it is passed
vertically through the punctum, turned medially
and advanced until it encounters the lacrimal
bone (Fig. 26.11A).
Through out the procedure the lid should
be firmly pulled laterally so that there is no
kinking of the canaliculi. It is then withdrawn
a few millimeters and rotated inferiorly and
slightly posterolaterally until the proximal part
of the nasolacrimal duct is felt. The probe is then
passed until it strikes the floor of the nose in

the inferior meatus (Fig. 26.11B). If in between
any obstruction is felt, the site of obstruction is
noted by grasping the probe with a forceps at
its entrance before withdrawing.
B
Figs 26.11A and B: Dilatation of punctum and probing
Obstruction can be felt as a soft stop in case

of a stenosis of the canaliculus or as a hard stop
as the probe hits the bone at the medial wall of the
lacrimal sac. Obstruction at less than 8 mm
indicates a canalicular block, 8-10 mm indicates
a common canalicular obstruction and distal to
that if the probe passes more than 10 mm.
While probing a child, a few considerations
should be noted. Probing is usually recommended through the upper canaliculi as the lower
canaliculus carries more tear flow than the upper
and it is wise to avoid the possibility of injury
to it. Up to 1 year of age, the distance from the
punctum to the nasolacrimal duct is
approximately 12 mm, whereas, to the floor of
the nose, it is approximately 20 mm.11
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Fluorescein Dye Test
Dye disappearance test or fluorescein dye retention
test: This is a semiquantitative test of delayed
or obstructed tear outflow. It is of particular
importance for the evaluation of congenital
dacryostenosis in infants and toddlers where
lacrimal irrigation is impossible without
anesthesia and deep sedation. One drop of 2%
fluorescein is instilled into the unanesthetized
conjunctival sac of both the eyes. The volume
of the tear lake is then noted preferably under
the cobalt blue light. The patient is instructed
not to wipe the eyes. The tear lakes are examined
5 minutes later, and the relative volume is
determined. Persistence of significant dye and
especially asymmetric clearance of the dye from
the tear meniscus over a 5 minutes period
indicates a relative obstruction of the side
retaining the dye.12,13
Jones tests: 14,15 The Jones tests are dye tests for
functional epiphora where the lacrimal drainage
system observed to be patent on syringing. There
are two types of Jones tests (Figs 26.12A
and B).
Jones tests I: It investigates the lacrimal outflow
under normal physiological conditions.
Fluorescein (2%) is instilled into the
conjunctival sac and presence of the dye at
the inferior meatus is noted at 2 minutes and
5 minutes with the help of a cotton tip
applicator. Rate of false negative is very high
with this test.
Jones tests II: It is a nonphysiological test that
determines the presence or absence of fluorescein in the irrigating saline fluid retrieved
from the nose. Flushing of the residual dye
(of the unsuccessful Jones test I) from the
conjunctival sac is done and after that topical
anesthesia is instilled into the conjunctival
sac. Patient is seated with head tilted forward
and a transcanalicular irrigation with saline
is done. Patient is then asked to blow or spit
Figs 26.12A and B: Jones test I and II
the fluid onto a paper tissue and fluorescein

dye is looked for.
A positive test is with the presence of the dye
on the tissue paper suggesting that the dye had
reached the lacrimal sac but in the presence of
a narrowed nasolacrimal duct or a nonfunctioning lacrimal pump requiring the syringing
pressure to force it down.
The test is said to be negative when the tissue
is clear of any dye indicating that it did not get
into the lacrimal sac with the Jones I test as in
eyelid malposition, lacrimal pump failure,
punctal or canalicular stenosis.
A positive Jones test II confirms anatomical
patency with a high-pressure wash out of
fluorescein.
Modifications of Tests
Taste test: One drop of saccharin is instilled into
the conjunctival sac and one gets the taste of
it after several minutes in case of a patent lacrimal
drainage system.
Endonasal dye test: This is done as the Jones test
I and presence of the dye is seen through an
endoscope inserted into the nares.
Oropharynx dye appearance test: Fluorescein 2%
is instilled into the conjunctival sac of one side
at a time and the oropharynx is checked
periodically for the appearance of the dye. This
test is of particular importance in infants where
sedation or anesthesia is otherwise needed.
Examination of Nasal Cavity

The key to success of a dacryocystorhinostomy
surgery lies in the intact anatomy of the nasal
cavity. Moreover, pathology of the structures
around the opening of the nasolacrimal duct
itself may be the cause of epiphora. Examination
of the nasal cavity can be done either with a
nasal speculum or more completely with a rigid
nasal endoscope. Treatment of the existing
pathology is necessary before contemplating
surgical intervention.
Fig. 26.13: Dacryocystography showing passage of

contrast into the nasal cavity
Ancillary Radiological Investigations

Radiological tests help in confirming the site of
obstruction or stenosis in case of blocked
syringing, confirm a functional cause of epiphora
and delineate the anatomical as well as the
pathological process pertaining to the problem.
Dacryocystography
Dacryocystography (Figs 26.13 and 26.14) is of
importance in case of blocked syringing to locate
the site of obstruction. Moreover, it gives
additional information regarding any fistula or
intrasac pathology.
After instillation of local anesthesia, a fine
catheter is introduced into the canaliculus
(preferably the superior one) and 0.5-2 ml of water
soluble iodinated contrast medium is injected
Fig. 26.14: Dacryocystography showing pooling of

contrast in the lacrimal sac (NLD obstruction)
continuously during either conventional tomography or CT acquisition. CT dacryocystography

is considered superior to conventional one as
it provides useful anatomical information about
the orbital wall, sinus as well as allowing
evaluation of the nasolacrimal duct.
MRI dacryocystography provides the same
information as the conventional studies, without
the use of catheterization and contrast medium.
Both the sides are preferably done simultaneously
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424

in case of a functional epiphora. Enhancement
of the film is done with digital subtraction (Fig.
26.15).16,17
underlying cause of epiphora which may be due

to craniofacial injury, congenital deformities or
lacrimal sac neoplasia. The paranasal sinuses,
especially the maxillary sinuses are imaged for
any abnormalities that might be affecting the
nasolacrimal duct. Preoperative assessment of
the cribriform plate is noted for any abnormal
position to avoid a possible cerebrospinal leak
at the time of surgery.
Newer Modalities
Chemiluminescence test 22 : Cyalume, a
chemiluminescent material is injected with a
sialography catheter to demonstrate the patency
of outflow passages.
Dacryoscopy: Dacryoscope, a mini rigid
endoscope allows the direct visualization of the
interior and the lining of the lacrimal
passages.23,24
Fig. 26.15: Dacryocystography after digital subtraction
Dacryoscintigraphy18-20
Functional epiphora becomes difficult to
differentiate from partial block of the lacrimal
drainage system. Dacryoscintigraphy assesses
the lacrimal drainage system under physiological
condition.Technetium-99, a gamma ray-emitting
radionuclide in saline or technetium sulfur
colloid are instilled into the conjunctival sac and
imaged with a gamma camera at fixed interval.
Delay in the passage of the dye may occur at
any site as in the region of the conjunctival sac
or the canaliculi, which may be due to lid or
canalicular diseases. Apart from being a
noninvasive technique, radiation exposure to the
lens is minimal compared to that of dacryocystography. The disadvantage of dacryoscintigraphy
is that it lacks in showing finer anatomical detail.
Computer Tomography (CT)21
The role of CT scan comes when anatomical or
pathological abnormalities are suspected as the
Standarized echography: Gross anatomical

structural defects can be evaluated with the
standardized echography.25
Thermography: Thermographic evaluation of the
lacrimal passage used in conjunction with
routine lacrimal irrigation to visualize the tear
ducts in normal subjects and in a patient with
obstructive epiphora has been described.26
References
1. Jane Olver J. Colour Atlas of Lacrimal Surgery.
London, Butterworth- Heinemann 2002;11-26.
2. Bron AJ, Tripathi RC, Tripathi B. Wolffs
Anatomy of the eye and orbit. 8th edn.
Edinburgh, Chapman & Hall Medical Publication
1997;72-84.
3. Tucker NA, Tucker SM, Linberg JV. The anatomy
of the common canaliculus. Arch Ophthalmol
1996;114:1231-34.
4. William MH Jr. (Ed). Adlers Physiology of the
Eye: Clinical Application 9th edn. Harcourt Brace
Asia 1992.
5. Doane MG. Blinking and the mechanics of the
lacrimal drainage system. Ophthalmology 1981;
88:844-50.
6. Becker BB. Tricompartmental model of the
lacrimal pump mechanism. Ophthalmology 1992;
99:1139-45.
7. Basic and clinical science course, American
Academy Ophthalmology, 2005; Orbit, eyelids
and the lacrimal system. Chapter 14-Evaluation
and management of the tearing patient, 272.
8. Conway ST. Evaluation and management of
functional nasolacrimal blockage: results of
a survey of the American Society of Ophthalmic
Plastic and Reconstructive surgery. Ophth Plastic
Reconstr Surg 1994;10:185-87.
9. Krupin T, Cross D A, Becker B. Decreased basal
tear production associated with general
anesthesia. Arch Ophthalmol 1977;95:107.
10. Lamberts DW, Foster CS, Perry HD. Schirmer
test after topical anesthesia and the tear meniscus
height in normal eye. Arch Ophthalmol
1979;97:1082.
11. Nesi FA, Lisman RD, Levine MR. Smiths
Ophthalmic plastic and reconstructive surgery.
2nd edn. St Louis, Mosby 649-60.
12. Flack A. The fluorescein appearance test for lacrimal obstruction. Ann Ophthalmol 1979; 11:237.
13. MacEwen CJ, Young JDH. The effect of fluorescein disappearance test (FDT): an evaluation of
its uses in infants. J Paed Ophthal Strab 1991; 28:305.
14. Zappia RJ, Milder B. Lacrimal drainage function.I.
The Jones fluorescein test. Am J Ophthalmol 1972;
74:154-59.
15. Zappia RJ, Milder B. Lacrimal drainage function.I.
The fluorescein dye disappearance test. Am J
Ophthalmol 1972;74:160-62.
16. Galloway JE, Kavic TA, Raflo GT. Digital

substraction
macrodacryocystography.
17. Lloyd GAG, Welham RAN. Substraction
macrodacryocystography. Br J Radiol 1972;47:
379-82.
18. Rossomondo RM, Carlton WH, Trueblood JH.
A new method of evaluating lacrimal drainage.
19. Hurwitz JJ, Maisey MN, Welham RAN.
Quantitative lacrimal scintillography. Br J
Ophthalmol 1975;59:308-12.
20. Jedrzynski MS, Bullock JD. Radionuclide
dacryocystography. Orbit 1998;17:1-25.
21. Kallman JE, Foster JA, Wulc AE, et al. Computer
tomography in lacrimal outflow obstruction.
22. Raflo GT. Assessment of efficacy of chemiluminance evaluation of lacrimal drainage system.
Ophthalmic Surgery 1982;13:36.
23. Coehn SW, Prescott R, Sherman M.
Dacryoscopy. Ophthalmic Surgery 1979;10:57.
24. Tsugihisa Sasaki, Yuuko Nagata, Kazuhisa
Sugiyama. Nasolacrimal duct obstruction
classified by dacryoendoscopy and treated with
inferior meatal dacryorhinostomy. Part I:
Positional diagnosis of primary nasolacrimal
duct obstruction with dacryoendoscope. Am J
Ophthalmol 2005;140:1065-69.
25. Dutton JJ. Standardised echography in the
diagnosis of lacrimal drainage dysfunction. Arch
26. Raflo GT, Chant P, Hurwitz JJ. Thermographic
evaluation of lacrimal drainage system.
Ophthalmic Surgery 1982;13:119.
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MANDEEP S BAJAJ, SANJIV GUPTA
27
Diagnostic
Techniques in
Proptosis
Introduction
Proptosis is defined as an anterior displacement
of the globe from its normal position in the orbit.
The orbit is a unique area packed with numerous
vital structures which are delicately poised in
a dynamic equilibrium. Even a minute alteration
in this balance can lead to clinically significant
ramifications. Orbit is a closed cavity which
usually does not allow for direct evaluation of
any pathological process developing inside, and
is often referred to as a Pandora box. It is a
watershed area, being the meeting ground of
many specialities and, therefore, a collaborative
approach is required in the diagnosis and
management of orbital disorders. A wide variety
of disease processes can involve the orbit such
as inflammations, parasitic infestations,
metabolic and endocrine disturbances (Fig. 27.1),
vascular anomalies, primary and metastatic
tumors (Figs 27.2 and 27.3), depending on the
age group and other predisposing factors.
Common orbital tumors encountered are
cavernous hemagioma, lacrimal pleomorphic
adenoma, meningioma, dermoid cysts, optic
nerve glioma and lymphoma, to name a few.
Parasitic involvement of the orbit, especially
cysticercosis and occasionally hydatid cyst are
Fig. 27.1: A patient with thyroid ophthalmopathy with

bilateral exophthalmos
Fig. 27.2: Clinical photograph of a patient showing proptosis

of the right eye with marked downward and outward
displacement of the globe
Diagnostic Techniques in Proptosis

important clinical parameters to be taken into
consideration are the laterality, direction of globe
displacement, characteristics of the mass if
palpable, visual status and posterior segment
evaluation. A vast array of diagnostic techniques
have evolved over the years to confirm the
presumptive clinical diagnosis. This chapter
describes techniques which complement the
process of diagnosis in a case of proptosis and
are crucial for appropriate management.
Diagnostic Techniques
Fig. 27.3: A child with acute onset proptosis of the
right eye suggestive of an orbital malignancy
not uncommon in developing countries.

Endocrine disturbances, such as thyroid
dysfunction, could have some of their earliest
manifestations in the orbit and adnexa.
In a case of proptosis, as in any other clinical
situation, the diagnostic work-up begins with
a careful history and clinical examination. The
degree of proptosis is quantified by performing
an exophthalmometry. The most commonly used
instrument is the Hertels exophthalmometer (Fig.
27.4), in which the position of the anterior corneal
surface is recorded, taking the lateral orbital rim
as a reference point. An absolute reading greater
than 21 mm or a relative difference of more than
2 mm between the two eyes is used as a cutoff value for diagnosing proptosis. Some of the
Fig. 27.4: Hertels exophthalmometer
A large number of diagnostic techniques are

available for evaluation of a case of proptosis.
However, as a general principle, one should
follow a graded approach in employing these
techniques, starting with the less invasive ones
and going on to the more invasive ones, only
if indicated. One should also be able to distinguish
as to which group of investigations would be
relevant in a particular case. The noninvasive
techniques include imaging studies, which are
the cornerstone in reaching a diagnosis in a case
of proptosis. Invasive techniques are aimed
mainly on efforts to reach a tissue diagnosis,
which entails harvesting of tissue and subjecting
it to routine and specialized histopathological
tests.
Imaging Techniques
Standard Roentgenography (Plain X-ray)
Standard X-rays of the orbit were a useful imaging
technique for initial screening before the advent
of CT. They are of value in demonstrating bony
changes and particularly fractures and foreign
bodies in the orbit. Special optic foramen views
can be obtained to visualize enlargement which
can denote apical tumors. There are a variety
of views of the orbit that can be requested, each
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428

with its own specific benefits. These include the
Caldwell view (general view), Waters view
(orbital view), Rhese view (optic foramen) and
Lateral view/axial basal view (paranasal
sinuses).
Important findings to look out for include
orbital enlargement (trauma, benign tumor),
orbital wall erosion (benign pathology), orbital
wall destruction (malignant pathology),
calcification (phlebolith, meningioma, lacrimal
gland carcinoma, retinoblastoma), hyperostosis
(meningioma, Pagets disease, malignant
osteoblastic secondary, fibrous dysplasia),
enlargement of the optic foramen (optic nerve
glioma, meningioma) and enlargement of the
superior orbital fissure (aneurysm or tumor with
posterior extension).
Ultrasonography (USG)
Ultrasonography is a rapid noninvasive tool for
the evaluation of orbital lesions causing
proptosis. As most USG machines are compact
and portable, it can be performed in an office
setting as well as peroperatively. It gives useful
information about the characteristics of the lesion
and can even clinch the diagnosis when done
by an experienced observer. Despite being inferior
to CT-scan and MRI in depicting the bony wall,
orbital apex, adjacent sinuses and intracranial
compartments, ultrasound is arguably a better
imaging modality in the detection of subtle
changes of the soft tissues within the orbit, and
the differentiation of extraocular muscles and
optic nerve lesions. The machine basically
consists of a transducer at the tip of a probe
which emits ultrasonic waves by the vibration
of a piezo-electric crystal inside the probe. These
waves are reflected, scattered and absorbed by
the medium. The reflected waves are then
processed in a computer to generate a single or
multidimensional picture on a screen.
Ophthalmic USG uses frequencies ranging
between 6 and 20 MHz (typically 10 MHz). The

speed of sound varies with the medium, and
in the orbit it is usually 1550 m/s. The lower
frequencies provide better penetration but lower
resolution and vice-versa. Ultrasound is, however,
of limited value in assessing lesions of the
posterior orbit; (sound waves at 8-10 MHz do
not penetrate beyond the mid-orbit) or the sinuses
or intracranial space.
Standardized A-scan is a time-amplitude
display mode where we get one dimensional
display of vertical (amplitude) spike and the
horizontal axis which is modified to display the
distance in millimeters. The A-scan gives us
important information regarding the internal
structure of a lesion. For example clear cysts and
homogenous solid lesions (e.g. lymphoma)
typically produce low amplitude internal spikes
(reflectivity) whereas heterogeneous lesions (e.g.
hemangioma and dermoids) produce higher
amplitude echoes within the normal orbital
pattern.
B-scan is a two dimensional intensity
modulated display. It is seen as a funnel-shaped
display on the screen, the mouth of the funnel
being on the right, the probe position (transducer
band) is on the right and the horizontal extent
on the right gives the depth of penetration of
sound beam. The vertical axis represents the
segment of the eye being scanned. B-scan allows
a real time evaluation of any lesion and
successive cross sections are displayed on the
monitor. The signal amplitude is displayed as
dots whose brightness gives an idea of the strength
of the returning echoes, which is referred to as
the Gray scale. Orbital B-scan can be transocular
where the beam crosses the globe, which is then
seen in front behind which the orbital shadow
is displayed, or par-ocular, which bypasses the
globe and is used mainly for anterior orbital
lesions. B-scan shows rather characteristic
alterations of the normal orbital pattern in various
lesions such as tumors, cysts and inflammation.
Fig. 27.5: Ultrasound picture in a case of thyroid ophthalmopathy showing

enlargement of the belly of an extraocular muscle with tendon sparing
For example, one can differentiate thyroid

orbitopathy from pseudotumor by demonstrating
tendon sparing thickening of extraocular
muscles in thyroid ophthalmopathy (Fig. 27.5)
as contrast to tendonitis and posterior scleritis
which typically occur in idiopathic orbital
inflammatory disease (IOID) or pseudotumor. In
addition certain lesions can be definitely
diagnosed on USG like cavernous hemangioma
(Fig. 27.6), cysticercosis and hydatid cyst (Figs
27.7 and 27.8).
Another important application of USG is for
serial measurements of size of lesions and
evaluation of response to therapy like in the case
of orbital cysticercosis, dysthyroid ophthalmopathy, and optic nerve thickness in optic neuritis.
Color Doppler (CD) imaging is one of the most
important developments of the last decade (Figs
27.9A and B). It allows evaluation of blood flow
along with simultaneous B scan imaging of the
lesion and can definitely diagnose lesions such as
orbital varices, A-V malformations and carotidcavernous sinus fistulas. The patterns obtained
Fig. 27.6: Ultrasound A- and B-scan of the orbit showing

a well demarcated, intraconal lesion with high internal
reflectivity and moderate sound attenuation, suggestive
of cavernous hemangioma
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430
Fig. 27.7: Ultrasound picture showing an orbital cyst

with scolex suggestive of cysticercosis
Fig. 27.8: Ultrasound picture showing an orbital cyst

with double wall sign typical of hydatid cyst
reveal information on the extent of arterial or

venous flow in the substance of the lesion.
Apart from these, there are other methods
of USG like C-scan which depicts orbital lesions
in a coronal plane and D-scan which provides
a three dimensional display.
Three-dimensional ultrasound (3D USG)
imaging is a novel way of imaging ophthalmic
pathologies in vivo, revealing valuable
topographic information in ways more familiar
and recognizable to the untrained eye, where
surfaces can be perceived and their approximate
relationships in three-dimensions can be
presented (e.g. to determine the contour and size
Figs 27. 9A and B: Color Doppler examination in a case

of orbital varices. A Before and B After Valsalva maneuver
showing low blood flow velocity on dynamic evaluation
of tumors, to ascertain the shape and relative

configurations of tissues and structures in the
eye). Three-dimensional USG imaging allows
volumetric and topographic reconstruction of the
vitreous, retina, choroid, sclera, and orbital
structures. Volumetric reconstruction is valuable
in tumor growth assessment, while topographic
mapping provides a more comprehensive
quantitative description of the surface and
marginal parameters responsible for volumetric
changes.
Fig. 27.10: Clinical and CT picture in a case of orbital lymphangioma. CT shows a

diffuse, poorly defined, heterogenous lesion with minimal enhancement
Computed Tomography
Computed tomography (CT) is one of the most
important investigations in a case of proptosis
as it gives anatomic details par excellence. It has
revolutionized the management of orbital
disorders and is valuable for delineating the
shape, locations, extent, and characteristics of
lesions of the orbit. Furthermore, current CT- scan
administers a dose of radiation which compares
favorably with an X-ray of the skull. Its spatial
resolution is 0.5 mm. Eight slices are required
to perform an orbital scan which extend from
the maxillary sinus below to inferior part of the
frontal lobe above, and include the optic chiasm
and pituitary area. Axial-scan is done in supine
position and coronal in prone position. For
sagittal views, re-formating of images is required
as they cannot be done directly. Bone windows
are available to enhance bony changes and three
dimensions reconstruction is possible to aid in
surgical planning. Suspected orbital disease
associated with paranasal sinus disease, thyroid
ophthalmopathy, foreign bodies, hemorrhage, or
orbital trauma is evaluated using noncontrast
CT, while the visualization of tumors that are
well supplied with blood vessels (e.g.
meningioma) or whose blood vessels leak is
improved by the use of IV contrast enhancing
agents. CT-scan has resolution and tissue contrast

capabilities allowing for the imaging of soft
tissues, intracranial structures, masses or
processes suspected of calcification such as
lymphangioma (Fig. 27.10), bones (e.g. sinus
anatomy) or bony destruction (e.g. leukemia,
lymphoma, histiocytosis, and rhabdomyosarcoma), contrast containing blood vessels and
foreign bodies. Coronal sections with 2-3 mm
slices should be specifically asked for in cases
of blow-out fractures and for assessing
extraocular muscle size in Graves ophthalmopathy. High resolution CT with 1 mm cuts is
useful for studying optic nerve lesions. Axial
sections show both globes, the horizontal rectus
muscles, optic nerve, other orbital soft tissue and
bony structures. Coronal section, anteriorly,
shows globe with relation to recti muscles and
posteriorly, all four rectus muscles, oblique
muscles, optic nerve and soft tissue of the orbit.
At the apex it also shows the optic foramen.
CT adequately documents findings such as
the extent of proptosis, muscle enlargement,
location (intraconal or extraconal) and size of
a lesion, compression of the globe or optic nerve
and presence or absence of bone erosion, as well
as the condition of adjacent sinuses and the
presence of intracranial involvement. It also
shows the internal characteristics of the lesion
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Fig. 27.11: CT-scan (axial view) showing a well delineated,

fusiform, intraconal mass isodense to the optic nerve,
suggestive of glioma
whether it is homogeneous or heterogeneous,

solid or cystic, presence of calcification and the
effect of contrast enhancement. Benign tumors
such as cavernous hemangioma, neurilemoma,
dermoids and gliomas (Fig. 27.11) usually have
rounded well circumscribed borders. Malignant
lesions on the other hand have diffuse, irregular
boundaries. Important features of thyroid
ophthalmopathy include swelling of muscles
maximally in the mid-portion (Fig. 27.12) (relative
sparing of the tendons), slight uveo-scleral
thickening, apical crowding, increase in the
diameter of the retrobulbar optic nerve sheath,
increased density of orbital fat, and anterior
Fig. 27.12: CT-scan (axial view) showing significant

enlargement of extraocular muscles with sparing of tendons
in a case of thyroid exophthalmos
Fig. 27.13: CT-scan (coronal view) showing an infiltrative

lesion in the lacrimal gland fossa with irregular internal
structure suggestive of a malignant lacrimal gland tumor
displacement of the lacrimal gland. CT is a useful

modality for the evaluation of lacrimal fossa
masses, especially epithelial tumors (Fig. 27.13).
CT can adequately depict osseous alterations
and calcifications, and can differentiate a group
of epithelial tumors from inflammatory and
lymphoproliferative conditions. Features specific
of orbital pseudotumor include a poorly defined
intra- or extraconal mass close to the surface
margin of the globe. In the myositic type one
may get enlargement of one or more muscles
close to their insertion, with ill-defined margins.
Other features of orbital pseudotumor are that
it typically involves muscles and tendon
insertions, there is increased density of retroorbital
fat, thickening and enhancement of sclera near
Tenons capsule and enlargement of the lacrimal
gland. Lymphangioma may be diagnosed if there
is a multi-lobulated pattern on CT-scan (Fig.
27.10) and a cystic internal structure in
standardized ultrasound evaluation. Cavernous
hemangiomas show as well circumscribed, solid,
masses involving the intra or extraconal
compartment. On CT-scan lymphoproliferative
tumors typically show up as a localized or diffuse
mass with moulding to the orbital structures.
Fig. 27.14: A patient undergoing an MRI-scan
Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a
noninvasive imaging technique which does not
employ ionizing radiation and has no known
adverse biological effects. The process involves
a strong magnetic field which is applied to the
body (Fig. 27.14). It excites protons in the body
tissues and causes them to align in a particular
orientation in relation to the magnetic field. When
the magnetic field is switched off, the protons
relax to their original alignment and re-emit the
energy gained. The signal is recorded in terms
of intensity and location. T1 weighting and T2
weighting refer to two methods of measuring
the relaxation times of the excited protons after
the magnetic field is switched off. The various
body tissues have different relaxation times and
a given tissue may be T1 or T2 weighted, implying
that is best visualized on that particular type
of image. Coronal, sagittal and axial images can
be directly obtained. A surface coil is used for
ophthalmic purposes to enhance spatial
resolution. Four basic parameters can be adjusted
to identify different tissues: proton density of
tissue, bulk motion of protons (flow), spin lattice
relaxation time (T1) and spin-spin relaxation time

(T2).
Tissues with high proton (hydrogen nuclei)
density (e.g. fat) emit a high signal as does low
proton flow (coagulated blood). Low signal is
produced by bone, sclera and sinus air and faster
proton flow like in flowing blood. In T1 image
(short TR and TE, i.e. relaxation time and echo
time, respectively), the fat is bright and vitreous
dark, and is reverse in T2 image (long TR and
TE). In proton density image (long TR and short
TE), the vitreous is intermediate density as seen
in muscle, and the fat is seen brightly.
Paramagnetic substances like melanin and
methemoglobin alter the signal character of the
image causing relative brightness on T1 weighted
image. Similarly, gadolinium, a paramagnetic
substance is used as a contrast agent (coupled
with diethylenetriaminepenta acetic acid or
DTPA). Using this, false negative tests have been
vastly removed and imaging of meningiomas,
demyelination, metastasis, meningeal lesions,
ventricular abnormalities and pituitary masses
have been greatly enhanced. A few contraindications are there to the administration of contrast,
the relative ones being severe hepatic or renal
dysfunction and absolute ones include sicklecell anemia and hemolytic anemia. Mild allergic
reactions may still occur.
Technical advances in MRI include the use
of various surface coils, motion artifact and fat
suppression techniques which greatly enhance
visualization of orbital images. Contrastenhanced MRI (using IV gadolinium) is helpful
in the evaluation of orbital lesions such as
cavernous hemangiomas, high-flow vascular
malformations (IV gadolinium enhancement
brightens vascularized lesions so that they
exhibit the same density as fat), nonthyroid
related extraocular muscle enlargement, which
includes myositis or metastases, or processes that
potentially extend into the cavernous sinus.
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Fig. 27.15: MRI-scan of the orbit (axial view, T1 weighted)

showing a hyperintense lesion at the posterior pole
suggestive of choroidal melanoma
On MRI, melanin within melanomas typically

gives such tumors a hyperintense signal on T1weighted scans (Fig. 27.15) and hypointense
signal on T2-weighted scans (Fig. 27.16) relative
to the vitreous. Non-contrast, fat-suppression
studies help to determine the extension of ocular
melanoma into the orbit and optic nerve.
Subretinal hemorrhage may be differentiated from
choroidal melanoma by MRI when visualization
is poor and ultrasound inconclusive. While MRI
is a more useful diagnostic modality in
lymphoangiomas (better anatomical illustration
Fig. 27.16: MRI-scan of the orbit (sagittal view, T2 weighted)

showing a hypointense lesion at the posterior pole
suggestive of choroidal melanoma
Fig. 27.17: MRI-scan of the orbit (sagittal view, T1

weighted) showing orbital metastasis
of the cystic nature of the lesion and the

hemorrhages in lymphangiomas), it is interesting
to note that these lesions typically do not enhance
with gadolinium. In thyroid ophthalmopathy one
notices a high signal intensity in enlarged eye
muscles on T2W1. In orbital pseudotumor the
lesion is isodense to fat on T2W1.
MRI of the orbit is especially useful in optic
nerve lesions or trauma, unusual orbital
inflammation, orbital metastasis (Fig. 27.17) and
tumors extending to the orbital apex or having
suspected intracranial extension.
Salient contraindications to performing an
MRI scan include the presence of ferrous metallic
foreign bodies (even mascara which contains
ferrous compounds cause artifacts), aneurysm
clips, cardiac pacemaker and cochlear implants.
In addition, claustrophobic and obese patients
may pose problems. Other limitations of MRI
are lack of bone visualization, higher cost and
longer time of scan.
An interesting advancement in MRI is
Magnetic Resonance Angiography (MRA) in which
special software is used to suppress normal soft
tissue to enhance vascular structures (Fig. 27.18).
This is analogous to bone window setting on
CT-scan. Gadolinium enhancement is needed
Fig. 27.18: Magnetic resonance angiography (MRA) scans of the brain
for visualizing venous structures but is not

required for the arterial system. It allows
noninvasive visualization of the large- and
medium-sized vessels of the arterial system but
does not provide as fine a detail as direct
arteriography. This modality is still evolving and
angiography remains the gold standard in
imaging of vascular structures of the orbit.
Orbital Venography
Orbital venography or phlebography is a
technique in which contrast is introduced in the
frontal or angular veins and sequential X-rays
are taken in the AP view. It is useful in cases
of orbital varices and changes in superior
ophthalmic vein, whose obstruction or distortion
by a mass lesion can be made out. Subtraction
and magnification techniques have been used
to increase the resolution of venography. A
relative disadvantage of orbital venography is

that apart from the adverse effects of the contrast
agent, it cannot pick up small lesions. Also, larger
lesions obstructing dye flow in the superior
ophthalmic vein do not allow the rest of the venous
system to be visualized. Prior to CT-scan and
MRI, orbital venography was used in the
diagnosis and management of orbital varices and
in the study of the cavernous sinus. With the
advent of MRA, orbital venography has fallen
from favor and is more or less obsolete in the
present era.
Orbital Arteriography
In orbital arteriography a suitable contrast material
is injected into the ipsilateral common or internal
carotid artery and then appropriate X-rays are
taken. It is useful in demonstrating rare cases
of A-V malformations, carotid-cavernous fistulas,
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aneurysms and hemangiopericytoma. Maximum
visualization can be obtained by the use of
magnification to allow viewing of the smaller
caliber vessels, and subtraction techniques to
radiologically eliminate bone. With the advent
of MRI and CT, particularly MRA, its role and
utility are gradually fading out.
Blood Tests
The nature of the blood investigations performed
will depend to a large degree upon the clinical
findings of the patient. Given herein are some
of the more commonly utilized blood investigations to assist in the evaluation of a patient with
proptosis.
Total and Differential Blood Counts

This test is particularly useful in evaluating
patients with leukemia and lymphomas.
Thyroid Function Tests

Thyroid function tests include tests of T3, T4
and TSH. These tests will be abnormal in a
majority of patients with thyroid ophthalmopathy. However, if thyroid disease is strongly
suspected and these tests are normal, additional
endocrine studies can be considered. Further tests
which can be done include the antithyroglobulin
and antimicrosomal antibodies, which are
abnormal in nearly 70% of patients with Graves
disease.
Antineutrophil Cytoplasmic Antibody

(cANCA) Serum Assay
Diagnosis of Wegeners granulomatosis should
be considered in patients with scelrokeratitis or
coexisting sinus disease and orbital mass lesions.
The antineutrophil cytoplasmic antibody
(cANCA) serum assay is a very sensitive test
for the presence of this rare disease.
Serum Angiotensin Converting Enzyme

The diagnosis of sarcoidosis may be assisted
by testing for serum angiotensin converting
enzyme (ACE). This multi-system granulomatous
inflammatory condition may present with
lacrimal gland enlargement.
ELISA for Cysticercosis

Elisa test is used for evaluating the presence of
an orbital cyst, if cysticercosis is suspected.
However, it needs to be corroborated with clinical
and imaging findings due to a high percentage
of both false positive and false negative results.
Biopsy Techniques
Although imaging techniques can help us in
making a provisional diagnosis and are
indicative in nature, a definitive diagnosis can
only be made by obtaining a tissue specimen
and subjecting it to routine and specialized
histopathological techniques. Biopsy techniques
which are commonly employed are described
below.
Fine Needle Aspiration Cytology

Fine needle aspiration cytology (FNAC) is
employed for rapid diagnosis of suspected
malignant orbital lesions. It is minimally invasive
in nature and can be performed in an office
setting. Although strict asepsis is mandatory,
a full fledged operative set up is not required.
It is done with the help of a hand held gun with
22 to 25 gauge needle (Fig. 27.19). After localizing
the mass by palpation (for anterior orbital lesions)
or under ultrasound or CT guidance (for relatively
posterior lesions), the needle is introduced into
the mass and the material is aspirated by using
negative pressure. The aspirate is then spread
over a slide, air dried, fixed in 95% alcohol and

Core Biopsy
Fig. 27.19: Instrument used for performing fine

needle aspiration (FNAC gun)
finally stained with hematoxylin and eosin. The

slide needs to be examined by a trained cytologist
for accurate interpretation. The accuracy has been
reported to be more than 80%. The principal
disadvantage of this technique is that scanty
cellular material is obtained from a limited region
of the mass which may be difficult to evaluate
and interpret. Secondly it uses cytology technique
rather than routine histopathology that fails to
detect tissue or tumor architecture. The main use
of FNAC is in cases of suspected lymphoma
metastatic tumors or orbital recurrence of
retinoblastoma or melanoma, which may require
to be treated by chemotherapy or radiotherapy.
It has also been used for diagnosing optic nerve
sheath meningioma.
Fine needle capillary sampling (FNCS) is
another similar technique in which instead of
aspiration with a syringe, a 25-gauge needle is
introduced in the mass after stabilizing it
manually. Gentle to and fro movement is
performed and the needle is withdrawn without
any aspiration. The material is then processed
like FNAC. Reported sensitivity of this technique
is said to be in the range of 90-95%. The
complications of these procedures include globe
perforation, retrobulbar hemorrhage and rarely
intracranial penetration. Transient visual loss,
diplopia and ptosis have also been reported.
A somewhat more invasive technique than FNAC

is core biopsy that uses a trephine which is 24 mm in diameter. It is passed with a gradual
rotatory motion into the lesion after exposure
under local infiltration, and an adequate
specimen is obtained. The advantages are that
it is a rapid, out-patient procedure with lesser
morbidity and much better yield of tissue than
FNAC, for a more accurate diagnosis. Its main
limitation is that posterior lesions are difficult
to access. An endoscopic biopsy can be performed
for the posterior lesions but requires greater
expertise to yield credible results.
Incisional Biopsy
Incisional biopsy is a surgical technique where
partial removal of the tumor is done under local
or general anesthesia. The purpose of this biopsy
is to obtain adequate tissue for histopathological
examination. Imaging studies should be done
for accurate localization of the lesion before
undertaking the biopsy procedure. These are
useful in planning the surgical approach. Care
should be taken to obtain tissue from the main
mass itself, because biopsy from superficial or
adjacent structures will give false results.
Excisional Biopsy
Imaging and supportive investigations certainly
help in establishing a good differential diagnosis,
but a definitive diagnosis is sometimes
established only after complete removal of the
mass and subjecting it to histopathology. This
is achieved by performing an orbitotomy
procedure through one of the surgical approaches
to the orbit. The principles of localization and
surgical planning are similar to the ones
described above. This, along with incisional
biopsy, is the gold standard for diagnosis and
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has the added advantage of being therapeutic
in benign encysted lesions like dermoids,
cavernous hemangioma, pleomorphic adenoma
of lacrimal gland, neurilemoma and fibrous
histiocytoma.
Pathology Techniques
This area is the most important part of any
diagnostic process as it provides actual tissue
diagnosis, which may have therapeutic and
medico-legal importance. It is imperative to have
proper communication with the pathologist
preoperatively, to facilitate and plan the
appropriate histopathologic technique for a given
case.
Fig. 27.20: Gross specimen of an orbital cavernous

hemangioma
Cytology
As already stated under the section on FNAC,
cytology is a low cost technique for rapid
diagnosis. The aspirate is spread over a slide
and air dried followed by alcohol fixation and
stained by Papanicolaou technique and H&E
or May-Grunwald-Giemsa stain; mainly used
for suspected malignant lesions. Cytology has
its limitations as discussed earlier.
Gross Examination
The gross excised specimen is inspected for shape,
size, consistency (firm/hard/cystic/nodular),
and whether the capsule is intact or broken.
Measurements are made in three dimensions.
Then it is cut to see the internal architecture
color, areas of necrosis, calcification and inner
structure (solid or cystic). For example, on gross
examination, pleomorphic adenoma of the
lacrimal gland displays an intact capsule, with
firm, bosselated appearance, and on cut section
it has whitish, firm solid areas with some interspersed friable areas. Cavernous hemangioma
on the other hand has a reddish-bluish color
Fig. 27.23: Gross section of an orbital cavernous

hemangioma (gross specimen)
and has a firm to soft spongy consistency (Fig.

27.20). On cut section, it has a typical honeycomb
pattern of innumerable cystic spaces (Fig. 27.21),
which can be very well appreciated on H&E stain
(Fig. 27.22). Parasitic cysts, such as hydatid cyst
are seen as a thin walled translucent fluid-filled
structure (Fig. 27.23). The gross specimen is sent
to the pathologist in a labeled bag filled with
10% formalin solution in adequate quantity.
Routine Histopathology
The biopsy or excised specimen is further
processed in the pathological laboratory by
Fig. 27.22: Histopathological picture (H & E) of cavernous

hemangioma showing large blood-filled spaces
Fig. 27.24: Histpathological picture (H & E) of

pleomorphic adenoma of the lacrimal gland
Histochemistry
Fig. 27.23: Gross specimen of a hydatid cyst of the orbit
dehydrating in alcohol. Then it is embedded in

paraffin and sectioned with a microtome knife.
This is followed by removal of paraffin and
staining with hematoxylin and eosin stain (Fig.
27.24). Hematoxylin is a basic dye that binds
acidic structures like DNA and nuclei in cells
while eosin is an acidic dye that stains basic
structures like proteins. This gives clues about
the nature of the lesion. For example, cells with
prominent nuclei and scanty cytoplasm will stain
blue as in lymphoma, retinoblastoma, inflammatory lesions and basal cell carcinoma. On the
other hand, cells with abundant cytoplasm like
epithelial cells and connective tissue as in
squamous cell carcinoma and amyloidosis, will
stain pink.
In situations where the routine histological

process is difficult to interpret, various
histochemical and immunohistochemical
techniques provide assistance. For example, Oil
red O or Sudan black are used to stain fat in
cases of sebaceous gland carcinoma or xanthomatous tumors. Similarly, Alcian blue is used
for mucinous substances and PAS (Periodic acid
Schiff) for glycogen and some fungal hyphae.
Fontana is used for staining melanin, esterase
for cytoplasmic granules in leucocytes and
Bodian for nerve fibers.
Immunohistochemistry
Immuno-histo-chemistry is a highly sensitive
technique, which utilizes the principle of antigenantibody reaction to capture certain specific
proteins in specific tissues, which can then point
out to the correct diagnosis. This reaction is
coupled by an enzyme, which then generates
a color reaction when combined with certain
chemicals called chromogens. Monoclonal
antibodies are directed against an important
group of cytoskeletal components called
intermediate filaments. These are specific for
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different tissues and can be diagnostic. For
instance, cytokeratins are found in epithelial cells
and carcinomas, vimentin in mesenchymal cells
and sarcomas, desmin in striated and smooth
muscle cells, GFAP in glial cells and
neurofilaments in neurons. Other examples are
LCA (Leucocyte common antigen) used to stain
lymphoid lesions; HMB 45 is used in melanomas,
especially in cases of amelanotic melanoma
where pigmentation may not be seen. S100 is
used for schwannomas and neurofibromas.
Similarly, specific antibody-antigen reactions are
used to differentiate B cell from T cell lymphomas.
Electron Microscopy
Scanning Electron Microscopy (SEM) and
Transmission Electron Microscopy (TEM) are
sometimes used in evaluating unusual lesions.
TEM can be vital in the diagnosis of certain tumors
such as leiomyoma, neurilemoma, neurofibroma
and amelanotic melanoma and also in certain
poorly differentiated tumors like alveolar
rhabdomyosarcoma and alveolar soft part
sarcoma. It is an expensive and time consuming
process. With the advent of the above mentioned
immunohistochemical stains, it is rarely used.
SEM can be used to see the three dimensional
ultrastructure of lesions and can provide elemental
details of retained foreign bodies.
Additional Investigations
Once the initial cause of the proptosis has been
determined, it is often necessary to undertake
additional investigations to further determine
the full extent of the pathology. This is
particularly true in the cases where the cause
of the proptosis is found to be a tumor. For
example patients with hematological and
lymphoproliferative tumors require the following
additional investigations: X-ray chest, blood
counts, serum immunoglobulin electrophoresis,

bone marrow aspiration and biopsy, bone scan,
liver and spleen scan and abdominal and pelvic
CT.
Conclusion
Diagnosis of a case of proptosis requires a
systematic approach through a proper clinical
evaluation coupled with appropriate
investigative techniques. If used effectively, these
techniques can guide the clinician in achieving
an accurate diagnosis and optimal management
in this rather challenging field.
Bibliography
1. Aburn NS, Sergott RC. Orbital Color Doppler
Imaging. Eye 1993;7:639-47.
2. Aviv RI, Miszkiel K. Orbital imaging: Part 2.
Intraorbital pathology. Clin Radiol 2005;60:288307.
3. Bartley GB, Gorman CA. Diagnostic criteria for
Graves ophthalmopathy. Am J Ophthalmol
1995;119:792-95.
4. Bilaniuik CT. Vascular lesions of the orbit in
children. Neuroimaging Clin N Am 2005;15:107-20.
5. Devis PC, Newman NJ. Advances in neuroimaging of visual pathways. Am J Ophthalmol
1996;121:690-705.
6. Dutton JJ, Byrne SF, Proia AD. Diagnostic Atlas
of Orbital Diseases. Philadelphia, Saunders, 2000.
7. Newton TH, Bilaniuk LT (Eds). Radiology of
Eyes and Orbit. New York, Raven, 1990.
8. Rootman J (Ed). Diseases of Orbit: A Multidisciplinary approach. Philadelphia, Lippincott
William & Wilkins, 2003.
9. Shields JA, Shields CL. Atlas of Orbital Tumors.
New York, William & Wilkins, 1999.
10. Shields JL, Shields JA, Honavar, SG, et al. Clinical
spectrum of primary ophthalmic rhabdomyosarcoma.Ophthalmology 2001;108:2284-92.
11. Wiersinga WM, Prummel MF. Pathogenesis of
Graves ophthalmopathycurrent understanding (Editorial). J Clin Endocrinol Metab
2001;86:501-03.
Neurological Disorders of Pupil
AMBAR CHAKRAVARTY
28
Neurological
Disorders
of Pupil
Introduction
Pupillary examination is a powerful tool in the
neurological evaluation. The key in understanding the significance of pupillary findings is to
know the anatomy of the system and to recognize
the various reactions of the pupil. It is further
important to correlate historical information with
clinical findings in the context of known anatomy
to arrive at a cogent diagnosis. Studies on pupil
have also figured significantly in advances of
autonomic physiology.1-4
Anatomy and Physiology

The normal pupil is slightly situated inferomedial
to the center of cornea. When viewed in the
natural state, the iris and pupil appear slightly
larger (12.5%) because of the corneal magnification. The sphincter muscle is located at the
pupillary border and is more powerful than the
dilator muscle. Blood supply of iris is through
the radially arranged vessels arising from the
major arterial circle at the iris base. Pupillary
control is essentially a balance between
parasympathetic and sympathetic system.
Although pupillary size and reactivity, as well
as ciliary muscle tone, are basically controlled
by the autonomic nervous systems, the major

role is played by the parasympathetic system
due to the mechanical superiority of the sphincter
muscle.
Parasympathetic impulses arise in the
Edinger-Westphal Complex (EWC), a central
paired subnucleus of the oculomotor nerve in
the midbrain. Light directed into either eye
usually produces bilateral pupillary constriction.
The pupillary light reflex (Fig. 28.1) begins with
hyperpolarization of the retinal photoreceptors.
Ultimately the retinal ganglion cells are activated.
The retinal ganglion cells send their axons
through the optic nerve, chiasm and optic tract
to synapse in the pretectal nuclei. Interneurons
then connect the pretectal nuclei to the EWC.
Efferent pupillary fibers arise from the EWC and
traverse the mesencephalon in the rostral
fascicles of the third cranial nerve. It enters the
orbit as part of the inferior division of the nerve,
and arrives at the ciliary ganglion by means of
the motor nerve to the inferior oblique muscle.
Most of the pupillomotor fibers synapse in the
main or accessory ciliary ganglion and reach
the iris sphincter muscle via the short ciliary
nerves. Interruption in this pathway, EWC to
the sphincter muscle will cause pupillary
dilatation and decreased reactivity. Afferent
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Fig. 28.1: Pupillary light reflex pathway from retina through

optic pathway to lateral geniculate body and then on to
Edinger-Westphal nucleus complex and then along the
third nerve trunk to the iris sphincter
visual system pathology does produce difference

in pupillary size. Pupillary constriction is also
a component of a number of synkinetic reactions
involving parasympathetic activitynear reflex
(miosis, accommodation, and convergence),
Bells phenomenon (levator inhibition, superior
rectus muscle stimulation, and miosis) and
Westphal-Piltz reaction (orbicularis spasm and
miosis). The cortical region responsible for
supranuclear generation of the near response
remains uncertain. It probably rises from diffuse
cortical projections. Ultimately, supranuclear
inputs for the near reflex converge upon the rostral
superior colliculus. From here connections are
made to the mesencephalic reticular formation,
pretectum and EWC to generate the near triad
pupillary constriction, lens accommodation and
convergence.
First order neuron of sympathetic pathway
(Fig. 28.2) arises in the hypothalamus and
descends through the reticular substance to
synapse in the intermediolateral gray substance
of the lower cervical and upper thoracic spinal
cord (ciliospinal center of Budge Waller, C8-T1).
Second order neuron arises in the intermediolateral gray column and then ascends without
synapse through the sympathetic paraspinal
chain to the superior cervical ganglion. From
Fig. 28.2: Sympathetic pathway to the iris dilator

muscle
the superior cervical ganglion the postganglionic

or third order neuron travels on the surface of
the common carotid artery. At the bifurcation
of the internal and external carotid arteries, fibers
controlling facial sweating follow the external
carotid artery, while those destined for the eye
and lid follow the internal carotid artery. In the
cavernous sinus these eye and lid fibers join the
fifth and sixth cranial nerves and enter the orbit
via the superior orbital fissure. Fibers destined
for the dilator muscle enter the eye via the long
posterior ciliary nerves or short posterior ciliary
nerves.
Examination of Pupil
The most important evaluation technique for
pupil is the history. A careful history of known
pupillary disorders is vital to establish whether
a pupillary sign has any meaning in the context
of the disorder under consideration. Rarely, a

patient will present with complaint of abnormality of pupil as a presenting symptom hence
the presenting complaints should be stressed
upon to get a proper clue into the diagnosis of
pupillary abnormality such as associated history
of trauma, features of raised ICT, irritative lesions,
poor visual acuity, lid lag, double vision and
use of drugs. Old photographs provide significant information and should be evaluated in all
cases of long-standing or asymmetry documented
on examination. Bedside evaluation of pupil and
its reactions require a good visibility with comfort
of patient and examiner. Examination of pupil
requires a good illuminator which provides
bright, even beam without hot spots or dim areas.
Evaluation should begin in darkness or in very
dim light as this allows the pupils to start their
constriction from a bigger size and increases the
amplitude of the pupillary movement making
it easier to see. There are three stages in the
examination of the pupils.
Evaluation of Anisocoria
Pupillary inequality is usually due to an iris
innervation problem. The best way to decide
whether it is the sphincter muscle or the dilator
muscle that is weak is to compare the amount
of anisocoria in darkness and in light. No
anisocoria in darkness or in light indicates an
intact efferent arm of the light reflex arc. Virtually
everyone has a measurable pupillary size
difference if sensitive enough techniques are used;
however, only 20% of normal individuals have
enough asymmetry to be recognized clinically
(i.e., 0.4 mm or more). Age plays a major role
in pupillary size. Newborns have small
hyporeactive pupils, young children have larger,
briskly reactive pupils and as the age progress
the normal pupillary size and reactivity
diminishes such that older individuals have
miotic, relatively slowly reactive pupils.
Evaluation of the Afferent Arm of

the Light Reflex Arc
Swinging-Light Pupil Test
The swinging-light pupil test is a rapid, low cost,
accurate and objective method of identifying
asymmetric optic nerve disease but it is useless
unless proper technique is used. The idea is to
look for a Relative Afferent Pupillary Defect
(RAPD) in one eye compared to the other by
alternate projection of light over each eye (Fig.
28.3).
Technique
1. The room illumination should be dim. Unless
the test is performed in darkness, the amplitude of pupil constriction will be too low.
2. The patient should fixate on a distant target.
This provides maximal relaxation of the iris
sphincter muscle. A near target would evoke
miosis associated with the synkinetic near
reflex.
3. Use a bright light stimulus. Dim lights do
not produce enough pupil constriction. If
neither pupil constricts very much to
Fig. 28.3: Left afferent pupillary defect (RAPD)
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444

flashlight illumination, use a more potent light
source, such as the indirect ophthalmoscope.
Avoid a light so bright that it causes
photophobia or extreme miosis.
4. Direct the light from below the level of the
patients eyes. This is done so as not to provoke
miosis from the patients fixing on the light.
5. Move the light briskly and rhythmically from
eye to eye several times. If you move the light
across the nose too slowly, you will evoke
too much constriction and miss a subtle
relative afferent pupil defect. Make about five
swings. This repetition is necessary to be sure
that any pupillary dilation on one side does
not reflect merely the adventitious sphincter
movement of physiologic pupillary unrest.
mild or severe, but a visual field abnormality

can almost invariably be detected by a perimetry.
The optic disk may appear normal or acutely
swollen but will later develop pallor. Examples
of optic nerve disorders include optic neuritis,
ischemic optic neuropathy, hereditary optic
neuropathy, compressive lesions, toxins, trauma,
and cellular infiltration.
1. The largest afferent defects occur in association with unilateral optic nerve disorders.
2. Resolved optic neuritis may result in optic
disk pallor and RAPD despite recovery to
normal visual acuity and normal visual field.
3. The extent of damage in bilateral optic nerve
disorders is rarely symmetrical. Therefore, a
RAPD will be found on the side with greater
damage on carefully examination.
Interpretation
Optic Chiasm
1. Compressive lesions of the optic chiasm can
produce asymmetric visual loss and, therefore,
a RAPD. Commonly, a junctional scotoma
is found.
2. Symmetric bitemporal hemianopsia is not
associated with a RAPD, because injury to the
visual and pupillary pathways is symmetric.
A relative afferent pupillary defect (RAPD) is

a sensitive indicator of unilateral or asymmetric
injury to the afferent pupillary pathway. If a
RAPD is found, it needs to be investigated. In
general, the size of the RAPD correlates with
the asymmetry of visual field loss and the
resultant asymmetry of pupillomotor input. It
also tends to vary with the location of the lesion
within the afferent pathway.
Retina
1. Large unilateral retinal lesions, i.e. retinal
detachment or central retinal artery occlusion
produce a clear RAPD. Visual acuity might
be good if the macula is spared. A careful
dilated funduscopic examination is usually
diagnostic, and a consultation with an
ophthalmologist/neurologist is important.
2. Cataracts and corneal opacities do not cause
afferent pupillary defects.
Optic Nerve
Damage to the optic nerve almost always
produces a RAPD. Visual acuity loss may be
Optic Tract
A pure optic tract lesion will produce a small
RAPD in the contralateral eye. Thus, a complete
homonymous hemianopsia with an afferent
defect in the eye with the temporal field loss
should raise the possibility of a tract lesion as
the cause of visual loss.
Pretectal Nucleus
1. The pretectal nucleus in the dorsal midbrain
is the final synapse site of pupillary fibers
coming from tract via brachium of the superior
colliculus. Visual fibers, however, have
separated off to go on to the lateral geniculate
nucleus. Therefore, a dorsal midbrain lesion
can produce a small contralateral RAPD and
no visual loss.

2. Afferent pupillary defects form optic tract or
midbrain injury are usually small and are
fairly rare.
Further Observations
The intensity of the RAPD, which is related more
closely to differences in visual field loss than
visual acuity loss in the two eyes, can be
quantitatively measured by placing progressively
higher neutral-density filters over the normal eye
until the RAPD is eliminated.5,6 The filters are
particularly useful when the diagnosis of RAPD
is equivocal. The examiner places the 0.3-log unit
filter over each eye consecutively and performs
the swinging-light test. If no RAPD is present,
the pupil of the eye covered by the filter dilates
slightly as the light is swung towards it. When
a RAPD is minimal, the filter placed over the
affected eye makes the pupil dilation in that eye
more obvious.
The swinging-light pupil test is useful even
when only one iris sphincter muscle is
operational. Constriction of the pupil in the
unaffected eye as the light is swung toward it
is equivalent to pupillary dilation in the eye with
the suspected RAPD. This phenomenon is called
(misleadingly) a reverse RAPD, it is merely
a different way to elicit a standard RAPD.
Evaluation of Near Response

The pupillary response to near effort must be
checked. If the light reaction seems a little weak,
the examiner should look to see if the pupils
constrict better to a near stimulus than to light.
If they better constrict to light this is called lightnear dissociation and may indicate underlying
pathology like neurosyphilis, lesions of the dorsal
midbrain (obstructive hydrocephalus, pineal
region tumors) and aberrant regeneration
(oculomotor nerve palsy, Adies tonic pupil).
Features of common causes of pupillary

asymmetry in neuro-ophthalmology have been
given in Table 28.1 and the sites of lesions causing
pupillary abnormalities are shown in Figure
28.4.
Pupillary Abnormalities
Anisocoria
Local Ophthalmologic Conditions
Typically, patients with anisocoria due to local
causes have a painful red eye with a small pupil
and visual disturbance.
a. Any condition resulting in an inflammatory
response within the anterior chamber may
cause spasm of the sphincter muscle,
resulting in anisocoria.
b. Acute closed-angle glaucoma results in a red
painful eye and visual disturbance. In this
condition, the pupil tends to be dilated, with
an impaired light reflex that may simulate
interruption of the parasympathetic nervous
system.
c. Prosthetic eyes have yet to show a brisk light
reflex.
d. Other important causes of irregular pupils
with poor light reflex are congenital malformation of the iris, postoperative changes, and
posttraumatic mydriasis due to tears in the
iris and its sphincter muscle.
Episodic Anisocoria
Either parasympathetic or sympathetic paresis
or over activity may produce intermittent
anisocoria. The common causes of episodic
anisocoria due to parasympathetic paresis
include uncal herniation, seizure disorder and
migraine. Parasympathetic hyperactivity
conditions like cyclic oculomotor paresis and
parasympathetic spasm7 are known to add to
445
General
characteristics
Round, regular
Small, round,
unilateral
Usually larger in
bright light,
sector pupil
palsy, vermiform
movement
unilateral or less
often bilateral
Small, irregular,
bilateral
Mid dilated, may
be oval, bilateral
Mid dilated,
unilateral, rarely
bilateral
Very large
round, unilateral
Condition
Essential anisocoria
Horners syndrome
Adie tonic pupil
Argyll-Robertson
pupils
Midbrain pupils
Oculomotor palsy
Pharmacologcally
dilated pupils
Fixed
Fixed
Poor to light,
better to near
Lighted
Dilates
Dilates
No change
Lighted
Poor
Dilates
Dilates
Dilates
Response to
mydriatics
No change
Lighted
Absent to
light, tonic to
near; tonic
redilation
Poor to light,
better to near
Darkened
No change
Room condition in
which anisocoria
is greater
Both brisk
Both brisk
Response to
light and
near stimuli
No
Constricts
Constricts
Constricts
Constricts
Constricts
Constricts
Response to
miotics
TABLE 28.1: CHARACTERISTICS OF PUPILS ENCOUNTERED IN NEURO-OPHTHALMOLOGY
Pilocarpine 1%
does not constrict
Pilocarpine 0.1%
constricts
Cocaine 4% poor
dilatation
Normal and rarely

needed
Response to
pharmacologic
agents
446
Fig. 28.4: Sites of lesions in pupillary abnormalities
the episodic anisocoria. Other conditions

producing the episodic anisocoria include
sympathetic hyperactivity conditions, sympathetic dysfunction producing alternating
anisocoria and pupillary dilatation.
Dilated Pupil (anisocoria that

increases in bright illumination)
The patient has anisocoria that increases in bright
light. Differential diagnoses of a dilated pupil
include Adie tonic pupil, III cranial nerve palsy,
and pharmacologic blockade.
Adie Tonic Pupil

Adie tonic pupil predominately occurs in females
aged 20-50 years. Patient may complain of
photophobia, episodes of blurred near vision or

blurred vision when switching from near to far
viewing and may even complain of unequal
pupils. Typically, the involved pupil displays
a poor response to light, with a relatively
preserved response to sustained near fixation
but an abnormally slow or tonic contraction. Slitlamp examination often reveals sector palsies
of the iris. The parasympathetic defect in Adie
pupil8 is believed to occur after the fibers leave
the ciliary ganglion. As a result of denervation
supersensitivity, the affected eye displays an
abnormally brisk response to dilute (1/8%)
pilocarpine and this test (Fig. 28.5) has been
suggested as a way of differentiating preganglionic and postganglionic parasympahetic
lesions. Recent literature reports many patients
who have mydriasis due to oculomotor nerve
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448
Fig. 28.5: Mid pilocarpine test for right Adies pupil
compression and have displayed reactivity to

dilute pilocarpine, should show other signs of
third nerve dysfunction. The combination of an
idiopathic tonic pupil with decreased deep
tendon reflexes and/or orthostatic hypotension
is termed Holmes-Adie syndrome. The condition
is common in young women. Adie pupil is
commonly unilateral, but may become bilateral
in 10% cases. The symptoms of a tonic pupil
tend to be self-limited. Adie pupil is believed
to be of uncertain etiology. However, neurosyphilis, diabetes, herpes zoster, giant cell
arteritis, and alcoholism have been incriminated.
A closely related rare condition is the Ross
syndrome characterized by the triad of segmental
anhidrosis, hyporeflexia and tonic pupils. Only
a handful of cases have been described in the

world literature so far.9 Harlequin syndrome
refers to segmental anhidrosis only without any
ocular manifestation. In fact, it is reasonable to
assume that all these dysautonomic syndromes
(Horner, Adie, Ross and Harlequin) represent
clinical manifestations of a generalized
autonomic injury with or without somatic
nervous system involvement (e.g. areflexia).
Third Cranial Nerve Dysfunction

The most worrisome cause of an enlarge pupil
is oculomotor nerve dysfunction. Anisocoria in
the setting of a head injury with decreased level
of consciousness may be due to uncal herniation.

An expanding supertentorial lesion forces
the inner basal edge of the uncus towards the
midline and over the edge of the tentorium,
thereby compressing the adjacent midbrain and
oculomotor nerve. This results in ipsilateral third
nerve palsy and decreased level of consciousness.
In addition, the contralateral cerebral peduncle
is compressed against the free edge of the tentorium, resulting in the ipsilateral hemiparesis.
Such patients require urgent intervention to lower
intracranial pressure and have a poor prognosis
without surgical intervention. When a parasympathetic pupillary defect coexists with ptosis
and extraocular muscle palsies in a patient with
a normal level of consciousness, the diagnosis
is third nerve palsy with pupillary involvement.
In these situations, one needs to exclude the
posterior communicating artery aneurysm.
Emergency neuroimaging is indicated unless
another etiology is apparent.
Nonisolated Third Cranial

Nerve Palsy
If other neurologic symptoms or signs are present,
they will, in most cases, direct the clinician to
the site along the oculomotor nerve pathway
where the responsible lesion is likely to be
residing. For example, a patient with contralateral
hemiparesis has a lesion in the midbrain
ipsilateral to the III nerve palsy, while a patient
with additional involvement of the VI cranial
nerve probably has a lesion in the ipsilateral
cavernous sinus. In some cases, the presence of
other neurologic or systemic features will suggest
the specific disorder responsible for the
ophthalmoplegia, as in an elderly patient with
headaches, weight loss, transient visual loss
and tenderness of the superficial temporal
arteries who is most likely harboring giant cell
arteritis.
Isolated Third Cranial Nerve Palsy

Many times, however, a patient develops III
cranial nerve palsy without other neurologic or
systemic symptoms or signs. In such patient,
consideration of specific characteristics of the
ophthalmoplegia (e.g. status of the pupil) and
historical details (e.g. static versus progressive)
will help guide one to the likely disorder
responsible for the presentation.
There are five important causes of acute third
nerve palsy seen in routine clinical practice.
1. Infarction of the peripheral cranial nerve
2. Compression by tumor
3. Compression by aneurysm
4. Trauma
5. Brainstem stroke.
The list should probably also include TolosaHunt syndrome or painful ophthalmoplegia
syndrome when considering clinical practice in
the Indian context. However, the overall
impression on the frequency of occurrence of this
condition in India is probably somewhat
overestimated and certainly the condition would
not appear to be as prevalent if strict diagnostic
criteria (neuroradiological) are employed (vide
infra).
Most of the less frequent disorders causing
oculomotor nerve palsy as well as trauma and
brainstem stroke listed above, occur in patients
with historical information or physical signs that
implicate the underlying cause of ophthalmoplegia (i.e. nonisolated). Therefore a neurologist
evaluating a patient with acute and neurologically-isolated III cranial nerve palsy faces
following dilemmas:
Is it due to infarction or compression (by
aneurysm)?
Can one wait and watch, or do one need
to image emergently?
Should one go directly to catheter angiography, or screen using a noninvasive test
following imaging to exclude aneurysm?
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450

Ischemic III cranial nerve palsy is the most
common pupil-sparing oculomotor palsy in
middle-aged or older adults. It is usually the
result of infarction of the extra-axial segment of
the oculomotor nerve,10 although patients with
similar clinical characteristics have been
described who have documented midbrain
strokes.11 This condition has traditionally been
referred to as diabetic III nerve palsy or diabetic
ophthalmoplegia since it frequently occurs in
patients with established diabetes. However, the
same condition may occur in patients who are
not diabetic but who have other overt or
unrecognized vascular risk factors, most notably
left ventricular hypertrophy (LVH) associated
with hypertension and polycythemia.
Patients with the ischemic III nerve palsy have
the following clinical profile:
Age usually greater than 45 years,
occasionally, younger and those with longstanding diabetes.
Abrupt onset.
Often times associated with a dull,
continuous pain around the ipsilateral brow,
eye, or temple lasting a week or two, at most.
Pupil usually normal, about 1/3 of patients
demonstrate small anisocoria (one millimeter
or less), but the pupil characteristically
remains reactive to light. Anisocoria greater
than one millimeter, or a blown pupil, is
not consistent with ischemic injury, and
usually indicates that a mass lesion is
compressing the oculomotor nerve.
Neurologically isolated, bilateral III nerve, or
ipsilateral IV or VI nerve, involvement is not
consistent with ischemic III nerve palsy.
Progression of external ophthalmoplegia
during the subsequent one to two weeks
occurs in about 2/3 of acutely-evaluated
patients who have incomplete deficits at their
first visit. Progression of deficits beyond this
period indicates that the initial diagnosis was
in error and that a mass lesion is compressing

the third nerve.
Excellent prognosis or spontaneous recovery
(without signs of aberrant regeneration) is
expected within 3 months in 90% of patients.
Recurrent events involving the same or other
ocular motor nerves occur in at least 15%
of patients.
Work-up for a Patient with Pupilsparing Complete Third Nerve Palsy

Following investigation should be performed:
Fasting and 2 hour postprandial glucose estimation and, if known diabetes, hemoglobin
Alc assay (It is not uncommon to identify
unsuspected diabetes in a patient presenting
with ischemic ocular motor nerve palsy. In
those with established diabetes, poor glycemic
control may be a predisposing factor).
Serial blood pressure measurement and ECG
looking for LVH (As with diabetes, it is not
uncommon to identify previously unsuspected hypertension in this population).
Hemoglobin and hematocrit (for polycythemia).
Other evaluations for vascular risk factors,
(as appropriate.)
Erythrocyte sedimentation rate and/or creactive protein if patient is older than 55
years to screen for giant cell arteritis.
Neuroimaging is generally not necessary
unless:
Age less than 45 years
Vascular risk factors not present
No recovery within 3 months
Signs of aberrant regeneration develop
Pupil becomes involved with anisocoria
> one millimeter
Other neurologic signs develop.
Tumors that compress the III cranial nerve
in ambulatory outpatients are usually located

in the parasellar, cavernous sinus or orbital apex
region. Common offenders include pituitary
adenomas, meningiomas, craniopharyngiomas
and chordomas. They often injure additional
neighboring structures, resulting in a combination of IV or VI cranial nerve palsy, trigeminal
neuropathy, post-ganglionic Horner syndrome,
or produce visual loss due to compression of
the optic nerve or chiasm. The pupil is usually
dilated and poorly reactive when the III cranial
nerve is compressed by tumor. When signs of
aberrant regeneration are present, a chronic mass
lesion within the cavernous sinus (e.g.
meningioma or aneurysm) should be suspected.
When a patient develops oculomotor palsy
following seemingly minor head trauma,
neuroimaging is indicated to exclude the
presence of a previously unsuspected mass lesion
at the base of the skull.
Aneurysms compressing the III cranial nerve
classically produce acute, painful ophthalmoplegia with pupil involvement. One must
remember that chronic progressive, painless, and
pupil-sparing/relative pupil-sparing presentations are not inconsistent with aneurysm. Three
aneurysmal sites are most often encountered:
1. Posterior communicating-internal carotid
junction: This is the most common site of
aneurysm that causes III cranial nerve injury.
Unruptured aneurysm in this location usually
does not produce other neurologic symptoms
apart from ipsilateral headache. The pupil
is blown (i.e. dilated and unresponsive to
light) in 50% to 75% of patients, but may
be normal in 14% especially if external
ophthalmoplegia is incomplete.12
2. Basilar tip: The posterior circulation is an
often forgotten source of aneurysms that can
compress the III nerve. They are often giant
or fusiform in appearance. These aneurysms
may compress the oculomotor nerve from
below; sparing the pupillomotor fibers that
are concentrated along the superior segment

of the nerve, producing pupil-sparing or
relative pupil-sparing ophthalmoplegia.13
3. Intracavernous carotid: Aneurysms are often
giant or dolichoectatic, and often produce
other signs of the cavernous sinus syndrome,
such as IV or VI nerve palsy, trigeminal
neuropathy, or Horner syndrome.14 If the
pupillomotor fibers have been injured, the
pupil may still appear normal in room light
due to aberrant regeneration or superimposed
oculosympathetic paresis. Evaluating the size
of the pupils in bright light, however, will
usually reveal that the affected pupil is larger
than the fellow pupil because of iris sphincter
paresis. In addition, evaluating the size of
the pupils in darkness will reveal that the
affected pupil is smaller than the fellow pupil
if affected by either aberrant regeneration or
Horner syndrome. These aneurysms have a
relatively lower risk of rupture and, when
they do, often cause signs of high-flow carotidcavernous fistula rather than subarachnoid
hemorrhage.
Ischemic vs Aneurysmal Damage to

Oculomotor Nerve
What elements of the history and physical
examination can be used to differentiate between
ischemic and aneurysmal injury to the
oculomotor nerve?
A complete history of the patient should be
recorded. The usual details include age, presence
of vascular risk factors, pain and progression
of ophthalmoplegia in the acute setting are
common enough in both disorders that none
provide sufficient clinical clue. The status of the
pupil, on the other hand, is variable. The
discriminating power of the pupil to differentiate
III nerve infarction from compression by a mass
lesion has become formalized into a clinical
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452

dictum, the rule of the pupil. While this rule
will work most of the time, there are important
pitfalls that must be recognized in order to avoid
missing aneurysms.
The rule states that a normal pupil implies
infarction while a dilated pupil implies
compression (by aneurysm) of the oculomotor
nerve. What is the anatomic basis of this rule?
The pupillomotor fibers are concentrated
peripherally along the superior to medial
longitudinal segment of the 3rd nerve as it course
from the interpeduncular fossa to the cavernous
sinus. Aneurysms arising from the junction of
the posterior communicating and internal carotid
arteries typically expand downward and
laterally, preferentially compressing the
pupillomotor fibers as the III nerve becomes
injured (producing pupil-involving third nerve
palsy). In contrast, the core of the III nerve receives
its blood supply via the vaso vasorum.
Accordingly, the peripherally located
pupillomotor fibers tend to be spared when the
core of the III nerve is injured by ischemia
(producing pupil-sparing third nerve palsy).
How reliable is the rule in clinical practice?
In regards to aneurysms, Kissel and colleagues12
reviewed the course of III nerve angiographically
in 51 patients with proven aneurysm at the
junction of the posterior communicating and the
internal carotid arteries. A similar study was
reported in a series of patients evaluated by a
single investigator. 15 The main clinically
relevant caveats to be derived from these studies
include:
None of the patients in either series has pupilsparing complete III nerve palsy; pupilsparing complete III nerve palsy is generally
not a sign of aneurysm. However, the
exceptional reports exit.
Kissel and coworkers12 observed that 14% of
the patients had pupil-sparing, but the
ophthalmoplegia was incomplete in all.
Therefore, pupil-sparing can be an important

sign of aneurysmal compression in patients
with incomplete ophthalmoplegia.
Complete third nerve palsy was observed in
5 of 7 patients with pupil-sparing, within
5 days. Therefore, always reevaluate those
patients with pupil-sparing incomplete III
nerve palsy within a week to identify pupil
involvement, a sign signifying aneurysm.
In Kissel and coworkers series 24% of patients
had partial involvement (i.e., relative pupilsparing III nerve palsy), the majority of whom
had incomplete ophthalmoplegia.
In the above series, 63% of patients had
complete pupillary involvement (i.e. pupilblown third nerve palsy) and the majority
(47%) of whom had complete III nerve palsy.
Indeed one does not have to see a pupil-blown
complete III nerve palsy to implicate
aneurysmal compression.
There are four important settings where a
patient with aneurysm and III cranial nerve palsy
may have a normal appearing pupil. If one does
not consider these traps, one may be at risk of
missing an aneurysm:
1. When external ophthalmoplegia is incomplete, it usually refers to a patient with all III
nerve innervated extra ocular muscles
affected, but not fully. Incomplete ophthalmoplegia may also refer to the situation where
not all of the extraocular muscles are affected.
2. When the inferior division of the third
nerve is spared. The oculomotor nerve travels
within the dural lateral wall of the cavernous
sinus where it bifurcates into a superior and
inferior division near the superior orbital
fissure. The superior division carries fibers
that innervate the superior rectus and levator
palpebrae, while the inferior division carries
fibers that innervate the inferior rectus, medial
rectus, inferior oblique, and iris sphincter
muscles. Intracavernous carotid or basilar tip
aneurysms not uncommonly preferentially

injure the superior division of the III cranial
nerve, producing ptosis and paresis of ocular
elevation, but no anisocoria.
3. When 3rd nerve palsy is combined with
Horner syndrome. Giant intracavernous
carotid artery aneurysms commonly injure
the oculomotor nerve and, less often, the oculosympathetic pathway. If III nerve palsy and
Horner syndrome occur in the same patient,
the size of the resulting pupil looks fairly
similar to the other pupil in room light. But,
observing the pupils with added light will
usually expose the paretic iris sphincter, the
affected pupil looks slightly larger than the
fellow pupil. In addition, the affected pupil
usually dilates so poorly that it appears
smaller than its fellow pupil if observed in
darkness.
4. When the injured third nerve has undergone
aberrant regeneration.16 In some cases of
chronic compression of the oculomotor nerve
by a giant aneurysm of the cavernous sinus,
regenerating fibers may become miss-wired,
a process called aberrant regeneration.
Fibers originally destined to innervate certain
extraocular muscles become re-routed into
pupillomotor fibers that innervate the iris
sphincter. The enhanced tone of the iris sphincter
that results from this process produces a pupil
that is smaller than normal, reacts poorly to light
but better to near, and dilates poorly in darkness.
The evaluation of a patient with III cranial
nerve palsy must proceed urgently because of
the threat of cerebral aneurysm, which may be
as frequent as 30% in some series of isolated
cases. As discussed, the relationship between
the degree of internal and external ophthalmoplegia is the best clinical predictor of whether
neurologically isolated and acute III cranial nerve
injury is due to compression or infarction. Except
in those patients with pupil sparing complete
III nerve palsy, neuroimaging, preferably using
MRI, is indicated to identify a mass lesion

compressing the oculomotor nerve (e.g. pituitary
apoplexy) or some other explanation for the
presentation (e.g. midbrain stroke). If the study
is unrevealing, one must then proceed emergently
to exclude aneurysm.
While catheter angiography remains the
gold standard for identifying aneurysm, it is
not without risk. The complication rate is higher
in certain patients in particular, those greater
than 70 years of age, as well as those with
symptomatic atherosclerotic cerebrovascular
disease, significant cardiovascular or renal
disease, or Ehlers-Danlos syndrome. Threedimensional magnetic resonance angiography
(MRA) is a tempting alternative to catheter
angiography. How sensitive is this screening
test for detecting aneurysms causing III cranial
nerve palsy? The answer depends, in part, on
considering the ability of MRA to detect
aneurysms of various sizes and the proportion
of aneurysms in each size class associated with
III nerve palsy. A recent metaanalysis disclosed
estimates regarding aneurysms at the junction
of the posterior communicating and internal
carotid arteries.17 With aneurysm size more than
or equal to 5 mm, the miss rate was 3% whereas
with sizes less than 5 mm, the miss rate exceeded
45%.
Because the sensitivity of aneurysmal
detection using MRA has become sufficiently
high, one may now substitute it for catheter
angiography in the diagnostic evaluation of
some, but not all, patients with III cranial nerve
palsy. However, it should be considered a
screening test to exclude aneurysm under certain
clinical circumstances, namely when the
likelihood of aneurysm is relatively high. The
use of MRA to detect aneurysm is subject to the
following two crucial caveats:
1. Most importantly, the skill of the interpreting
neuroradiologist must be first rate.
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454

2. Furthermore, the detection rate is dependent
upon review of all imaging data, including
source images, maximum intensity projections (the angiogram), multiplanar
reformatted images, and spin echo images.
If any shortcuts are taken, the failure rate
will increase.
Before ordering MRA to evaluate patients with
third nerve palsy, one must first discuss its
potential role with his/her radiologist. If there
is any doubt about the quality of the study or
its interpretation, stick with catheter angiography
as the definitive study to rule out aneurysm.
Lumbar puncture is generally not necessary
when evaluating patients with acute and
neurologically isolated III cranial nerve palsy.
In India, isolated third nerve palsy may be
an uncommon manifestation of CNS tuberculosis.
CSF study is often warranted if third nerve palsy
is preceded by systemic symptoms (fever,
headache, vomiting, etc.), associated with other
cranial nerve palsies (where imaging had been
negative or non-contributory) and in immunocompromised subjects.
The third cranial nerve palsy (with or without
pupillary involvement) is a prominent feature
of Tolosa-Hunt syndrome.
Tolosa-Hunt Syndrome and Painful

Ophthalmoplegia18
Almost any process causing ophthalmoplegia
can be painful, with the possible exceptions of
myasthenia gravis and chronic progressive
external ophthalmoplegia. The physician should
always be concerned about infection and tumor.
However, there are a group of patients who
present with painful, combined ophthalmoplegia
due to a granulomatous inflammatory process
that affects the carvernous sinus, extending
forward to the superior orbital fissure, and orbital
apex. Called the Tolosa-Hunt syndrome, it is
usually a disease of middle or later life that may

spontaneously remit and relapse. The presenting
complaints are steady, retro-orbital pain and
diplopia. The third, fourth, sixth or a combination
of ocular motor nerve may be affected. Visual
impairment occurs in some patients. There is
some overlap with orbital pseudotumor.
Sensation supplied by the ophthalmic and
maxillary trigeminal divisions may be impaired.
The pupil may be either constricted or dilated,
depending on whether the sympathetic or
parasympathetic innervation is involved,
respectively. Pathologic examination has shown
a low-grade, noncaseating, granulomatous,
inflammatory response in the cavernous sinus
encroaching on the carotid artery and nerves.
Diagnosis is by imaging, which demonstrates
soft-tissue infiltration in the cavernous sinus,
sometimes with extension into the orbit apex,
but without erosion of bone. The infiltrate is either
hypointense on T1-weighted images and
isointense on T2-weighted images; or
hyperintense on T1-weighted and intermediate
weighted images. Angiography may show
narrowing of the carotid siphon, occlusion of
the superior orbital vein, and non-visualization
of the cavernous sinus.
It has been suggested that the Tolosa-Hunt
syndrome is a variant of a larger syndrome of
recurrent multiple cranial neuropathies. There
is also an association with other forms of vasculitis, such as lupus or Wegeners granulomatosis.
Patients with the Tolosa-Hunt syndrome usually
respond promptly to corticosteroid treatment.
However, caution is required in attributing
diagnostic value to a positive response, since
tumors in the cavernous region may respond
similarly to steroids, or even resolve
spontaneously. Thus, serial MRIs to monitor such
patients are advisable.
The differential diagnosis of Tolosa-Hunt
syndrome includes orbital myositis that may

usually be distinguished by swelling and
erythema of the eyes. The combination of painful
palsies of the ocular motor nerves associated
with Horner syndrome is so-called Reader
paratrigeminal syndrome and usually reflects
coexistent involvement of the oculosympathetic
fibers in the cavernous sinus, usually due to
mass lesions. Ophthalmoplegic migraine is
reported to affect each of the ocular motor nerves.
Distinction may sometimes be difficult from
Tolosa-Hunt syndrome.
Years ago, Mathew and Chandy19 and then
Mathew20 described a similar syndrome which
they considered akin to the Tolosa-Hunt
syndrome and this accounted for nearly half of
all cases of acute ophthalmoplegia encountered
at Vellore, South India. CT or MRI was not
available at that time but catheter angiography
did demonstrate intercavernous carotid artery
narrowing in one case. Over the years, most
neurologists in India, must have encountered
many such angio-negative, steroid responsive
acute painful ophthalmoplegias (though not well
documented in literature) and given the diagnosis
of Tolosa-Hunt syndrome. With ready availability of MR-scan now, personal experience of
the author is that radiological evidence of
cavernous sinus-orbital fissure inflammatory
lesion can be detected in about half of such cases.
The nosology of the Indian variant, therefore,
remains a little uncertain and needs studying
a large series.
Optic Nerve Pathology

The commonest condition is optic neuritis and
in fact any lesion of optic nerve might cause
pupillary dilatation.
Pharmacologic Mydriasis
The final common entity accounting for an
isolated dilated pupil is pharmocologic
mydriasis. If high suspicion exists for the use

of mild dilating drops, 1% pilocarpine in the
affected eye confirms the diagnosis (Fig. 28.6).
Eyes exposed to parasympatholytic medications
do not respond to 1% pilocarpine. Sympathomimetics that commonly are used to facilitate
nasotracheal intubation or ophthalmologic
examination also cause mydriasis. In one study,
dilute pilocarpine (1/8%) was used to differentiate between pathologic and sympathomimetic
mydriasis; 1% pilocarpine overcomes sympathomimetic mydriasis. Inadvertent ocular exposure
to anticholinergic agents also has been reported.
Patients using scopolamine patches have been
noted to have self-limited mydriasis, which has
been dubbed as cruise ship anisocoria.
Miosis Increases in Dim Illumination

Horner Syndrome21-23
Hallmark features of Horner syndrome include:
(1) unilateral miosis, (ii) ptosis and (iii) anhidrosis.
It is the result of disruption of the sympathetic
innervation to the eye at any place along the
pathway. The affected eye has a delayed response
dilation lag to reduced illumination, as a result,
the anisocoria of Horner syndrome is greater
seconds after entering a dark environment than
it is after 15-30 seconds. In patients with an
unestablished diagnosis, instillation of 4-10%
cocaine solution is indicated. Cocaine inhibits
the reuptake of norepinephrine, causing more
norepinephrine to be available at the neuromuscular junction of the iris dilator muscle. One
should assess the pupils at baseline and at
40-60 minutes. In a positive test, the sympathetically impaired pupil fails to dilate, and the
degree of anisocoria increases. In some studies,
this test has been both sensitive and specific for
Horner syndrome (Fig. 28.7). The delineation of
the level of a lesion causing Horner syndrome
has proved more problematic. This becomes
455
456
Fig. 28.6: Pilocarpine (1%) test for right pharmacologic pupil
Fig. 28.7: Cocaine test for right Horner syndrome

important, as patients with postganglionic Horner
syndrome tend to have a very good prognosis,
while preganglionic lesions are often the hallmark of myelopathy or malignancy. The exception
is in patients with carotid dissection, which may
result in postganglionic Horner syndrome.
Fortunately, such lesions are associated with
acute neck pain or other neurologic deficits.
Therefore, in cases of painful Horner syndrome,
emergent evaluation of the anterior cerebral
circulation is indicated. In patients with Horner
syndrome without pain, a chest X-ray to exclude
a Pancoast tumor probably is indicated, but
further work-up may be pursued on an outpatient
basis. Horner syndrome also can occur in incipient
transtentorial herniation. Such patients typically
experience a rapid deterioration in brainstem
function and have a decreased level of
consciousness. Due to the proximity of the carotid
sheath, Horner syndrome may occur as a
complication of an inferior alveolar nerve block.
Causes of Horner syndrome are detailed in
Table 28.2.
Hydroxyamphetamine Test
Hydroxyamphetamine test is employed to
differentiate between a preganglionic and a postganglionic Horner syndrome. The importance
of such distinction has already been mentioned.
Hydroxyamphetamine enhances the release of
norepinephrine from the third order terminal.
If the postganglionic neuron is injured, the pupil
will not dilate or will dilate poorly. Cremer
et al23 found that a 1 mm increase in the amount
of anisocoria is associated with 85% probability
that the lesion is postganglionic. 2 mm increase
is associated with a probability of 99% that
postganglionic defect exists. However, the
hydoxyamphetamine test is not perfect. Cremet
et al23 found that anisocoria increased in 93%
of postganglionic cases. The anisocoria did not
change in 90% preganglionic cases. Therefore,
one has to assume an approximately 10% error
rate with this test. In case with non-availability
of hydroxyamphetamine, one may substitute with
adrenaline. Instillation of adrenaline (1:1000) in
a case of postganglionic Horner syndrome will
TABLE 28.2: COMMON CAUSES OF HORNER SYNDROME

Central
Preganglionic
Postganglionic
Dorsolateral medullary infarct (Wallenbergs syndrome)

Hypothalamic, thalamic, or mesencephalic infarct, hemorrhage, tumor or demyelination
Multiple system atrophy
Cervicothoracic spinal cord lesions
Cervicothoracic paraspinal mass (including neuroblastoma)
Cervical disk herniation
Apical lung cancer
Cervical sympathectomy
Neck injury during forceps delivery
Internal carotid artery dissection
Cervical adenopathy
Cervical tumors
Neck trauma
Neck injury during forceps delivery
Internal carotid artery dissection
Cervical adenopathy
Cervical tumors
Neck trauma
Otitis media
Cavernous sinus lesion
Cluster headache
457
458

cause pupillary dilatation due to the phenomenon
of denervation supersensitivity. This test has its
limitations.
Simple Anisocoria
Simple anisocoria may be found in approximately
20% of the general population and may vary
from day to day in the same individual. In most
patients, the degree of anisocoria is less than
1 mm, and not associated with ptosis, dilation
lag, or vasomotor dysfunction. In some patients,
simple anisocoria may be provoked by oral
medications (e.g. pseudoephedrine, selective
serotonin reuptake inhibitors). Installation of
4-10% cocaine solution causes dilation of both
eyes. Old photographs can provide evidence that
the anisocoria had been present for some time.
Simple anisocoria may be the result of a variety
of cholinergic antiglaucoma medications. A small
pupil may be the result of a chance exposure
to cholinergic agents. Suspect pharmacologic
miosis in an otherwise asymptomatic patient
who wears contact lenses and has experienced
acute onset of miosis. Implicated agents include
anticholinesterases (e.g. flea-collar anisocoria)
and inhaled anticholinergics (ipratropium
bromide). In such case, withdrawal of exposure
to the agent confirms the diagnosis.
Bilateral Constricted Pupils

The constricted pupil indicates lesion in the
various circuitous pathway taken by the
sympathetic supply to the dilator muscle. The
lesion may be in the hypothalamus, brainstem,
lateral aspect of the spinal cord, the sympathetic
chain, the cervical sympathetic ganglia, the
pericarotid plexus, or in the sympathetic fibers,
which run to the orbit by accompanying the
ophthalmic division of the trigeminal nerve. The
common causes for bilateral constricted pupils
include pontine hemorrhage, primary or

secondary tumors involving the cervical
sympathetic chain, vascular lesions of the carotid
artery or its sheath and toxins. Bilateral spontaneous miosis means almost invariably an upper
brainsteam lesion.
Argyll-Robertson Pupils
Argyll-Robertson pupils are classically associated with neurosyphilis. The exact location of the
pathologic lesion is hotly debated. Consensus
places the lesion in the dorsal midbrain interrupting fibers serving the light reflex with sparing
of the ventral accommodative pathways. Clinical
features include: (a) small pupils nonreactive to
light stimulation with an intact near response
(Fig. 28.8), (b) irregular pupils, (c) pupils that
dilate poorly in the dark and to mydriatic agents.
Similar pupillary findings may be seen in diabetic
patients. Other causes of light-near dissociation
are:
1. Dorsal midbrain syndrome: Besides light-near
dissociation these patients have other clinical
features like eyelid retraction, convergence,
retraction-nystagmus and decreased up gaze.
2. Severe bilateral visual loss of optic nerve or
retinal origin: These patients would have
dilated pupils nonreactive to light but nearconvergence reaction with pupillary constriction may be preserved by proprioceptive
input to the brain.
Bilateral Dilated Pupils

Differential diagnosis of the dilated pupil is
relatively small. Once angle-closure glaucoma
and a mechanically damaged sphincter pupillae
muscle are eliminated from the possible etiologies,
dysfunction of the parasympathetic nervous
system clearly remains the possibility. Such
pupils are dilated and show poor reactivity.
Fig. 28.8: Light and near response of Argyll-Robertson pupil
Dilated pupils are caused by the paralysis of

the parasympathetic fibers either at their origin
form the pretectal nuclei and the EdingerWestphal nucleus in the midbrain, during their
course with the oculomotor nerve or at the ciliary
ganglion in the orbit. The common causes of the
dilation include vascular accidents in the
midbrain, tentorial herniation or aneurysms of
the carotid artery.
Conclusion
Almost all pupillary conditions would be
diagnosed with the above approaches delineated.
Further work-up will depend on the specific
diagnosis and requires investigations like chest

X-ray, CT/MRI-scan of the head and cervical
spine. Episodic conditions may be difficult to
diagnose at first evaluation and requires repeated
evaluations to make a diagnosis.
The management of pupillary abnormalities
will depend upon the cause of asymmetry, which
may include the management of raised intracranial pressure and removal of irritative cause
local or distant.
References
1. Lowenfeld IE. The pupil: anatomy, physiology
and clinical application. Ames: Iowa State
University Press, 1993.
459
460

2. Burde RW, Savino PJ, Trobe JD. Clinical decision
in Neuro-Ophthalmology (2nd ed). St. Louis:
Mosby, 1998;221-45.
3. Kordon RH, Thompson HS. The pupil. In. Rosen
ES, Thompson HS, Cumming WJ, Eustace P.
Eds. Neuro-ophthalmolog. London, Mosby
1998;13.1-13.19.
4. Muller NR, Newtron NJ (Eds). In: Walsh and
Hoyts Clinical Neuro-ophthalmology. 5th ed.
Vol 1. Baltimore. William and Wilkins 1998; 8271042.
5. Thompson HS, Montague P, Cox TA, et al. The
relationship between visual acuity, pupillary
defects and visual field loss. Am J Ophthalmol
1982;93:681-86.
6. Johnson IN, Hill RA, Bartholomew MJ. Correlation of afferent pupillary defect with visual loss
on automated perimetry. Ophthalmology 1988;
95:1649-55.
7. Thompson HS, Corbett JJ. Spasms of the iris
sphincter. Ann Neurol 1980;8:547-49.
8. Adler FW, Scheie HG. The site of disturbance
in tonic pupils. Trans Am Ophthalmol Soc 1940;
38:183-88.
9. Chakravarty A, Mukherjee A, Roy D. Ross
syndrome a case documentation. Acta Neurol
Scand 2003;107:72.
10. Asbury AR, Alderedge H, Hersberg R, Fisher CM.
Oculomotor palsy in diabetes mellitus: a clinicopathological study. Brain 1970;93:555-56.
11. Breen LA, Hopf HC, Farns BK, Gutman L. Pupilsparing oculomotor palsy due to midbrain
infarction. Arch Neurol 1995;48:10-16.
12. Kissel JT, Burde RM, Kingele TG, et al. Pupil
sparing oculomotor palsies with internal carotid-
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
posterior communicating artery aneurysms.

Ann Neurol 1983;13:149-54.
Guy JR, Day AL. Intracranial aneurysms with
superior division paresis of the oculomotor
nerve. Ophthalmology 1989;96:1071-76.
Linskey ME, Sekhar LM, Hirsch W, et al.
Aneurysms of the intracavernous carotid artery:
clinical presentation, radiographic features and
pathogenesis. Neurosurg 1990;20:71-79.
Keane JR. Aneurysms and third nerve palsies.
Ann Neurol 1983;14:696-97.
Ford FR, Walsh FB, King A. Clinical observations
on the pupillary phenomenon resulting from
regeneration of the third nerve. Bull Johns
Hopkins Hosp 1941;68:309-18.
Jacobson DM, Trobe JD. The emerging role of
magnetic resonance angiography in the
management of patients with third cranial nerve
palsy. Am J Ophthalmol 1999,128:94-96.
Kline LB, Huyt WF. The Tolosa-Hunt syndrome.
J Neurol Neurosurg Psychiatry 2002,71:577-82.
Mathew NT, Chandy J. Painful ophthalmoplegia.
J Neurol Sci 1970;11:243-56.
Mathew NT. Painful ophthalmoloplegia. In
Tropical Neurology. Ed. Spiliane JD. London,
Oxford University Press, 1972;120-23.
Tompson HS. Diagnosing Horners syndrome.
Trans Am Acad Ophthalmol Otolaryngel 1977; 82:
840-48.
Malmey WF, Younge BR, Mayer NJ. Evaluation
of the causes and accuracy of pharmacological
localization in Horners syndrome. Am J
Ophthalmol 1980;90:394-420.
Cremer SA, Thompson HS, Digre KB, et al.
Hydroxyamphetamine mydriasis in normal
subjects. Am J Ophthalmol 1990;100:66-70.
Index
Index
A
A- and B-scan 240
A and V syndromes 369
Aberropia 69
Abnormal fluorescence angiography
190
blocked choroidal fluorescence 191
blocked retinal fluorescence 190
hyperfluorescence 194
hypofluorescence 190
Acanthamoeba 320, 321
Acanthamoeba cysts 322
Acanthamoeba keratitis 318
Accommodation 7, 442
Accommodative convergence 375,
378
Acquired deficiency of color vision 18
Acridine orange 323
Acute dacryocystitis 417
Acute posterior multifocal placoid
pigment epitheliopathy
212, 213
Adenoviral keratoconjunctivitis 328
Adie tonic pupil 446, 447
Adverse reactions to intravenous
fluorescein angiography 185
anaphylaxis 186
local tissue necrosis 186
nausea 185
pruritus 186
shock and syncope 186
vasovagal attacks 186
vomiting 185
Age-related macular degeneration
205, 254
CNVM 206
hemorrhagic PED 207
hot spot 206, 208
laser photocoagulation 207
photodynamic therapy 207
pigment epithelial detachment 206
polypoidal choroidal
vasculopathy 209
retinochoroidal anastomosis 207
transpupillary thermotherapy 207
Alternate cover test 374
Amblyopia 171, 374, 387, 403

classification 387
contrast sensitivity 389
crowding phenomenon 388
diagnosis 388
disparometer 393
distance stereopsis tests 391
fixation disparity 392
fixation disparity curves 392
Frisby stereotest 390, 391
Lang stereotest 390
Lang two pencil test 392
normal stereoacuity 391
preferential looking tests 389
random-dot E stereotest 390
random-dot stereograms 389
special 3-D pictures 390
stereoacuity tests 389
stereopsis 389
Teller acuity 388
Titmus Fly stereotest 389
TNO test 391
Wesson card 393
Wesson fixation disparity card 394
American optical company plates
25
A-mode (Amplitude modulation) 217
A-mode ultrasonography 272
Amplitude modulation scan 240
Andersons criteria 142, 146
Aneurysmal damage to oculomotor
nerve 451
Aneurysms 397, 451-453
Angle kappa 372
Angle-closure glaucoma 113, 458
Anisocoria 443, 445, 446
Anomalies of color vision 16
acquired 16
congenital 16
Anomaloscope
Nagel 28
Pickford-Nicolson 29
Anterior chamber estimation
method 39
Anterior chamber paracentesis 337
Anterior chamber tap 336
Anterior ischemic optic neuropathy
124, 125, 306, 310
Anterior segment evaluation

immersion technique 220
Anterior segment photography 179
Anteroior chamber paracentesis 337
Antibiotic susceptibility 325
Antimicrobial susceptibility 321
Antineutrophil cytoplasmic antibody
436
Applications of indocyanine green
angiography 205
Aqueous tear deficiency 405
Arden index 282
Argyll-Robertson pupils 446, 458,459
Arrangement tests 25
Edridge-Green Lantern test 30
Farnsworth D-15 test 27
Farnsworth Lantern test
(Falant) 29
Farnsworth-Munsell 100-hue
test 25
Holmes-Wright Lantern 29
Lantern tests 29
Lanthony desaturated D-15 test 27
A-scan ultrasonography 216, 240,
428
A-scan versus B-scan 237
Asteroid hyalosis 242, 243
Asymmetry of optic disk cupping
118
Atrophic bulbi 256
Atypical retinal pigmentary
dystrophies 296
Audiometry 349
Automated perimetry 115
Automated perimetry fixation 136
Autonomic nervous systems 441
A-V patterns 377
B
Bacterial colonies 320
Bacterial keratitis 317
Bagolinis striated glasses
Basic perimetry 128
Bebies curve 140, 145
Behets syndrome 350
370
461
462

Bells phenomenon 400, 404, 442
Bests vitelliform macular dystrophy
282
Bilateral superior oblique palsy
397
Biometry in ocular pathologies 233
congenital glaucoma 233
myopia 234
nanophthalmos 234
tumor height 234
Biopsy 339, 436
Black and white films 174
Blepharitis 405, 418, 419
Blood vessels 113
Blow-out fracture 403, 404
B-mode (Brightness modulation) 218
Botulinum toxin 399
Bracketing (staircase technique)
130, 131
Brightness 12
Brightness modulation scan 240
Browns syndrome 395, 402, 403
B-scan ultrasonography 239, 240,
259, 428
B-wave amplitude 289
C
Calcium alginate swab 317
Calcofluor white 319, 322, 323
Calibration Goldmann applanation
tonometer 104
Camera
35 mm 165
35 mm SLR 173
CCD 201
Canaliculi 413, 419
Carrier stage detection 305
Catheter angiography 453, 454
Causes of Horner syndrome 457
Cavernous hemangioma 432, 438
C/D ratio 162
Central areolar atrophy 312
Central scotoma 7
Central serous chorioretinopathy
210, 211
Central serous retinopathy 185, 197
Chloroquine 93, 304
Choroidal and retinochoroidal
biopsy 340
Choroidal coloboma 255
Choroidal detachment 250, 365
Choroidal hemangioma 253
Choroidal inflammatory conditions 212
Choroidal melanomas 282
Choroidal neovascular membrane

185, 203, 206, 214
Choroidal pigment 179
Choroidal thickening 249
Choroidal tumors 213
choroidal hemangiomas 213
choroidal metastasis 213
Choroideremia 282
Ciliary block glaucoma 264
Ciliary body tumor 267
Clinical uses of EOG 282
Clinical uses of visual electrophysiological tests 295
Closed circuit TV 136
Closed-angle glaucoma 445
CNVM 203, 214
Cocaine 455
Cocaine test 456
Collection of samples 316, 326
Color blindness 12
Color coded cells 15
Color constancy 13
Color contrast simultaneous 13
Color contrast successive 13
Color Doppler imaging 429, 430
Color performance 31.
Color photography 184
Color triangle 14
Color vision
12
Color vision testing 19, 348
City University test 20
color confusion tests 19
color matching tests 20
Edridge-Green Lantern 21
FALANT 21
Farnsworth-Munsell
dichotomous-15 test 20
FM-100 test 20, 21
Hardy-Rand-Rittler plates 23
Ishihara pseudoisochromatic
plates 20
Lantern tests 21
Nagel anomaloscope test 21
pseudo-isochromatic plates 19
Comitant strabismus 369
Complete third nerve palsy 450
Compression gonioscopy 112
Computed tomography 431
Condensing lens 154
Cone dystrophies 300
Cones 15
Condensing lens 20D 153
Confocal microscopy 84, 85
Congenital color vision deficiency 16
anomalous trichromats 17
blue deficient 17
dichromats 17
green deficient 17
monochromats 17
red deficient 17
X-linked 16
Congenital fibrosis 395
Congenital fibrosis of extraocular
muscles 403
Congenital glaucomas 110
Congenital optic disk pit 124
Congenital ptosis 401
Congenital stationary night
blindness 282
Conjunctival and lacrimal gland
biopsy 344
Conjunctival impression cytology 410
Constricted pupil 458
Contact lenses 115, 152, 93
Contact lenses for gonioscopy 107
Barkan 107
Goldmann 107
Koeppe 107
Layden 107
Sussman 107
Swan-Jacob 107
Thorpe 107
Zeiss and Posner 107
Contact tonometers 96
applanation 96
indentation 96
Contrast sensitivity 9
Contrast-enhanced MRI 433
Convergence 442
Convergent strabismus 369
Core biopsy 437
Corneal aberrometry 63
astigmatism 65
coma 65
high order aberrations 65
low order aberrations 65
measuring corneal wavefront
aberration 64
measuring total wavefront
aberration 63
optical and image quality 66
ray tracing system 64
Shack-Hartmann method 63
spatially resolved refractometer 64
trefoil 65
Tscherning technique 63
wavefront maps 65
Zernike polynomials 64
Zernike terms 65
Corneal astigmatism 50
Corneal biopsy 317, 318
Corneal dystrophies 89
Fuchs endothelial dystrophy 89
granular dystrophy 89
Index
posterior polymorphous
dystrophy 89
Corneal grafts 91
Corneal reflection tests 378
double Maddox rod test 380
grading oblique overactions 381
Hess chart 380
Hess screen 379
Hirschbergs test 378
Krimsky test 378
Lees chart 380
Lees screen 379
Maddox tangent scale 379
measurement of cyclodeviations
380
synoptophore 378
Corneal samples 317
Corneal scraping collection 318
Corneal scrapings 317, 322
Corneal topography 46, 52
absolute scale 55
artificial intelligence programs 62
average corneal power 62
axial map 56
color-coded scales 54
corneal eccentricity index 62
corneal indexes 60
corneal maps 56
difference map 56
diffuse reflection techniques 52
elevation map 56
interferometric method-based
systems 52
irregularity map 59
Moire deflectometry-based
systems 52
normalized scale 55
placido disk system 52
Placidos rings 47
raw photokeratoscope image 53
refractive map 56
relative map 56
simulated keratometry reading 61
specular reflection techniques 52
surface asymmetry index 62
surface regularity index 62
tangential curvature map 56
techniques using scattered lightslit-based systems 52
videokeratoscopy 47
Corneal ulceration 405
Corneal wetting time 406
Corrected comparison 140
Corrected pattern standard
deviation 137
Cover test 372
Cover-uncover test 372, 374
Cryotherapy for retinopathy of

prematurity 358
Crystalline lens 12
CT-scan 349, 404, 428, 432,
435, 436
Culture media 320
Culture methods 319
Cultures 324
Cup-disk ratio 116, 126
Cyclovertical muscle palsy 397
Cysticercosis 249, 403, 426, 430
Cytology 438
Cytopathic effect 329
D
Dacryocystography 423
chemiluminescence test 424
CT dacryocystography 423
CT scan 424, 428
dacryoscintigraphy 424
dacryoscopy 424
MRI dacryocystography 423
standardized echography 424
thermography 424
Dark adaptation 281
Dark trough 281
Diabetic III nerve palsy 450
Diabetic maculopathy 189
Diabetic retinopathy 18,212
Diagnosis of uveitis 333
angiotensin converting enzyme
334
antineutrophil cytoplasmic
antibody test 334
antinuclear antibody 333
basic investigations 333
fluorescent treponemal antibody
absorption test 334
human leucocyte antigens 334
rheumatoid factor 333
serological tests 333
serological tests for syphilis 334
venereal disease research
laboratory test 334
Wegeners granulomatosis 334
Diagnostic biopsies 335
Diagnostic vitrectomy 338
Differential blood counts 436
Diffuse lamellar keratitis 91
Digital subtraction ICGA 214
Digital angiography 183
Digital camera 370
Digital imaging 181
Digital stereo imaging 214
Dilated pupil 447, 458

Diplopia 396, 400
Diplopia testing 379
Direct ophthalmoscope 115, 161, 370
Direct ophthalmoscopy 151, 160
Direct smear examination 318, 326
Disciform macular scar 254, 255
Disk-diffusion tests 321
Dislocated lens 251
Dissociated vertical deviations 376
Divergent strabismus 369
Double elevator palsy 403
Double Maddox rod set 370, 396
Double opponent color cells 15
Draeger applanation tonometer 103
Drug or metal toxicity 280
Drugs causing color deficiency 19
Dry eye
405
Dry eyes syndrome 405
Duanes retraction syndrome 395,
400, 401, 403
E
Ectropion 418
Edinger-Westphal complex 441
Edinger-Westphal nucleus 459
Electrode placement 286
Electrooculogram 279, 280
clinical uses 282
limitations 282
Electrophysiological tests 279
Electroretinogram 279, 283
ELISA test 328, 410, 436
Emmetropic eye 151
Endonasal dye test 423
Endophthalmitis 244, 245, 249
Endothelium corneal 87
Enophthalmos 404
Entropion 418
EOG recording procedure 281
Epicanthus 372
Epiphora 412, 415
Episcleritis 268
Episodic anisocoria 445
Epithelium corneal 86
ERG 305
ERG amplitudes and latency 289
ERG response 287
Esotropia 369
ETDRS chart 3, 11
Evaluation of the retina 244
Evaluation of the vitreous 242
Evaluation of traumatized eye 250
Evaporative DE 405
463
464

Examination of eye in nine gaze
positions 377
Examination of nasal cavity 423
Examination of pupil 442
Examination of the sensory status 382
ambylopia 383
binocularity 382, 383
diplopia 382, 383
stereopsis 383
suppression 382, 383
Excisional biopsy 437
Exophthalmometry 427
Exotropia 369, 371
External ophthalmoplegia 450
External photography 173
Exudative retinal detachment 247, 248
Eyelid laxity 417
F
Fabrys disease 93
Failure of filtering surgery 265
False negatives 136, 138
False positives 136, 138, 143
Fast oscillations of EOG 282
Fine needle aspiration cytology
(FNAC) 436
Fine-needle aspiration biopsy 341
corneolimbal-zonular approach
342
limbal approach 341
pars plana approach 341
subretinal approach 342
Fixation target positions 377
Flash stimulus characteristics 286
Flicker cone response 30Hz 289
Fluorescein angiogram phases 187
arteriovenous phase 188
prearterial phase 187
recirculation phase 189
transit phase 189
venous phase 188
Fluorescein angiography 177, 181, 200
arterial and venous phase 178
film type and development 177
late phase 178
mid-phase 178
preinjection or control
photograph 178
principle 177
procedure 184
Fluorescein dye test 416, 422
Fluorescein stain 407
FNAC 437
Focal ERG 283
Focal macular ERG 312
Force duction test 400, 404

Foreign body 43
Fourth cranial nerve palsy 397
Foveal threshold 136
Full-field flash ERG 283
Functional epiphora 416
Fundus camera 166, 182
digital hand-held fundus camera
167, 168
hand-held Kowa genesis
camera 167
mydriatic fundus camera 165
non-mydriatic fundus camera
166
photo slit-lamp 167
portable slit-lamp with video
camera 168
Fundus drawing sheet 154
Fundus drawing: color code 156
color code black
157
color code blue 156
color code brown 156
color code green 156
color code red 156
color code yellow 157
cross lines 156
interrupted lines 156
solid 156
Fundus fluorescein angiography
165, 181,345
Fungal hyphae 322
Future applications of indocyanine
green angiography 214
G
Ganglion cells 280
Ganzfeld bowl 283, 287
Gaze monitoring 134
Genetics of congenital color
deficiencies 18
Giant retinal break 247
Giemsa stain 323, 326
Giemsa-stained smears 324
Glaucoma 263
Glaucoma hemifield test 134,
137, 138, 141, 143
Glioma 432
Global indices 134, 137
Goblet cells 410
Goldenhar syndrome 401
Goldmann contact lens 117
Gonioscopic landmarks 109
Gonioscopic lenses 168
Gonioscopy 106, 108, 151

Grading of anterior chamber angle
38, 111
Shaffers grade
111
Spaeths system 111
Gram stain 323
Gram-stained smears 322
Graves disease 436
Graves ophthalmopathy 431
Gray scale 137, 138
H
Haidinger brushes 13, 378
Haidinger brushes and after
images 370
Hand-held Goldmann-type
tonometers 100
Draeger tonometer 100
Mackay-Marg tonometer 100
Maklakov applanation tonometer
101
Perkins tonometer 100
tonopen 101
Handling of biopsy material 342
Harlequin syndrome 448
Head posture 370
Head tilt 370
Head tracking 134
Heijl-Krakau method 136
Hemosiderosis 93
Herings opponent color theory 16
Herpes simplex virus 326
Herpetic epithelial keratitis 329
Hertels exophthalmometer 427
Hess chart 370, 404
Histochemistry 439
Histopathology 438
HLA association with uveitis 335
Holmes-Adie syndrome 448
Homonymous hemianopia 370
Horner syndrome 453, 455, 446, 457
HRT print out 118
Hruby lens direct ophthalmoscopy 162
HSV keratitis 328
HSV type 1 and 2 330
Hue saturation 13
Humphrey field analysis 132, 133
Humphrey single field printout
134, 135
Hydatid cyst 426, 430, 438, 439
Hydoxyamphetamine test 457
Hydroxychloroquine 304
Hypercomplex cells 16
Hyperfluorescence 194
autofluorescence 194
Index
pigment epithelial window defect
195
pre-injection fluorescence 194
pseudofluorescence 194
Hyperlipidemia 93
Hypertelorism 372
Hypotropia 399
I
Identification of fungal species 321
Idiopathic orbital inflammatory
disease 429
III cranial nerve palsy 453
IMAGE-net digital imaging system 183
Imaging system 169
Imaging techniques 427
Immersion B-scan 257
Immunofluorescence assay 327
Immunoglobulins 410
Immunohistochemistry 343, 439
Incisional biopsy 437
Incomitant strabismus 395
Indications of diagnostic
paracentesis 336
amyloidosis 336
Behets disease 336, 337
endophthalmitis 336
hemorrhagic glaucoma 336
leukemia 336
malignant melanoma 336
persistent hyperplastic primary
vitreous 336
phacolytic glaucoma 336
retinoblastoma 336
sarcoidosis 336
toxocara canis 336
toxoplasma gondii 336
Indications for diagnostic biopsies 335
Indications for electroretinography 296
Indications for vitreous tap 337
amyloidosis 337
asteroid hyalosis 337
Behets disease 337
CMV retinitis 337
endophthalmitis 337
reticulum cell sarcoma 337
retinoblastoma 337
sympathetic ophthalmia 337
Indications of A-scan 222
anterior chamber depth 222
asteroid hyalosis 223
biometry 222, 231
choroidal detachment 230
choroidal hemangioma 226
choroidal hemorrhage 226
choroidal melanoma 226

choroidal thickening 230
congenital glaucoma 222
corneal thickness 222
dislocated lens in vitreous 231
endophthalmitis 224
foreign body localization 230
intraocular tumors 226
measurement of the axial
length 222
metastatic carcinoma 226
ocular trauma 230
phthisis bulbi 231
posterior vitreous detachment 224
preretinal foreign bodies 230
retinal detachment 224, 231
retinoblastoma 227
retinoschisis 226
vitreous floaters 223
vitreous hemorrhage 224
Indirect immunofluorescence 328
Indirect immunoperoxidase 328
Indirect ophthalmoscope 153, 154, 370
Indirect ophthalmoscopy 151, 158, 181
head mounted indirect 152
modified monocular indirect 152
monocular indirect 152
penlight ophthalmoscopy 152
slit-lamp indirect 152
Indirect ophthalmoscopy in
operating room 157
Indocyanine green 214
Indocyanine green angiography
165, 200, 345
advantages 203
adverse reactions 201
limitations 203
procedure 202
Infectious keratitis 280
Infectious keratitis: diagnostic
procedures 316
Infrathreshold 130
Inner retinal dysfunction 300
Instant type film 174
Intermediate uveitis 348
Intermittent exotropia 375
International Society for Clinical
Electrophysiology of
Vision 280, 314
Interpretation of A-scan 222
Interpupillary distance 371, 377
Intervention for ROP 358
cryotherapy 358
laser ablation 359
parental counseling 360
scleral buckling 359
surgical intervention 359
vitrectomy 359
Intracorneal deposits 93
Intranuclear intracytoplasmic
inclusions 326
Intraocular foreign body 243, 251, 362
binocular indirect
ophthalmoscopy with
scleral indentation 363
corneal wound 363
foreign body in the angle 363
gonioscopy 363
initial fundus examination 363
intralenticular foreign body 363
intraretinal hemorrhage 364
iris hole 363
lens opacity 363
metallic 362
non-metallic 362
siderosis bulbi 363, 364
signs of double perforation 364
slit-lamp examination 362
vitreous hemorrhage 364
vitreous track 364
Intraocular lenses 263
Intraocular tumors 252
Iris and ciliary body biopsy 339
Iris cyst 267
Iris fluorescein angiography 198
Iris melanomas 266
Iris neovascularization 198
Iris nevi 266
Iris thickness 262
Iris-ciliary process distance 262
Iris-lens angle 262
Iris-zonule distance 262
Ischemic III cranial nerve palsy 450
Ischemic vascular retinal disorders 301
Ishihara pseudo-isochromatic
plates 22
ISNT rule 118
Isolated rod response 287
Isolated third cranial nerve palsy 449
J
Jaeger notation 3
Jaegers charts 3
Jones tests 422
Jones tests I 422
Jones tests II 422
K
Keratitis 326
Keratoconjunctivitis sicca
407
465
466

Keratoconus 88
Keratometer 46, 47
Keratometry 62
Keratoplasty 261
Kinetic echography 222
Kinyoun method 324
Knapps transposition 400
Kllners rule 16
Kowa genesis with slit-lamp
attachment 168
KOWA VK-2 system 170
Krukenbergs spindle 40
L
Lacrimal excretory apparatus
412
Lacrimal gland 412
Lacrimal sac 413
Lacrimal sac swelling 416
Lacrimation 415
Lactoferrin assays 410
Lactophenol cotton blue 323
Laser in situ keratomileusis 90
LASIK surgery 91, 157
Latex agglutination 328
Leak 195
choroidal leak 197
disk edema 196
retinal leak 196
vitreous leak 196
Leakage of fluorescein 189
Lebers congenital amaurosis 305
Lebers hereditary optic neuropathy
307
Lees screen 370
Lens rim artifact 146
Letter E 6
Leukemic infiltration of iris 266
Light adaptation 281
Light and electron microscopy 343
Light peak 281
Light source 153
Light-induced rise of the resting
potential 281
Light-near dissociation 445
Limbal dermoid 262
Limitations of ERG 290
Listers perimeter 377
Loss variance 140
Low speed angiography 201, 204
Low-coherence interforometry 269
Lumbar puncture 349, 454
Luminescence 181
Lymph node biopsy 345
Lymphangioma 431
Lysozyme assays 410
M
Mackay-Marg tonometer 103
Macula 7
Macular edema 347, 348
Macular photoreceptor function 280
Magnetic resonance angiography
(MRA) 434, 435, 453
Magnetic resonance imaging 433
Magnification 34
continuous zoom 34
flip type 34
Malignant lacrimal gland tumor 432
Malingering 308
Mantoux test 349
Marcus Gunn jaw-winking
Maximal combined response 288
Maxwell spot 13
Mean defect 140
Mean sensitivity 140
Measurement of ocular deviation 375
Measurement of vergences 381
convergence sustenance 382
horizontal vergences 381
near point of convergence 382
torsional vergences 381
vertical vergences 381
Medial canthal tendon laxity 417
Meibomian gland dysfunction 405
Melanoma 252
Metastatic choroidal carcinoma 253
Methods for localization of IOFB 364
Berman and Roper-Hall
localizers 364
Bromleys method 366
combined B- and vector A-scan
364
computerized tomographic scan
367
Dixons method 366
Mac Kenzies method 366
magnetic resonance imaging 367
Mc Rigors method 366
plain X-ray 365, 366
radio opaque markers 366
Sweets method 366
ultrasonography 364
ultrasound biomicroscopy 365
use of contrast material 366
use of limbal ring 366
Microbial keratitis 316
Microbiological cultures 343
Microbiology 339
Mild pilocarpine test 448
Minimal inhibitory concentrations 321
Minimum angle of resolution 2
Minimum criteria for the diagnosis
of glaucoma 141
Miosis 442, 455
Mbius syndrome 395, 400
Modified monocular indirect
ophthalmoscopy 159
Molecular microbiology 322
Monochromatic fundus photography
179
Monocular elevation deficiency 399
Monocular indirect ophthalmoscopy
158, 159
Morning glory syndrome 124, 401
MRA 454
MRI 349, 428, 434, 435, 436, 453
Mucosal biopsy 344
Multifocal ERG 283, 308, 311
Multifocal VEP 308
Multinucleated giant cells 326, 327
Multiple evanescent white dot
syndrome 212
Multiple pinholes 7
Myasthenia gravis 396
Mydriasis 397
Myopia 214
Myopic disk 123
N
Nasalization of the vessels 121
Nasolacrimal duct 414
Near blindness 10
Near vision chart 5
Necrotizing scleritis 268
Negative a-wave 288
Negative ERG 300
Nerve fiber layer 179
Nerve supply 412
Neurological disorders of pupil
441
Neuroretinal notch 120
Neuroretinal rim 118, 121, 123
Neuroretinal rim notch 119
Nikor Medikor lens 173
Nodular scleritis 267
Noncom robo 170
Noncontact lenses 115, 116, 152
Noncontact tonometer 96
Non-invasive break-up time 406
Nonisolated third cranial nerve
palsy 449
Index
Non-viral keratitis : bacterial,
fungal and acanthamoeba
316, 319, 322
Normal cornea 85
Normal cornea, shape 48
Normal fundus fluorescein
angiography 187
Normal globe 242
Normal macula 270
Nystagmus 370
O
Occluder 7, 370
Occult choroidal neovascular
membranes 200
OCT in macular diseases 270
central serous chorioretinopathy
275, 276
diabetic macular edema 273
diabetic retinopathy with cystoid
macular edema 274
diabetic retinopathy with serous
retinal detachment 274
foveal retinal detachment 273
high myopic eyes 272
juvenile retinoschisis 277
macular hole 270
normal macula 271
posterior staphyloma 272
preretinal macular fibrosis 272, 273
retinoschisis 273
rhegmatogenous retinal
detachment 276
vitelliform macular dystrophy 277
Octopus 139
Octopus field analyzer 132
Octopus single field printout 138
Ocular albinism 305, 307
Ocular anatomy on ultrasound
biomicroscopy 261
Ocular deviation 371
Ocular ischemic syndrome 302
Ocular microbiology 316
Ocular movements 171
Ocular trauma 266
Oculomotor palsy 446
Open-angle glaucoma 123, 133
Ophthalmic imaging systems 170
Ophthalmic photography 165
Ophthalmoplegia 396, 452
Ophthalmoplegic migraine 455
Ophthalmoscopy 151
Opponent color cells 15
Optic chiasm 444
Optic coherence tomography 269

Optic disk cupping 142
Optic disk evaluation in glaucoma 115
Optic nerve 7, 444
Optic nerve avulsion 252
Optic nerve demyelination 306
Optic nerve drusen 255
Optic nerve head coloboma 124, 257
Optic nerve head drusen 256
Optic nerve hypoplasia 404
Optic tract 444
Optical coherence tomography
115, 269, 346
Optical principles 106
Optical system of fundus camera 174
Optico kinetic nystagmus drum 370
Optics 84
Optics of slit-lamp 34
clinical procedure 35
Haag-Streit type illumination 34
illumination system 34
observation system 34
Zeiss type illumination system 34
Orbicularis oculi 414
Orbital arteriography 435
Orbital blow-out fractures 395
Orbital venography 435
Oropharynx dye appearance test 423
Oscillatory potentials 288
Overlay technique 214
P
Painful ophthalmoplegias 455
Pair of scleral depressors 153
Papanicolaou stain 326, 327, 330, 331
Papilledema 306
Parallelopiped 39, 40, 41, 43, 110
Paralytic strabismus 395
Pattern deviation plot 137
Pattern electroretinogram 280, 283,
290
clinical uses 292
evaluation of macular function 292
ganglion cell dysfunction 292
Pattern standard deviation 137
PCR technique 329
Pediatric ERG recording 290
Pediatric visual assessment 280
Pediatric visual impairment 305
Penlight ophthalmoscopy 160
Perimeter 370
Perimetry 128, 151
Peripapillary atrophy 121, 122
Peripheral anterior synechia 112
Peripheral choroidal tumors 267

Peripheral iridoplasty 264
Perkins applanation tonometer 103
Pharmacologic miosis 458
Pharmacologic mydriasis 455
Pharmacologically dilated pupils 446
Phases of ICGA 204
arteriovenous phases 204
between 2 and 5 seconds 204
between 5 seconds and
several minutes 204
beyond several minutes 204
early phase 204
first 2 seconds 204
late phase 205
middle phase 205
prearterial and arterial phases 204
Photography in operation theatre 168
Photography of face 172
Photography of pupil 172
Photoreceptor dysfunction 295
Phthisis bulbi 254, 255
Physics of ultrasound 217
Physiological cupping 123
Pigmentary glaucoma 265
Pigmentation 113
Pilocarpine (1%) test 456
Pilocarpine 455
Pinch test 417
Pinhole 7
Pitfalls of A-scan 234
artifacts 235
cataract 236
errors in the axial length
measurement by
biometry 235
intraocular foreign bodies 235
low reflective spike 235
methylcellulose 236
misalignment 236
multiple reflection artifacts 234
posterior staphyloma 236
refractive errors 236
tumors 235
vitreoretinal diseases 235
Pituitary tumor 125
Plateau iris syndrome 263
Pneumatic tonometer 103
Poland anomaly 400
Polaroid or Fuji film 174
Polymerase chain reaction 322, 325,
339, 343
Poor vision in infants 280
Positive b-wave 288
Posterior globe rupture 252
Posterior staphyloma 255, 272
467
468

Posterior vitreous detachment 243,
365
Potassium hydroxide 323
Pretectal nucleus 444
Prethreshold ROP 359
Primary angle-closure glaucoma 263
Principles of ophthalmoscopy 151
Prism bar 370
Prism bar cover test 375
Probing 416, 421
Procedures in uveitis 333
Proliferating vitreous membrane 246
Proliferative diabetic retinopathy 243
Proliferative vitreoretinopathy 245
Properties of sodium fluorescein 182
Proptosis 426
Pseudoepiphora 416
Pseudofluorescence 202
Pseudoptosis 400
Pseudostrabismus 372
Pseudotumor 434
Pterygium 43, 418
Ptosis 396, 401
Pulzone-Hardy rule 371
Puncta 412, 416, 417, 418
Pupil: Neurological disorders 7, 281,
441
Pupillary abnormalities 445
Pupillary light reflex 441
Q
Quantitative echography
Quinine 304
221
R
Radio immunoassay 328
Radiological studies 349
Radionucleotide studies 349
RAPD 443
Reader paratrigeminal syndrome 455
Reading charts 11
Record visual acuity 2
Recording electrode 284
Burian-Allen 284
contact lens 5
gold foil 285
ground 286
LVP-Zari 285
reference 285
Red and green goggles 370
Red-free photography 179
Reference values for corneal
aberrations 68
Reflection 239
Refraction 239
Refractive surgery 74, 93, 263
postastigmatic keratotomy 75
postintrastromal corneal rings
implantation 77
postkeratoplasty 79
postlaser in situ keratomileusis 77
postlaser thermal keratoplasty 77
postphotorefractive keratotomy 75
radial keratotomy 74
Relative afferent pupillary defect 443
Relative pupil block glaucoma 263
Reliability factors 138
Reliability indices 134
Reproducibility 134, 138
Retcam 358
Retinal correspondence 377, 386
after image test 387
anomalous retinal
correspondence 386
Bagolinis striated glasses 386
diagnosis of ARC 386
harmonious ARC 386
normal retinal correspondence 386
unharmonious ARC 386
Worth four dot test 387
Retinal detachment 224, 231,
243, 244, 246, 348
Retinal fundus cameras 181
Retinal nerve fiber layer
abnormalities 122
diffuse areas 122
slit-like defects 122
wedge-shaped 123
Retinal photoreceptors 280
Retinal pigment epithelium 280
Retinal tear 246
Retinitis pigmentosa 282, 295
Retinoblastoma 253
Retinochoroidal anastomosis 207
Retinopathy of prematurity 353
arrested vasculogenesis 353
classification 353
early treatment 353
etiology 353
international classification 354
stage 1: dermarcation line 354
stage 2: dermarcation ridge 354
stage 3: extraretinal fibrovascular proliferation 354
stage 4: partial retinal
detachment 354
stage 5: total retinal
detachment 354
management 353
multicenter trial of cryotherapy 353
pathogenesis 353
plus disease 355
prethreshold 355, 356
risk factors 353
birth weight 353
multiple birth 353
respiratory distress
syndrome 353
young gestational age 353
Rush disease 355
screening 353, 357
screening procedure 357
threshold 355, 356
zones 353
zone-I 354
zones II and III 354
Retinoschisis 247, 273
Retroillumination 44
Rhegmatogenous retinal
detachment 157
Ring scotoma 146
Rod monochromatism 305, 309
Rod-photoreceptor disorders 282
Rose Bengal stain 407, 408
Ross syndrome 448
Royal air force binocular gauge 382
S
Sampaolesi line 110
Scanning electron microscopy 440
Scanning laser ophthalmoscope 202
Scattering 239
Schitz tonometer 95, 102
Schirmer I test 406, 419
Schirmer II test 407, 420
Schirmers strip 408
Schirmers test 408, 419
Schirmers test with nasal
stimulation 407
Scleral depression 154, 157
Scleral staphyloma 268
Scotoma suppression 385
Sensors 136
Serum angiotensin converting
enzyme 436
Serum autoantibodies 410
Seven in one printout 138, 139
Seven in one single field printout 145
Shell vial technique 329
Short term fluctuation 137, 140
Simple anisocoria 458
Single-flash cone response 289
Sixth cranial nerve palsy 398, 399
Sjgrens syndrome 410
Index
Slit-lamp
33, 259, 317,
Slit-lamp attachments 44
digital camera 44
Goldmann tonometer 44
gonioscope 44
Hruby lens 44
pachymeter 44
Slit-lamp biomicroscopy 151, 181, 270
Slit-lamp examination 33, 36, 418
Smears 322
Snap back test 417
Snellen chart 2, 3, 370, 388
Specialized types of ERG 284
Specular microscopy 169
Specular photography 169
Spielmann occluder 370
Spielmann translucent occluder 373
Splinter hemorrhages 121
Split limbal technique 38
Stargardts macular dystrophy
305, 313
Statistical analysis 134
Statpac program 134
Stereophotography 185
Sterilization of different tonometers
102, 104
Steriopsis 33
Stevens-Johnson syndrome 410
Strabismus 365,369, 395
Stroma 87
Subepithelial nerve plexus 86
Superior oblique palsy 397
Suprathreshold 130
Suprathreshold screening 132
Swedish interactive thresholding
algorithm (SITA) 132
Swinging-light pupil test 443, 445
Sympathetic pathway 442
Sympathomimetic mydriasis 455
Synoptophore 370, 371, 377,
384, 387
Syringing 416, 420
T
Table-top retinal cameras 174
Taste test 422
Tear deficient DE 405
Tear ferning 410
Tear film break-up time 406
Tear film osmolarity 410
Tear secretion 415
Techniques of slit-lamp
examination 36
broad beam 39
conical beam 39
diffuse illumination 36
direct 36
direct focal illumination 37
indirect illumination 40
narrow beam 37
oscillatory illumination 43
retroillumination 41
sclerotic scatter 42
specular reflection 42
tangential illumination 43
Telecanthus 372
Teleophthalmology 170
Teller acuity cards 370
Temporal hemianopia 125, 147
Tendency oriented perimetry 133
Test programs 133
Humphrey 10-2, 30-2, 24-2
133
macular grid program 133
macular program M2X 133
octopus G1X, G2 133
Testing strategy 132
Tests for suppression 383
after image test 384, 385
Bagolini glasses test 384
Bjerrum screens 385
binocular perimetry 385
depth of scotoma 385
Hess screen 385
Lees screen 385
suppression scotoma 385
synoptophore 384
Theories of color vision 14
Granits theory 14
Herings theory 14
Young-Helmholtz theory 14
Thioridazine 304
Third cranial nerve dysfunction 448
Third cranial nerve palsy 396
Three-dimensional ultrasound
tomography 240
Three-step test 397
Threshold 130
Threshold determination 132
Thyroid function tests 436
Thyroid ophthalmopathy 426, 432
Time-gain compensation 259
Tissue culture methods 328
Tolosa-Hunt syndrome 449, 454
Tonomerty 95, 151
Goldmann applanation
tonometer 95
Schitz tonometry 95
Tonometry on irregular corneas 103
Tonometry over gas filled eyes 103
Tonometry over soft contact lens 103

Topographic echography 220
Total deviation plot 137
Trabecular-iris angle 262
Traction retinal detachment 247, 248
Transillumination 158
Transmission electron microscopy
440
Transport of corneal samples 317
Trichromatic theory of Young 16
Trophozoites 323
Tumors of uvea 266
Types of gonioscopy 106
direct 106
indirect 108
Types of perimetry 129
automated 129
computerized 129
Goldmann perimeter 129, 130
kinetic 129
manual kinetic 129
static 129, 130
tangent screen 129
U
Ultrasonography 151, 428, 430
Ultrasound 346, 430
Ultrasound biomicroscopy 259, 262,
346
Ultrasound unit 240
Uses of corneal topography 69
keratoconus 69
keratoglobus70
pellucid marginal degeneration 70
pterygium 74
Terriens marginal degeneration 71
Uveitis diagnostic procedures 333
V
Van Hericks technique
38, 39
Varicella zoster virus 328
Vascular filling defect 192
choroidal vascular filling defect 192
retinal vascular filling defects 192
vascular filling defects of the
disk 192
Vector A-scan 240
Vector A-scan display 219
VEP 308
Viral antigens in corneal scrapings 328
Viral corneal ulcers 316
Viral keratitis 326
469
470

Virus isolation 327
Vision 1
color contrast 1
Vision loss 10
Visual acuity 1
Visual acuity assessment
307
Visual acuity in low vision 9
Visual acuity testing in young
children 8
Allen and Osterberg charts 8
binocular fixation pattern 8
illiterate E chart 8
Landolt broken ring 8
objective retinoscopy 8
occlusion 8
optokinetic nystagmus 8
preferential looking test chart 8
sensory amblyopia 8
visual evoked potentials 8
Visual electrophysiology tests 279
Visual evoked potential 279, 293
flash 293, 295
limitations 295
normal waveforms 295
pattern-onset 293
pattern-onset/offset 295
pattern-reversal 293, 295
Visual field defect 118
Visual field indices 140
Visual field testing 349
Visual function assessment 279
Visual loss assessment in infants
and children 308
Visual pathway 279
Visual scale 409
Visual thresholds 2
light discrimination 2
spatial discrimination 2
temporal discrimination 2
Vitrectomy 275
Vitreoretinal surgery 93
Vitreous hemorrhage 214, 243,
244, 250
Vitreous tap 338
Vogt-Koyanagi-Harada disease
247, 249
Volk superfield lens 117
Vortex keratopathy 93
VZV infections 330
W
Wegeners granulomatosis 436, 454
Westphal-Piltz reaction 442
Wide-angle angiography 214
Wide-angle viewing system 163
panoret 163
retcam 163
Wilsons disease 93
X
X-ray 404, 427, 431
Z
Zeiss fundus camera 201
Zernike polynomials 64
Ziehl-Neelsen 323
Ziehl-Neelsen technique 324

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Diagnostic Procedures in

Former Professor and Head

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

Dr RP Centre for Ophthalmic Sciences

Consultant, Narayana Nethralaya

Dr RP Centre for Ophthalmic Sciences

Head, Ocular, Pathology and Uveitis

Honorary Professor and Head

West Virginia University

Diagnostic Procedures in Ophthalmology

Glaucoma Imaging Centre

Consultant, Sankara Nethralaya

Monongalia Eye Clinic

MD, FRCS, FACS

LV Prasad Eye Institute

Professor and CMO

Manotosh Ray MD, FRCS

Harinder Singh Sethi MD, DNB, FRCS

Senior Research Associate

Yog Raj Sharma

Deependra Vikram Singh

Consultant, Glaucoma Imaging Centre

Vice Chairman and Director

Rajani Sharma MD (Ped)

Garima Tyagi B Opt

Tarun Sharma MD, FRCS

Consultant, Retina-Vitreous Service

Preface to the Second Edition

Diagnostic Procedures in Ophthalmology

Preface to the Second Edition

Preface to the First Edition

2. Color Vision and Color Blindness ........................................................................... 12

3. Slit-lamp Examination ................................................................................................... 33

4. Corneal Topography ....................................................................................................... 46

5. Confocal Microscopy ...................................................................................................... 84

7. Gonioscopy ...................................................................................................................... 106

8. Optic Disk Assessment in Glaucoma ................................................................... 115

9. Basic Perimetry .............................................................................................................. 128

10. Ophthalmoscopy ............................................................................................................. 151

11. Ophthalmic Photography ............................................................................................ 165

12. Fluorescein Angiography ............................................................................................ 181

13. Indocyanine Green Angiography ............................................................................ 200

14. A-scan Ultrasonography .............................................................................................. 216

15. B-scan Ultrasonography .............................................................................................. 239

Diagnostic Procedures in Ophthalmology

17. Optical Coherence Tomography .............................................................................. 269

18. Electrophysiological Tests for Visual Function Assessment ........................ 279

19. Diagnostic Procedures in Infectious Keratitis ................................................... 316

20. Diagnostic Procedures in Uveitis ........................................................................... 333

21. Retinopathy of Prematurity: Diagnostic Procedures and Management .... 353

22. Localization of Intraocular Foreign Body ............................................................ 362

23. Comitant Strabismus: Diagnostic Methods ......................................................... 369

24. Incomitant Strabismus ................................................................................................. 395

25. Diagnostic Procedures in Dry Eyes Syndrome .................................................. 405

26. Evaluation of Epiphora ............................................................................................... 412

27. Diagnostic Techniques in Proptosis ...................................................................... 426

28. Neurological Disorders of Pupil ............................................................................. 441

Index .................................................................................................................................................. 461

STEPHEN C HILTON, LEELA V RAJU, VK RAJU

Vision is the most important of all senses.

Definition and Terminology of

human optic system to identify two points as

Diagnostic Procedures in Ophthalmology