Abbreviations

Abbreviations EOG electro-oculogram

ERG electroretinogram
ESR eryrthrocyte sedimentation rate
AAU acute anterior uveitis FA fluorescein angiography
AC/ A ratio accommodative convergence/accommodation ratio FAP familial adenomatous polyposis
ACTH adrenocorticotrophic hormone FAZ fovea l avascular zone
AD autosomal dominant 5-FU 5-fluorouracil
AIDS acquired immune deficiency syndrome GCA giant cell arteritis
AI ON anterior ischaemic optic neuropathy GPC giant papillary conjunctivitis
AMD age-related macular degeneration HAART highly active antiretroviral therapy
ANA antinuclear antibody HIV human immunodeficiency virus
APD afferent pupillary defect HSV-1 herpes simplex virus type 1
APMPPE acute posterior placoid pigment epitheliopathy HSV-2 herpes simplex virus type 2
AR autosomal recessive HZO herpes zoster ophthalmicus
ARC abnormal retinal correspondence ICG indocyanine green (angiography)
ARN acute retinal necrosis Ig immunoglobulin
BDR background diabetic retinopathy INOP internuclear ophthalmoplegia
BDUMP bilateral diffuse uveal melanocytic proliferation IOL intraocular lens
BRAO branch retinal artery occlusion lOP intraocular pressure
BRVO branch retinal vein occlusion IRMA intraretinal microvascular abnormality
BSV binocular single vision ISNT inferior. superior. nasal and temporal
cANCA antineutrophilic cytoplasmic antibody JFRT juxta foveolar retinal telangiectasia
CAU chronic anterior uveitis JIA juvenile idiopathic arthritis
CHED congenital hereditary endothelial dystrophy KCS keratoconjunctivitis sicca
CHRPE congenita l hypertrophy of retinal pigment epithelium KP keratic precipitate
CMO cystoid macular oedema LASEK laser in situ keratectomy
CMV cytomegalovirus LASIK laser in situ keratomi leusis
CNS central nervous system MD mean deviation
CNV choroidal neovascularization MEWDS multiple evanescent white dot syndrome
CPEO chronic progressive extemal ophthalmoplegia MLF medial longitudinal fasciculus
CPSD corrected pattern standard deviation MPS mucopolysaccharidosis
CRAO central retinal artery occluSion MRA magnetic resonance angiography
CRV centra l retinal vein MR magnetic resonance imaging
CRVO centra l retinal vein occlusion MS multiple sclerosis
CSF cerebrospinal fluid MU mega units
CSR central serous retinopathy NF 1 neurofibromatosis 1
CSMO clinically sign ificant macular oedema NF 2 neurofibromatosis 2
CT computed tomography NFL retinal nerve fibre layer
CV co lour vision NSAID non-steroidal anti-inflammatory drug
DA dark adaptation NVD new vessels at disc
DCR dacryocystorhinostomy NVE new vessels elsewhere
DR diabetic retinopathy OCT optical coherence tomography
DVD dissociated vertical deviation OKN optokinetic nystagmus
ECCE extracapsular cataract extraction PACG primary angle-closure glaucoma
EKC epidemic keratoconjunctivitis PAM primary acquired melanosis
ELISA enzyme-linked immunosorbent assay PAS peripheral anterior synechiae
( xviii Abbreviations Chapter

PCF pharyngoconjunctival fever

PCR polymerase chain reaction
PDR proliferative diabetic retinopathy
PED pigment epithelial detachment
PEX
PIC
pseudoexfoliative material
punctate inner choro idopathy
Ocular Examination
PMMA polymethylmethacrylate
Techniques
POAG
POHS
PORN
primary open-angle glaucoma
presumed ocular histoplasmosis syndrome
progressive outer retinal necrosis
...... •
PPDR pre proliferative diabetic retinopathy Slit· lamp bio microscopy of the anterior segment 2
PPRF pontine paramedian reticular formation
Fun dus examination 2
PRK photorefractive keratectomy
PRP panretinal la ser photocoagulation To nometry 3
PSD pattern standard deviation 4
GonioscoPY
PVD posterior vitreous detachment
Psycho physical t est s 6
PVR proliferative vitreoretinopathy
RD retinal detachment Orthopti c examination 9
RP retinitis pigm entosa 16
Electl'Ophysical tests
RPE retinal pigment epithelium
Perimetry 19
SF short-term fluctuation
SLK superior limbic keratoconjunctivitis
SRF subretina l fluid
TB tuberculosis
TGF transforming growth factor
TlNU tubulointerstitial nephritis and uveitis
TTT transpupillary thermotherapy
US ultrasonography
VA visual acuity
VEP visua l evoked potential
VF visual fie ld
VZV varice lla zoster virus
X-L X-linked
X-LD X-linked dominant
X-LR X-l inked recessive
(2 Ocular Examination Techniques Tonometr-y 3]
Slit-lamp biomicroscopy
of the anterior segment
1. Direct illumination - diffuse light is

x
.,.~ ..
t
Tonometry
1. Goldmann - applanation tonometer
with a double prism (Fig. 1.6).

- fl.· ·
• Excess fluorescein - semi-circles
used to detect gross abnormalities
are too thick and the radius too
and a narrow slit-beam provides
b
,.',•-I',. , ...

~ ~
small (Fig. 1. 7a).
a cross-section of the cornea '".' ~ ... '"
(Fig. 1.1a).
2_ Scleral scatter - detects subtle
stroma l lesions (Fig. 1.lb).
..A
Fig. 1.2 Slit-lamp biomicroscopy of the

./,
.~.",
i ilf:,J~'L• .,~jc\
'"1
..-'I .... . • Insufficient fluorescein - sem i­
circle s are too thin and the radius
too large (Fig. 1 .7b).
3. Retroillumination - detects fine fundus r.· " 11~,.,:,. • Appropriate - semi-circles of
correct thickness and radius

~~
epithelial and endothelial changes
(Fig. 11c).
2. Goldmann three-mirror examination

(Fig. l,7c),

- len s consists of a central part and

three mirrors set at different angles Fig. 1.4 (a) U-tear left of 12 o'clock and
a
an island of lattice degeneration; (b) the

~
(Fig. 1.3).
same lesion seen with the three-mirror
• Central mirror - afford s 30°
Goldmann lens positioned at 6 o'clock
upright view of the posterior pole.

J
: 'r
• Oblong-shaped - from 30° to the
equator.
• Square-shaped - from equator to
• When viewi ng the hori zontal
meridian the image is laterally ,I "

~
the ora se rrata. reversed.

I
• Dome-shaped - for goni oscopy.
• When viewing the vertica l meridian Indirect ophthalmoscopy
the image is upside-down but not
The light emitted from the instrument is ~ .,,,: '" ___' I
laterally reversed (Fig. 1.4).
transmitted to the fundus through a con­ ~ '- \ tl· .
c densing lens whic h provides an inverted Fig. 1.6 Goldmann tonometer

~
and laterally reversed image of the
fundus (Fig. 1.5).

Fig. 1.1 Slit-lamp biomicroscopy of the

anterior segment

Fundus examination
Slit-lamp biomicroscopy
1. Indirect biomicroscopy - high power
convex lenses obtain a wide field of
view (Fig. 1.2); image is vertically
inverted and latera lly reversed.
Fig. 1.7 (a) Too much fluorescein;
(b) insufficient; (c) correct
Fig. 1.3 Goldmann three-mirror lens
Fig. 1.5 Indirect ophthalmoscopy
(4 Ocular Examination Techniques Gonioscopy
2. Perkins - hand-held, portable , the onset of the puff to applanation
applanation tonometer (Fig. 1.8). of the cornea is related to the lOP;
3. Tono-Pen - hand-held, portable, examples include the non-portable
contact tonometer (Fig. 1 .9 ). Reichert and the portable Keeler
4. Non·contact tonometers - central Pulsair (Fig. 1.10).
part to the comea is flattened by a
jet of air and the time taken from
Gonioscopy
Goniolenses
1. Indirect - provide a mirror image of
the opposite angle and can be used
only in conjunction with a slit·lamp.
Fig. 1.10 Keeler Pulsair
Fig. 1.11 Zeiss lens
a. Goldmann (see Fig. 1.3) ­
diagnostic lens that requires a
coupling fluid; modifications with
one mirror and two mirrors are
available for laser trabeculoplasty.
b. Zeiss - diagnostic four-mirror lens
(Fig. 1.11a) that does not require
a coupling fluid; simultaneous
view of the entire angle
(Fig. 1.11b); may be used for
indentation gonioscopy.
2. Direct (gonioprisms) - provide a
direct view of the angle.
a. Koeppe - diagnostic lens.
b. Swan-Jacob - used for goniotomy
(Fig. 1.12) .
Fig. 1.12 Swan-Jacob lens
Identification of angle structures
(Fig. 1.13)
Fig. 1.13 Normal angle structures
1. Schwalbe line - demarcates the
peripheral termination of Descemet
membrane and the anterior limit of
the trabeculum.
2. Trabeculum - extends from
Schwalbe line to the scleral spur.
• Anterior non-functional part lies
adjacent to Schwalbe line.
• Posterior functional pigmented
part is adjacent to the scleral
spur.
3. Scleral spur - narrow, dense, often
shiny, whitish band.
4. Ciliary body - band just behind the
scleral spur.
5. Angle recess - posterior dipping of
the iris as it inserts into the ciliary
body.
6. Iris processes - insert at the level of
the scleral spur.
(6 Ocular Examination Techniques Psychophysical tests 7\
Shaffer grading of angle width • At 6 metres a 6/ 6 letter subtends Contrast sensitivity
Psychophysical tests

The Shaffer system assigns a numerical
grade (4-0) to each angle with associ­
ated anatomical description, angle width
in degrees and implied clinical interpreta­
tion (Fig. 114).
Grade Grode
Grade 2 1
~ distance at wh ich the letter wou ld
Fig. 1 .14 Grading of angle width
!
5 min of arc and a 6/ 60 letter
50 min. This is a measure of the minimal amount
Visual acuity of contrast required to distinguish a test
• Snell en fraction (i.e. 6/ 6 = 1;
6/ 60 = 0 .10). object. The PelIi-Robson contrast sensi­
Spatial visual acuity is quantified by the
2. 8ailey- Lovie - records the minimum tivity letter chart (Fig. 1.17) is viewed at
minimum angle of sepa ration (subtended
angle of resolution (MAR) that 1 metre and consists of rows of letters
at the nodal point of the eye) between
relates to the resolution required to of equal size but with decreasing con­
two objects that allow them to be per­
resolve the elements of a letter trast of 0 .15 log units for every group of
ceived as separate.
(Fig. 1.16). three letters.
1. Snellen - testing distance over the
• 6/ 6 equates to a MAR of 1 min
subtend 5 min of arc vertically of arc and 6/ 12 equates to
(Fig. 1.15). 2 min.
• LogMAR is the log of the MAR; as
letter size changes by 0.1 10gMAR
,,~--- ~ .. units per row and there are five
letters in each row, each letter
can be assigned a score of 0.02.
60

• Grade 4 (35--45°) - ci liary body

visua lized with ease; closure
impossible.
F N P R Z: I
Fig. 1.17 Pelli- Robson contrast
• Grade 3 (25--35°) - at least the
EZHPVI
scleral spur identified; closu re
impossible.
• Grade 2 (20°) - only the trabeculum
identified; closure possible but
P N·
oP N F R
sensitivity letter chart

Amsler grid
unlikely.
• Grade 1 (10°) - only Schwalbe line
and perhaps the top of the
D Z U ,.
R 0 F U V
U R Z V H
• Evaluates the 20° of the visual field
centred on fixation .
• There are seven charts, of wh ich
trabeculum identified; high risk of cha rt 1 is the most frequently used.
closu re.
• Slit angle - no angle structures
FRVE··
H NOR U
zvU
v PHD
0 N
E
• Grid consi sts of 400 squares each
of which measures 5 mm.
identified without obvious iridocor­ • When viewed at about one-third of a
neal contact; very high risk of Z H N U 0 .2
P " E H ,Ii
metr.e, each small square subtends
closure. ... an angle of 1°.
• Grade 0 (0°) - inability to identify the v POE F R
Fig. 1.16 8ailey-Lovie cha rt
. ./
• The subject draws the perceived
apex of the corneal wedge; angle is abnorm ality such as a scotoma or
PRE U H 0 N Z
an area of metamorphopsia on a
closed.
UVDHENFP
separate paper grid (Fig. 1.18).

. U ZPNHDF

£DNZJ"HP U

Fig. 1.15 Snellen chart

~
--=­

. -
•
 8 Ocular Examination Techniques
Fig. 1 .18 Amsler grid recording
Dark adaptometry
1. Definition - phenomenon by which
the visua l system adapts to
decreased illumination.
2. Indications
• Investigation of nyctalopia.
• Diagnosis of fundus dystrophies.
3. Goldmann-Weekes adaptometry
• Subj ect is exposed to an intense
light that bleaches the photore­
ceptors and is then placed
in the dark.
• Flashes of light of gradually
increasing intensity are presented.
• The threshold at which the subject
just perceives the light is plotted.
4 . Sensitivity curve - plot of the light
intensity of a minimally perceived
spot versus time (Fig. 1.19).
a. Cone branch - represents th e
initial 5-10 minutes of darkness
during which cone sensitivity
rapidly improves.
b. 'Rod-cone' break - in normals
occurs after 7-10 minutes when
cones achieve their maximum
sensitivity and the rods become
Orthoptic examination
perceptibly more sensitive than the two end caps are fixed whi le the
... .....•......•..•.. ..
cones.
c. Rod branch - slower and
others are loose so they can be
randomized by the examiner ...-.....................
--
...•..•. ........ .. . . ... .
.....•..•.•.••....•.
represents the continuation of (Fig. 1.23).
improvement of rod sensitivity.
Fig. 1.23 Farnsworth-Munsell 100-hue
test
.)
~ -6
Orthoptic examination
I
~ -5
~ Visual acuity
i .,
~
'; Testing in preverbal children
~ .,
1. Fixation and following - using bright
attention-grabbing targets.
10 ,0 30
MI!lIIl u lndndr.
2. Comparison - occlu sion of one eye.
if strongly objected to, indicates
Fig. 1.19 Dark adaptation curve poorer acuity in the other eye
(Fig. 1.24) .
Colour vision tests
Fig. 1 .20 Ishihara test a b
1. Ishihara - used mainly to screen for
;Jj
congenital protan and deuteran
defects.
• Consists of a test plate followed
by 16 plates each with a matrix of
dots arranged to show a central
shape or number which the
subject is asked to identify
(Fig. 1.20). Fig. 1.24 (a) No objection to coveri ng
• A colour deficient person identifies eye with worse acuity; (b) objection to
some of the figures. Fig. 1.21 Hardy-Rand-Ritter test covering better eye
2. Hardy- Rand- Rittler - similar to
Ishihara but can detect all three
congenital defects (Fig. 1.21). 3. Fixation behaviour - to establish
3. City University - 10 plates each unilateral preference if a manifest
containing a central colour and four squint is present.
peripheral colours (Fig. 1.22); subject 4. The 10 ~ test - promotion of
selects one of the pe ri pheral colours diplopia.
which most closely matches the 5. Rotation t est - gross qualitative test
central colour. of the ability of an infant to fixate
4. Farnsworth-Munsell 100-hue - for with both eyes open.
both congenital and acquired colour
Fig. 1.22 City University test
defects; 85 hue caps conta ined in
four separate racks in each of which
(10 Ocular Examination Techniques Orthoptic examination

6. Preferential looking - infants prefer

to look at a pattern rather than a ..,.,,..

~"" "~ , ,,,,,,,, ,lI."

........ ~~.(..~~¥ ..~.
.~:c , ""~ :e ~~~~~:'~"
~:. ,..
homogeneou s stimulu s; Cardiff (Fig.
, '.~ .~_.£ ~
.
1.25), Teller or Keeler acuity card s.
~":'~",~. ''''~ ' ;41(~ "'~""':: .,-.,.;.,r.. j
lII...~.
"'~" "~.", .",
,", .~
,
, .~~~~ ~ "'A '·.:'~' ~
,~.~
~-~ . . -::":; iIII '_~'~"' ""'f ,
';.f~ ~"-=;:..:.,,,.. . -, I~ ' . . . . ".~,
~ ...
'

:4j ....;.c . ~:~ ...~~./(-:'" ~ ~~

..' ,.
''''74 ~.,/~:_ ~
.~ .",..~. :..~~~
.
' ...

~ " ....... ~ •..t..: 4.~~'

,.' .1'.. " ,
~ ~". '~'~
, ~ . -,~ . . .

.. ...
. ~ . ' • ..,.......... r

!.:..... ~~~ , ~. 'J. ."' ~

Fig. 1.27 Sheridan--Gardiner test .. '~ ; ....... ~:
-,.. '~' ~).~ !'I
.. .. 4 .... ~.

:..~ ,~~. ,~'

~j~" ~!.;.~
A.~" ... :.-~~ ....... ~ -.. ~ ,.-;~~~~

Tests for stereopsis

Fig. 1.25 Cardiff acuity card
Testing in verbal children
1. Age 2 years - picture naming test
such as the crowded Kay pictures
(Fig. 1.26).
2. Age 3 years - matching of letter
optotypes; Sherida n-Gardiner (Fig.
1 .27) , Keeler 10gMAR or Sonksen.
Stereopsi s is mea sured in seconds of Fig. 1.29 Fri sby test
arc (1 0 = 60 min of arc; 1 min = 60 sec
of arc); normal spatial visual acuity is 1
min and normal stereo-acuity is 60 sec
(which equals 1 minute); the lower the
value the better the acuity.
1 . TNO - requires complementary red­
green spectacl es (Fig. 1.28);
di spari ty is 480-15 sec.
2. Frisby - spectacles not required
(Fig. 1.29) ; disparity is 6 0 0-15 sec.
3. Lang - spectacles not required
(Fig. 1.30); disparity is 1200-600 sec. Fig. 1.30 Lang test
4 . Titmus - requires polarized
spectacl es (Fig. 1.31 ).

IG~br!J1

• Fly - di sparity is 3000 sec.

• Circles - disparity is 8 00-40 sec.
• Ani mals - di sparity is 400-100
71fT
sec.

Fig. 1.28 TNO test

- -- --

Fig. 1.26 Kay pictures

Fig. 1.31 Titmu s test

 12 Ocular Examination Techniques
Tests for sensory anomalies
1. Worth four-dot - requires red-green
spectacles (Fig. 1.32).
2. Bagolini striated glasses - lenses
with fine striations at 45 0 and 1350
convert a point light source into an
oblique line perpendicular to that
seen by the fellow eye (Figs 1.33 &
1.34).
3. Synoptophore - compe nsates for the
angle of squint and allows stimuli to
be presented to both eyes simulta­
neously (Fig. 1.35); can be used to
investigate the potential for binocular
function in the presence of a
manifest squint (Fig. 1 .36).
~;J
. ~
' ~TIJ
'0' •
test. (a) Normal fusion or ARC;
,1",1'\',':1
.~~ l .~11111
..
\j ~ .. 1
"­
Fig. 1.32 Worth four-<iot test. (a)
Patient wears a right red lens and a
left green lens and views a box with
one red light, two green lights , and one
white light; (b) normal fusion or ARC;
(c) left suppression ; (d) right suppres­
sion ; (e) diplopia
Orthoptic examination
.. .", ~
r~
'!E! ~ cb
~~lfoJ~
Fig. 1.33 Bagolini glasses
-,~ rE ~]
Fig. 1.38 Possible results of the
uncover test
a b
-­
L8JEZ
-
Fig. 1.36 Grades of binocular vision
" ","lilt
Cover tests
1. Cover-uncover test
-
c d • Cover test for heterotropia
[SJ~
lsOClc'<o'tij l'flfl
(Fig. 1 .3 7).
• Uncover test for heterophoria
(Fig. 1.38).
2. Alternate cover test - reve als the
-
[ . , .. k,.. ...",1JoQ
tota l deviation when fu sion is
Fig. 1.39 Poss ible results of the
suspended (Fig. 1.39 ); performed
alternate cover test
Fig. 1.34 Possible results of Bagolini after the cover-uncover test.
(b) diplopia ; (c) suppression; (d) small
central su ppression scotoma
3. Prism cover test - measures the
angle of deviation and combines the
alternate cover test with pri sms.
Measurement of deviation
1. Hirschberg - each mm of deviation
. =7°(1°", 21'.).
j.l. 2. Krimsky test - prisms are placed in
a
front of the fixating eye until the
corneal reflexes are symmetrical
(Fig. 1.40).
3. Maddox wing - dissociates the eyes
.
for near fixa tion (1/3 m) and
measures heterophoria; right eye
f• . sees only a white vertical arrow and
*~
a red horizontal arrow; left eye sees
.~;; only horizontal and vertical rows of
-~ numbers (Fig. 1.41).
Fig. 1.35 Synoptophore Fig. 1.37 Possible results of the cover
test
(14 Ocular Examination Techniques Orthoptic examination

4. Maddox rod - dissociates the eyes 1. Recently acquired right 4th nerve 2. Right 6th nerve palsy (Fig. 1.45).
but cannot differentiate heterotropia palsy (Fig. 1.44 ). • Right chart - sma ller than the left.

@ ~
from heterophoria; fused cylindrical • Right cha rt - sma ller than the left.
red glass rods convert a white spot • Right chart - underaction of the
of light into a red streak at an angle superior oblique and overaction of
of 90° with the long axis of the rods the inferior oblique.
(Fig. 1.42); amount of dissociation is • Left cha rt - overaction of the
measured by the superimposition of inferior rectus and underaction
the two images using prisms. (inhibitional palsy) of the superior
No hori zonlal d-:viati on
rectus.
• Primary deviation FL is R/ L 8°.
• Secondary deviation FR is R/ L 17°.
• Right esotropia - note that the
fixation spot of the right inner
chart is deviated nasally.
• Right cha rt - marked underaction
of the lateral rectus and slight
overaction of the medial rectus.
• Left chart - marked overaction of
the medial rectus.
• Primary angle FL is +15°.
• Secondary angle FR is +20°.

[ ~ode vi <lli o n

f sodcvi a(i oll

Fig. 1.40 Krimsky test

nasal

Fig. 1.42 Maddox rod

LEfT H'(P( RPHQRIA

I.

n
2"
16
Investigation of diplopia
"
12 The Hess test and the Lees screen
"
22-20-18-16-14-12-108·6-4 ·2·0 1·)·5·7 9·11 ·1).( 5
(Fig. 1.43) plot the dissociated ocu lar
position as a function of the extraocular
EXOPHORIA
,6 ~ ESOPH()f(j"
~
Graen beloit, lett eye Green before r'9ht uyc
2 ..... muscles.
o • II' -
I ~-
3 '! Fig. 1.44 Hess chart of a recently acquired right 4th nerve palsy
5
7
9
II
J3
I(tGI'IT H ~'Plwt>H OR IA

Fig. 1.41 Maddox wing

Fig. 1.43 Lees screen

( 16 Ocular Examination Techniques Electrophysical tests 17)
b. Cone flicker - isolates cones by
using a fl ickeri ng light stimulus at
a frequency of 30 Hz to which
rods ca nnot respond.

Multifocal ERG
Cod
Multifocal ERG is a topographical map of
nasal --.. CombllxKJ retinal function. The stimulus is scaled
for variation in photoreceptor density
across the retina . The information can be
~ Ooc"" summarized in the form of a three-dimen·
siona l plot which resembles the hill of
Cone
vision (Fig. 1.48). The technique can be
used for almost any disorder which
affects retinal function.

Fig. 1.45 Hess chart of a recently acquired right 6th nerve palsy !:tm ::;/rj l\l k.Jl,..I.- Jv. "
Jv. k Jv. ".,. -A. ....
.,...,J.../o.--A.- "", """./'O.
,Jt,. .,J.. .fot. k""" ""' ...... ·...
Fig. 1.47 Normal ERG .J.. Jv. J\,.
.J.. Jv."....,.,
.Jr ~\, ;... ..,.. ...... ......
..... ..... --. .....

Electrophysical tests Rolofenee ulectfOde .J.. h- Jv."" -A ~ ..,...

-Iv Jv. .t.- .,. ...... oh
...... .JI,. -h- ~.... Itr

1 . Scotopic ERG
Electroretinography
a. Rod responses - elicited with a
Principles very dim flash of white light or
a blue light resulting in a large
The electroretinogram (ERG) is the record
b-wave and a small or Fig. 1.48 Multifocal ERG
of an action potential produced by the
non·reco rdable a·wave .
retina when it is stimu lated by light
b. Combined rod and cone responses
of adequate intensity. The potential
- elicited with a very bright white Electro-oculography
between the active electrode and the
flash resulting in a prominent a­ 1. Principle - measures the standing
reference electrode is amplified and dis·
wave and a b-wave. potential between the electrica lly
played (Fig. 1.46).
c. Oscillatory potentials - elicited by positive cornea and the electrically
1. The a-wave - initial fast negative
using a bright flash and changing negative back of the eye (Fig. 1.49).
deflection directly generated by
the recording parameters. Diffuse or widespread disease of the
photoreceptors.
2. Photopic ERG RPE is needed to affect the EOG
2. The b-wave - next slower positive Fig. 1 .46 Principles of ERG a. Cone responses - elicited with a response significantly.
deflection with larger amplitude;
single bright flash , resulting in an
amplitude of the b-wave is measured
after 30 min of dark adaptation (scoto­ a·wave and a b-wave with small
from the trough of the a·wave to the
pic), and the last two after 10 min of osc illations.
peak of the b-wave , and increases
with both dark adaptation and adaptation to moderately bright diffuse
increased light stimulus . illumination (photopic).

Normal ERG
The normal ERG cons ists of five record­
ings (Fig. 1.4 7); first three are elicited
( 18 Ocular Examination Techniques Perimetry

Visual evoked potential sensitivity) of a pre-determined area

Perimetry of the hill of vision; non-moving

~o·'

1. Principle - recording of electrical stimuli of varying luminance are

activity of the visual cortex created
by stimulation of the retina;
monitoring of visual function in
babies and the investigation of optic
neuropathy, particularly when
o ..' associated with demyelination .
2. Technique - stimul us is either a
flash of light or a black-and-white
checker·board pattern, which
Types of perimetry
1. Kinetic - two-dimensional assess­
ment of the boundary of the hill of
vision; a moving stimulus of known
luminance or intensity is presented
from a non-seeing area to a seeing
area until it is perceived (Fig. 1.51a ).
2 . Static - three-dimensional assess­
ment of the height (differential light
presented in the same position to
obtain a ve rtical boundary of the
visual field (Fig. 1.51b).
3. Suprathreshold - stimuli at
luminance levels above normal
threshold va lues are presented in
various locations.
4. Threshold - plots the threshold
luminance value in various locations

I
roo:
...
•
Dark trouyh
1"-"
:oo':r oo : I ,. I
bqht pfrnk
!
periodically reverses polarity on a
screen (Fig. 1.50).
a
and com pares the results with age­
matched 'normal' values.

Humphrey perimetry
lIght peilk k 1(1)" 185% Pattern Flash
O,lIk UOUllh ~ Programs

~ Q 1. Suprathreshold - rapid (6 minutes

i'"*
Fig. 1.49 Principles of EOG per eye) 88 point screening test
/ / II' using a 3-zone strategy.

\
fA 2. Full·threshold strategy - initially four
2. Technique points are tested to determine
• The test is performed in both threshold levels which are then used
light· and dark·adapted states. b
as a starting level for neighbouring
• Electrodes are attached to the pOints and so on until the entire field
skin near the medial and lateral has been tested; points where the
canthi. .~ anticipated response is out by 5 dB
• The patient is asked to look ~ of that expected are re-tested.
rhythmically from side to side. ~
3 . SITA - standard program shows
making excursions of constant ~ greater sensitivity than full-threshold

amplitude.
• The potential difference between
the two electrodes is amplified
and recorded.
3 . Interpretation - maximal height of
the potential in the light (light peak)
is divided by the minimal height of
the potential in the dark (dark
trough); expressed as a ratio (Arden
ratio) or as a percentage; normal is
over 1.85 or 185%.
E9
in
for early defects; fast program is
Quicker but less sensitive.
Fig. 1 .51 (a) Kinetic perimetry;
(b) static perimetry
Fig. 1.50 Principles of VEP
3. Interpretation - latency (de lay) and
amplitude are assessed; in optic
neuropathy there is prolongation of
latency and decrease in amplitude.
(20 Ocular Examination Techniques Perimetry

Displays (Fig. 1.52 ) by other factors such as lens

CEHTRRl... 30 - 2 THRESHOLD TEST
""ME BIRTHOOTE 2 2-08 -36 OOT E: 28 -01-88 1. Numerical - gives the threshold (dB) opacities or miosis.
SI!lU.1£ ![[.IHJT[, !IllW31's.QS8 a.llO 'lOi Q£O:SIZE 111 FJ))lll(1I 1m rom.. ID 1·lJw.j IU£ r5 :e:..-j 5. Probability values (P) - indicate the
SliJIlIC'1flllnmmn P'J\1D \S ro: IE F\flL ~1.tKla4 .0 !tl '61 for all points checked; figures in
brackets indicate threshold at the significance of the defects are
same point checked a second shown as <5%, <2%, <1% and
,/, ,11 ,111 " <0.5%; the lower the P value the
"Ill! time .
Rl: 2 2. Grey scale - decreasing sensitivity greater its clinical significance and
Fl:tAJ10l l.!EiS ilIlI the lesser the likelihood of the
fll!l posm:us 0!15 ~ ~ represented by darker tones is the
FlU:!6UJm o m simplest to interpret; scale at the defect having occurred 'by chance'.
Q[STill6lS:ID 41S
00: 35m bottom shows corresponding values Reliability indices
lBT filE 00 :\):" of the grey tone symbols in abs and
.. '" ~ ~
dB; each change in grey scale tone
is equivalent to 5 dB change in
1. Fixation losses - stimuli are
presented in the physiological blind
72 lJ [Z51 2S ·1
o .z
."a ~ t" "
1) ·5 -01
threshold .
spot; if the patient respond s, a
11 ·1 0 fixation loss is recorded; the less
• il 0 ~ -J e ·1 .! 0 3. Total deviation - deviation of the
a.JlU)Il l£lll fl El.ll [Sf (GIl } the number of losses the more
W1 ~I (£ II)liL
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.('4 -JJ.n ·33 ,nl-33 ,n -ol -4 ·1 matched controls; upper numerical
·12 ~ -l1 .J J ·S .J .J 2. False positives - stimulus is
display illustrates the differences in
·l~ ·~ .. .... ... .J accompanied by a sound; if the
IQTJl PA'~ .5-01 .) ·3 dB and the lower display exhibits
sound alone is presented (without
1Il~
'.lA"~~ III -11.00 1'8 PC O. $(
these differences as grey symbols.
4. Pattern deviation - similar to total
an accompanying light stimulus) and
. ... Pm l~ . 41Cf! P ( OS\ the patient responds a false positive
deviation except that it is adjusted
........
..... ..
. . ' . '

. . . . . . . . 'if I ,~ l 00 is recorded; grey scale printout in

CJ'W 1~.1) 1'fI , It.S! for any generalized depression in the
.
'trigger happy' patients appears
: : p( S1.
. overall field which might be caused
12 P< lc
••• .J~ . abnormally pale (Fig. 1. 53).
SP (
.p < o.~
l~

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~~~~~~~~~~ ' E~: RI GHT
I tIAME; 1 ~?e94 I CI : DOS: 1 3- 11 -1 9241
co.ll!II.l H I}I ~.tsllCl Ol m

i( ~It~ ~ITJI!I ' AUr8lI"!\iMl l STlr.:;Lt"5 : !II . 111m: Hlf fL O J~E1 ER ; Dim : 14·Q2 ·?tIilI Z
f1~A IlIII r ~1l: !I: (O li" I'CfUW; J l .~ IIi:I I.'I SUII/. ~cml' : 11nI: 5:i'3n
rl1ll.'l e" ' Ii:'~ : '1!4 S ntQ TE ~ Y:SIl H~P.& ~1. : OS (If x JU: 71
HII. ~ mllt.l!l'l : 667. . . . ­
m !.l IllC {"DJ~ : ]3 ~

lIS! IXJI'ItHll: 11 :11

rU~ Q : err
j2 l~ ~ ii8 29

n la it I~ l7 16

J) 3J J2 II t Je 19 111 ~

" I ~ ~ :: r ~~, ~ i ~! ~~ .. . .i ,." . ,.

28 l~ :3 6 jS ' 12 12 12 1I

Fig. 1.52 Humphrey perimeter and display n J4 H III J1 J'

J2 J' t ~ 13

Fig. 1.53 High false-positive score (arrow) with an abnormally pale display
 Ocular Examination Techniques Chapter
3. False negatives - detected by 2. Pattern standard deviation (PSO) -
presenting a stimulus much brighter mea sure of focal loss or variability
than threshold at a location where taking into account any generalized
sensitivity has already been depression in the hill of vision;
recorded; if the patient fails to increased PSO is a more specific Imaging Techniques
respond a fal se negative is
recorded ; grey scale printout with
high false negative responses has a
indicator of glaucomatous damage
than MD.
3. Short·term fluctuation (SF) -
... ...............................................
clover leaf shape (Fig. 1.54). indicati on of the consistency of Cornea 24
responses. Fluorescein angiography 24
Global indices
4. Corrected pattern standard
Global indices summarize the results deviation (CPSO) - mea sure of IndocY<lnine green angiogr aphy 26
in a single number and are principally variability after correcting for short­ Ultrasonography 2.1
used to monitor progression of glauco­ term fluctuation (intra-test variability) .
matou s damage rather than for initial
O ptical coherence to mogr aphy 28
diagnosis. Imaging in glaucoma 29
1. Mean deviation (MO) (elevation or Neuroimaging 30
depression) - measure of the overall
field loss.

SI NCkE FIEl.D ANAL YS I S E YE : R I GHT

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C£II ~ 24 ·l Tif£S111l.Il Tt S T

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U XUltI TAren : Cfll ll1l1l ~r~ :ll. ~Ii:' V!l:IR!lCU !1T : Tnt : ] :)] P~

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1
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' 15
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2 U 26 15 1 19 n 26 21
18 26 21 I Ii 18 2~

18 18 ;11 IS

Fig. 1.54 High false-negative score (arrow) with a clover leaf-shaped display
 Imaging Techniques Fluorescein angiography

• Flat curvatures (low dioptres) are 5. Venous Causes of abnormal

Cornea
Specular microscopy
• Specular microscopy is a study of
the changes in different layers of the
cornea under magnification which is
100 times greater than slit-lamp
biomicroscopy.
• It is principally used to photograph
the corneal endothelium and the
image is analysed with respect to
cellular size, shape, density and
distribution.
• The normal endothelial cell is a
regular hexagon with a density of
about 3000 cells/mm 2 (Fig. 2.1);
foveal avascular zone.
counts below 1000 are associated
• Blockage of background choroidal
coloured violet and blue.
• Most normal corneas remain within
the yellow-green spectrum.
• Absolute scales have fixed end­
points and each individual colour
represents a specific power interval
in dioptres.
• An absolute scale should always be
used to facilitate comparison over
time and between patients.
• Relative (normalized) scales are not
fixed and vary according to the range
in dioptres of the individual cornea.
, ............ I
Fig. 17.32).
,.--. ,
• Staining due to prolonged
a. Early - complete arterial and
capillary filling , with more marked
laminar venous flow.
b. Mid - almost complete venous
filling (Fig. 2.3d).
c. Late - complete venous filling with
reducing concentration of dye in
the arteries (Fig. 2.3e).
6. Late (elimination) - continuous
recirculation , dilution and elimination
of the dye; late staining of the disc
is a normal finding (Fig. 2 .3f).
7. Dark appearance of the fovea
caused by three phenomena .
• Absence of blood vessels in the
fluorescence
1. Hyperfluorescence
• Transmission (window) defect
caused by deficiency of the RPE
(e.g. dry AMD - see Fig. 17.8).
• Pooling in the subretinal space
(e.g. CSR - see Fig. 17.28) or
sub-RPE space (e.g. PED - see
Fig. 17.11).
• Leakage from neovascularization
in the retina or choroid (e .g. CNV
- see Fig. 17.14).
• Breakdown of the inner blood­
retinal barrier (e.g. CMO - see

with a significant risk of endothelial
decompensation.
~
......... fluorescence by increased density
_.'-"­ of xanthophyll at the fovea.
• Blockage of background choroidal
fluorescence by the RPE cells at
the fovea, which are larger and
contain more melanin than
~ elsewhere.
retention of dye in tissue (e.g.
macular drusen - see Fig. 17.3b).
2. Hypofluorescence
• Blockage of normal fluorescence
(Fig. 2.4).

Fig. 2.2 Norma l relative scale map

shows 3.5 D of with·the-rule astigma­
tism and a typical bow-tie pattern

Auoresceln angiography
Fig. 2.1 Specular micrograph of normal Phases of the angiogram
endothelium
1. Red free image (Fig. 2.3a).
2. Choroidal (pre-arterial) - patchy
Corneal topography choroidal filling.
3. Arterial - arterial filling and the
Corneal topography provides a colour­
continuation of choroidal filling
coded map of the corneal surface; power
(Fig. 2.3b) .
in dioptres of the steepest and flattest
4. Arteriovenous (capillary) - complete
meridia and their axes are calculated
filling of arteries and capillaries with
and displayed (Fig. 2.2).
early laminar venous flow (Fig. 2.3c). Fig_ 2.3 Normal fluorescein angiogram
• Steep curvatures (high dioptres) are
coloured orange and red.
 Imaging Techniques Ultrasonography

Pigment Abnormal Blood

• . Inadequate perfusion due to • Hypofluorescence of the optic disc 2. Hypofluorescence
fl'I.')lerial vascu lar occlusion or loss of the and poor perfusion of the • Blockage of fluorescence by

Xantho,,",. I (~
EKuda lO o
~
vascular bed (e.g. severe degene­
rative myopia - see Fig. 1 7.43).
watershed lone.
• Prominent filling of choroidal

pigment, blood or exudate.

• Obstruction of the circulation .

arteries and early filling of
• Loss of vascular tissue.
choroidal veins.
• PED (see Fig. 1 7.9b).
Indocyanine green • Retinal arteries are vis ible but not
HypcrpltJSi:l
angiography veins.
01 APE

2. Early mid phase (1-3 min - Fig. 2.5b)

Fig. 2.4 Causes of blocked fluorescence
Normal angiogram
1. Early phase (within 2- 60 sec of
injection - Fig. 2.5a )
3. Late mid phase (3-15 min ­
4. Late phase (1 5- 30 min - Fig. 2.5d)
Ultrasonography
• Fi lling of watershed zon e. A-Scan
• Fading of choroida l arteries with
increased prominence of choroida l 1 . Indications - measurem ent of
veins . ante rior chamber depth, lens
• Both retinal veins and arteries are thickness , and axial length .
vis ible. 2. Display - vertical spil~es along a
basel ine (Fig. 2.6) the height of
Fig. 2.5c) which is proportional to the strength
• Fading of choroidal vascular filling. of the echo; the greater the distance
• Diffuse hyperfluorescence due to to the right, the greater the distance
diffusion of dye from the between th e source of the sound
choriocapillaris. and the reflecting su rface.
• Retinal vessels are sti ll visib le.
• Hypofluorescence of choroida l
vasculature against a background
of hyperfluorescence resu lting
from sta ining of extrachoroidal
tissue.
• Decreased visibi lity of retinal
va sculature.
• Dye may remain in neovascular
tissue after it has left the
choroidal and retinal circulations. Fig. 2.6 A-scan display

Causes of abnormal
fluorescence
1. Hyperfluorescence
• RPE 'window ' defect.
• Leakage from the retinal or
choroida l circu lations, or the optic
nerve head.
• Abnormal blood vessels.
Fig. 2.5 Normal indocyanine green angiogram
B-Scan
The amount of reflected sound is por­
trayed as a dot of light; the more sound
reflected , the brighter the dot; the fre­
quency of the transducer determines
which part of the globe or orbit is exam­
ined.
1. Low (2-5 MHz) - for orbital
pathology (Fig. 2.7).
 Imaging Techniques Imaging in glaucoma

of the density of the NFL estab­

lished ; the thicker the NFL the
greater the polarization (Fig. 2.12).
ILA

~r~

~~.~
..... -'. ': ... Fig. 2.10 Normal OCT

Fig. 2.7 Low frequency ultrasonography
shows an anterior orbital capillary
haemangioma
2. Moderate (7-10 MHz) :
• Detection of RD in eyes with
lenticulocorneal apposi tion
opaque media (Fig. 2.8 ).
• Evaluation of posterior intraocula r
tumours.
• Detection of ca lcification (e.g.
retinoblastoma and optic disc
drusen).
Fig. 2.8 B-scan shows intragel vitreous
haemorrhage and total tractional retinal
detachment
Z L
Imaging in glaucoma
1. Heidelberg Retinal Tomograph (HRT)
Fig_ 2.9 High frequency ultrasonogra­ - scanning laser ophthalmoscope
phy shows corneal opacification and that can interpret differences in the
profile of the optic nerve head and
pe ri papillary NFL to produce a
compute ri zed three-dimensiona l
Optical coherence topographical image (Fig. 2.11). Fig. 2.12 GDxVCC display
tomography
3. STRATUS OCT images and analyses
1 . Physics - cross-sectional images are the NFL, macular thickness, and the
generated by scanning the optical optic nerve head (Fig. 2.13).
beam in the transverse direction,
thus yielding a two-<iimensional data
set that can be displayed as a fa lse­
..u_
=:::..oo;.:... _ _ .
~ •
colour or grey scale image.
2 . Indications
• Macular pathology. .. --.­
-tIJ~t
- -~ ~.
-.,--..d ~-
• To monitor progression of disease
processes and response to .",. ""l
treatment.
• Analysis of the optic nerve head
and retinal nerve fibre layer (NFL)
thickness . ., . ., ., .
3 . Normal appearance (Fig. 2 .10)
• Nerve fibre and plexiform layers ­
red , yellow or bright-green.
mm1
Iit _ _ _

.2
EEi- M

• Inner and outer nuclear layers ­

blue or black.
Fig. 2 .11 HRT display
5ES -

3. High (30-50 MHz) - for high­

definition imaging of the anterior
segment, particularly in the
evaluation of congenital corneal
opacification (Fig. 2.9).
• Inner and outer plexiform layers ­
bright-green.
2. GDxVCC analyser measures the
change in polarization caused by the
birefringence of NFL axons; degree
of po larization is assessed over an 3
area of 1 .75 disc diameters
concentric to the disc and the profile Fig. 2.13 STRATUS OCT
 Imaging Techniques
• Acute cerebral or subarachnoid
Neuroimaging haemorrhage.
3. Iodinated contrast material -'
Computed tomography improves sensitivity and specificity
1. Physics - x·ray beams obtain tissue but is not indicated in acute cerebral
density values from which detailed haemorrhage, bony injury or
cross-sectional images are formed 10ca li zatiCn of foreign bodies
by a computer; t issue density is because it may mask visua lization of
represe nted by a grey scale, white these high densi ty structures.
being maxi mum density (e.g. bone)
Magnetic resonance imaging
and black being minimum density
(e.g. air); image may be coronal
Physics
(Fig. 2.14) or axial (Fig. 2 .15).
Magnetic resonance imaging (MR)
depends on the rearrangement of hydro­
gen nuclei when a tissue is exposed to
a short electromagnetic pu lse, When the
pulse subsides, the nuclei return to their
normal position, re-radiating some of
the energy they have absorbed. Exposed
tissues produce radiation with character­
istic intensity and time patterns. The
signals are analysed, computed and
Fig. 2.14 Coronal CT image shows a
displayed as a cross-sectional image
right orbita l tumour
whi ch may be: (a) axial, (b) corona l or (c)
sagittal.
Imaging sequences
Weighting refers to two methods of mea­
suring the relaxation times of the excited
protons after the magnetic field has been
switched off. Various body tissues have
different relaxation times so that a given
tissue may be Tl- or T2·weighted (i.e.
best visua lized on that particular type of
image).
1. T1-weighted - best for normal
Fig. 2.15 Axi al CT image of the same
anatomy (Fig. 2.16).
patient
• HYPointense (dark) - CSF and
vi treous .
2 . Indications • Hype rintense (bright) - fat , blood,
• Orbital disease and trauma.
and contrast agents.
• Intraocular foreign bodies.
• Detection of intraocular
Fig. 2.17 T2-we ighted axia l MR image
ca lcification .
2. T2-weighted - useful for pathological
changes (Fig. 2.17).
• HYPointense - fat and contrast
agents.
• Hyperintense - CSF and vitreous.
• Blood vessels - black unless
occluded.
Fig. 2.16 Ti-weighted sagittal MR
image
(MRA) - for the carotid and
N euroirnaging
Enhancement
1. Gadolinium - acquires magnetic
moment when placed in an electro­
magnetic field; only visualized on
Tl-weighted images, and enhancing
lesions suc h as tumours (Fig. 2. 18)
and areas of inflammation which
appea r bright.
f. -' '.....~ ( '\
.;'.. '~'.~
.
• . I. :- '."
~ t' , .
• '\
~-t, "
•. ,f
Fig. 2.18 Ti-weighted MR images of
an acoustic neuroma; (left) without
gadolinium; (right) with gadolinium
2. Orbital fat-suppression techniques ­
the bright signal of orbita l fat on
conventional Tl-weighted imagi ng
obscures other orbital contents; two
fat suppress ion sequences are Tl
fat suppression with gadolinium and
STIR (Short Tl Inversion Recovery)
for detecting intrinsic lesions of the
intraorbital part of the optic nerve.
3. FlAIR (fluid attenuation inversion
recovery) - suppresses the bright
CSF on T2-weighted images to allow
better visua lization of adjacent
pathological ti ssue such as
periventricu lar plaques of demye lin­
ation (see Fig. 24.60).
Angiography
1. Magnetic resonance angiography
vertebrobas il ar circulations (Fig.
2.19) to demonstrate stenosis,

 32 Imaging Techniques
dissection, occ lu sion , arteriovenous
ma lformati ons. and aneurysms;
thrombosed aneurysms may be
missed and is unre liable in detecting
very sma ll lesions.
uses radioactive glucose that accumu­
Fig. 2.19 MR angiogram
2. Magnetic resonance venography
(MRV) - for venous sinus
thrombosis.
3. Computed tomography angiography
(CTA) - for intracranial aneurysms ;
images of the vesse ls can be
reconstructed in three dimensions
(Fig. 2.20).
4. Computed tomography venography
(CTV) - useful when MRA is
contraindicated or there are
difficul ties in distinguishi ng slow flow
from thrombus on MRA; similar to
CTA but images are acquired in the
venous phase of contrast enhance­
ment (Fig. 2.21).
N euroimaglng
Positron emission tomography
!
~y~ . -< . Positron emission tomography (PET/ CT)
,~"~1:;d\
.. /p.-.i;t;;i y,..,........,~. i
lates within malignant cells because of
~4'e
their high rate of metabolism . Following
injection the patient is imaged on a
whole body scanner to reveal tumours
that may have been overlooked by con­
ventional CT or MR. It is a sensitive tool
for the detection and staging of hepatic
~ \., and extra-hepatic metastatic choroida l
melanoma.
Fig. 2.20 CT angiogram showing a left
superior cerebe llar artery aneurysm
Fig. 2.22 Conventional intra-arterial
angiogram with subtraction
Fig. 2.21 CT venogram
5. Conventional intra-arterial catheter
angiography - a catheter is passed
through the femora I artery into the
internal carotid and vertebral arteries
in the neck under fluoroscopic
guidance; digital subtraction results
in images of the contrast-filled
vesse ls without any background
structure such as bone (Fig. 2 .22).