MACULAR FUNCTION

TEST

DR. PUSHPANJALI
 macula
• The International ARM Epidemiological study group, defined
macula as the posterior part of retina centered on the foveola.
• 5.5-6 mm diameter.
• Comprises of fovea centralis(1.5mm), foveola(0.35mm) and
FAZ(0.4-0.6mm).
Fovea differs from retina in that it has only the following 6 layers :

• Retinal pigment epithelium,

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

FUNCTIONAL
DISTINCTION
• highest discriminative ability(VA),
• colour perception and
• light plane polarity.
 Specific anatomic configuration
• Densest concentration of cones and a one to one
photoreceptor-ganglion cell relationship. Cones more
elongated and slender.
• Absence of rods - fovea and foveola.
• RPE more deeply pigmented.
• Presence of xanthophyll.

Imparts certain properties

…MFTs.
 USES of macular function tests:
• Diagnosis;
• Follow up of macular diseases &
• For evaluating the potential macular function
in eyes with opaque media such as cataract
and dense vitreous hemorrhage.
 Macular function tests
methods
• Psychophysical tests • Electrophysiologic tests
1. Visual acuity 15. Electroretinography (ERG)*
2. Contrast sensitivity 16. Electrooculography (EOG)*
3. Photostress test 17. Visually evoked
4. Amsler grid response(VER)*
5. Two point discrimination test*
6. Entoptic phenomenon
7. Tests dependent on macular
pigment*
8. Maddox rod test*
9. Color vision
10. Foveal flicker sensitivity
11. Dark adaptation
12. Perimetry/Scanning laser
ophthalmoscopy*
13. LI, PAM*
 Visual Acuity
• A guide to the functioning of the entire visual
pathway i.e. the visual axis, the macula and the optic
pathways once the eye has been corrected for
refractive errors.
• The best-corrected visual acuity is a measure of
actual foveolar function.
• Visual acuity is measured by the visual resolution of a
letter, symbol or a pattern under conditions of
maximal contrast.
Visual acuity testing
 The Snellen Chart
• The Snellen score = test distance/size of the smallest
letter correctly identified.
• The numerical value of the denominator is the distance at
which the height of this smallest identified
test letter subtends 5 minutes of visual angle
on the retina.
• Each component of this letter subtends 1 min
at this distance.
LANDOLT C CHART :
NAS-NRC recommended.
SLOAN LETTERS
• Bailey-Lovie chart (ETDRS study)
• Illiterate E chart (used with illiterate
patients)
• Sheridan-Gardiner cards (children>3 yrs)
• Cat ford Drum - Based on Oscillatory
movements
• Teller’s acuity cards (useful in case of
children from 6 months to 2 years).
• Cardiff vision chart ( useful for children
from 2-3 years).
• Angular visual acuity cards
(to avoid crowding phenomenon).
• Near vision - by near vision charts for
each eye separately.
 Teller’s Acuity Cards
(with Black & White strips)

Caradiff vision charts

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

Pupillary reactions
• The pupillary reactions are usually normal in
eyes with macular diseases.
• The defect usually indicates either a lesion of
the optic nerve(APD) or extensive retinal
disease.
 Contrast sensitivity
• Contrast sensitivity is a
measure of the minimum
amount of contrast
needed to distinguish a
test object & indirectly
assesses the quality of
vision.
• Unlike VA, it is a measure
of visual function under
conditions of reduced
contrast.
• Uses :
1. To detect early/subtle visual loss esp
when VA is Normal.
2. To detect retinal conditions like DR,
ARMD and other retinal, macular and
optic nerve diseases. Sinusoidal gratings

3. Optical conditions like refractive error,

refractive surgery, cataract and
intraocular lens implantation and
normal aging of the eye.
• In macular diseases, there is a marked
impairment for the intermediate and Functional acuity contrast test
higher spatial frequencies. CONTRAST
SENSITIVITY
GRATINGS
L
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TI The Hamilton-veale The Pelli Robson Chart developed
VI Contrast Sensitivity in 1988 is the accepted gold standard for
T Chart measuring contrast sensitivity.
Y
 Laser interferometer
• Useful subjective test of the
resolving power of eye by using
Laser generated interference
fringes.
• Rodenstock interferometer. Small helium-neon laser
• Dilated pupil. collimated beam
• Coarse to fine fringes, change optically divided
orientation. 2 beams
Overlap at/post. to plane of lens
Intersection of 2 beams
Interference fringes,
imaged on macula.
• Brightness increased in pts with dense cataracts.
• The laser interferometer resolving power converted to
standard V.A.
• Fringes not dependent on optical components of eye,
except large r.e. uncorrected aphakia.
• Limitations : 1. subjective,
2. Laser fringe vision>> vision of letter
acuity.
3. overpredicts visual potential in
amblyopes,
4. requires atleast 2 clear areas.
• Greatest usefulness – 1. Moderate cataracts,
2. Macular diseases.
 Potential acuity meter
• GUYTON and MINKOWSKI.
• It consists of a slit lamp attachment that can project
an entire V.A. chart on the macula.
• Emits 0.1mm beam into windows of pt’s cataract.
• Focusing with a slide scale
ranging from +13 to-10D.
• Dilated pupil, relaxed pt.
• Easier than laser interofer-
metry, does not overpredict
V.A. in macular diseases.
 Amsler Grid TEST
• Evaluates the 20* of visual field centered on
fixation.
• Used in screening and monitoring macular
diseases like
1. Maculopathy – congenital, stargardt, ARMD.
2. Retinopathy – diabetic, CSR, chloroquine related.
3. Macular holes and
4. Optic neuropathies.
GRID : square 10*10 cm divided
into 400 5*5 mm squares to be held
at 28-30 cm. Chart subtends angle
Of 20*,each small square 1*.
 Amsler Grid Testing
• Procedure : reading glasses, cover 1 eye.
• SIX standard questions to be asked :
1. Ability to see the central spot.
2. Ability to see the 4 corners and sides of the grid.
3. Presence of any interruptions in the network of small
squares by holes or blurry areas.
4. Ability to see all the horizontal and vertical lines straight and
parallel to each other.
5. Presence of abnormalities like blurred areas, holes,
distortions, movement of certain lines, vibrations or
waning, something shining or an abnormal colour or tint.
6. Distance of above abnormalities from the fixation point and
the presence of any intact square between the central point
and the abnormal areas.
• Recently 7 different charts have been used
for increasing the sensitivity.

CHART 1
CHART 2 CHART 3 CHART 4

CHART 5 CHART 6 CHART 7

Central Scotoma  Arcuate Scotoma  Positive/Absolute Paracentral Scotoma 

Macropsia Micropsia Metamorphopsia

 Colour vision
• The central 30-60 degree of visual field processes
trichromatic color vision.
• Hereditary dystrophies of posterior pole, non-hereditary
maculopathies & certain optic nerve conditions often result
in acquired color defects.
• Congenital:not particularly rare, affect males, symmetric,
involve red-green color & occur as isolated visual defect.
• Acquired: asymmetric, accompanied by other visual
dysfunctions, most commonly show irregularity in color
testing not usually seen in congenital variety. Eg.
• BLUE-YELLOW defect – CSR & RP, or
• RED-GREEN defect – Acq cone degeneration/optic
neuritis.
 COLOR CONFUSION TESTS
1. ISHIHARA CHART
2. Farnsworth panel D-15
3. The American Optical Hardy-
Rand-Rittler pseudoisochromatic
plates.
4. Sloan Achromatopsia Test.
• HUE
DISCRIMINATION
TEST :
Farnsworth-Munsell 100
Hue test.
• SPECTRAL TEST :
Nagel Anomaloscope : the
best method for accurate
classification of red-green
defects.
 Two Point Discrimination
Test
• The ability to distinguish two illuminated
points of light suggests good retinal
function.
• “Rule of 2” : Two illuminated points of 2
mm diameter size and 2 inches apart are
placed 2 feet away from the patient’s eye.
The patient is then asked to indicate
whether he can perceive the two points
separately.
 Maddox rod test
• Simplest, most reliable test(opaque med).
• Rod consists of several cylinders of glass
placed side by side in a frame.
• Pt is asked to fixate light at a distance of 1/3 m through
M.R. with opposite eye occluded.
• Image formed is a straight line(vertical/horizontal streak)
running perpendicular to the axis of rods.
• Any breaks/holes; discoloration/distortion indicates a
macular lesion.
• RED: more sensitive, tells us about color perception.
• Test various meridians by rotating : may reveal a RD/ a
glaucomatous field defect.
 Photostress test:
• Bailliart in 1954.
• Methods of assessing macular function by timing the
recovery of visual acuity after adaptation to an
intense light source have been called macular
photostress tests.
• PRINCIPLE : The test involves exposing the macula to
a light source bright enough to bleach a significant
proportion of the visual pigments.
• Return of normal retinal function and sensitivity
depends on the regeneration of the visual pigments.
• This regeneration can be measured by the rate of
recovery of visual acuity or of contrast sensitivity.
• As the rate and extent of this regeneration is
determined by anatomical and physiological apposition
of photoreceptors and RPE, pathological states that
affect the photoreceptors, Bruchs membrane, chorio-
capillaris or choroid can prolong visual recovery time.
• In contrast no such prolongation is observed in diseases
affecting the neural conducting pathways.
• USES : 1. to quantify subtle maculopathies,
2. discriminate between optic neuropathy & maculopathy,
3. to plot the recovery or progression of macular disease.
Often the photostress test will show changes
where other more standard clinical tests may fail to show
any change.
 TECHNIQUE
• The patient's pre-stress BCVA is noted.
• The patient is asked to cover or occlude one eye while the
other eye is subjected to a bright light from fully charged
ophthalmoscope directed onto the macula for 15
seconds/indirect ophthalmoscope light held 3cm away for
10 seconds.
• Photostress recovery time (PSRT) is the time it takes for
the patient to read the line just above its pre-test best
acuity line backwards.
• Normal PSRT ranges
from 8-70 seconds.
CONDITIONS WITH PROLONGED
PSRT
• Central serous retinopathy,
• Age related maculopathy,
• Macular edema,
• Retinal detachment,
• Diabetic retinopathy,
• Systemic hypertension,
• Retinal pigmentary degeneration,
• Chloroquine retinopathy,
• Alcohol or marijuana ingestion.
 Dark adaptation
• Dark adaptation refers to the ability of the visual
system,(both rods and cones mechanisms) to recover
sensitivity following exposure to light.
• Most primitive model-photometer of Richard Forster.
• Hemispherical adaptometers are used nowadays
(Goldman-Weekes by Haag Streit).
• Useful in pts presenting with c/o night blindness as in
hereditary macular degenerations.
• Normally the whole process of dark adaptation requires
15-30 minutes.
• When performed at 5* a typical biphasic curve is
obtained.
• PROCEDURE:
1. Subject exposed to intense light that bleaches
photoreceptors.
2. Then Suddenly placed in dark.
3. Threshold at which sub just perceives light is plotted.
4. Flashes repeated at regular intervals; sensitivity of eye
to light gradually increases.
5. By taking a threshold reading every min a curve of
changing threshold Vs time of dark adaptation is
obtained.
• Sensitivity curve : a. cone branch
b. rod-cone break
c. rod branch
Dark Adaptation Curve
 Clinical applications
1. Disorders of pigment degeneration
a. Vitamin A deficiency; b. Fundus albipunctatus
2. Disorders of neural adaptation
a. Oguchi’s disease
b. Congenital stationary night blindness (CSNB)
3. Chloroquine toxicity,
4. Retinitis pigmentosa Type II,
5. Tapetoretinal degenerations,
6. High myopia,
7. Glaucoma.
 The entoptic phenomenon (or Scheerer's
phenomenon)
• visual perceptions that are produced or influenced by the
native structures of one’s own eye.
• Structures producing – N anatomic parts/Media opacities.
1. PURKINJE VASCULAR E.P. :
Visual elements underlying bld vsls become adapted to this
pattern of illumination.
Focal source(at an unusual angle),
pressed firmly against globe, retinal
blood vessel pattern transiently.
-Useful in pts with media opacities.
-Limitation : intelligent & perceptive patients.
2. The blue field Entoptic Phenomenon
(Flying spots)
• series of fast moving, luminous points or
spots seen on looking at a bright and diffusely
illuminated surface with no contrasting
features.
• Best seen in background illuminated by
blue light in spectral region of 350-450nm.
• Capillaries full of RBCs too close to each other, too far
away from retina; so normally invisible. WBCs large act
like gaps.
• White blood cells passing through the snake like retinal
capillaries executes a sinusoidal wiggle motion.
• 5/> - normal.
• Abnormal:
(a) failure to see any, (b) partial loss in 1 part of the field,
(c) less no., (d) slow movement.
• More accurate than : Two light discrimination,
color perception &
purkinje vascular entoptic phen.
• Disadvantage : subjective, poorly quantifiable.
• Little use in significant vitreous opacity.
• D/d : FLOATERS : variable appearance, almost stationary
or drift slowly, dont follow well-defined paths & are due
to debris floating in vireous.
 Haidinger’s Brushes
• Subject looks at a surface illuminated with blue light through a
polarizer.
• N – hourglass shaped yellowish brushes seen radiating from the pt
of fixation. On rotating polarizer, brushes rotate.
• Phenomenon - caused by variations in absorption of plane polarized
light by oriented molecules of xanthophyll pigment in foveal retina.
• Screening test for retinal or macular pathology in strabismus
patients with amblyopia.
 Maxwell’s Spot
• Subject looks at a brightly illuminated white surface
through blue filter.
• N - dark/greyish spot in the visual field corresponding to
fovea surrounded by a dark ring is seen that gradually
fades with time.
• Now used clinically to detect eccentric fixation by
placing a fixation pt in the diffusely illuminated field.
• Perception is related to the arrangement of the yellow
pigment in the inner retinal layers of the macula.
• Thus, both these tests utilise the phenomenon of the
entoptic imagery of the fovea.
 erg
• The clinical ERG is the
recording of the electrical
potential waveform generated
by the total (pre-ganglionic)
retina in response to a diffuse
light stimulus.
• Test-performed in dark adaptation
using a corneal contact lens(active)
electrode which records changes in
the corneo-retinal potential with each
light stimulus. Reference electrode is
attached to forehead.
• Negative ‘a wave’ – activities of
rods & cones.
• Positive (composite)‘b-wave’ –
from Muller cells in the bipolar
region(inner retinal layers).
• c-wave – retinal metabolism
(RPE).
• Peak amplitudes and latencies as
well as waveform shape are
considered in the interpretation of
the ERG.
• Monitors preganglionic retinal
activity so optic atrophy – N
ERG.
• ERG - mass retinal response; an
isolated lesion of the macula
would not be expected to affect
this test as it contains only 7% of
total retinal cone population.
The Multifocal ERG
• Produces topographical maps of
retinal function.
• Stimulus is scaled for variation in
photoreceptor density across the
retina; at fovea where receptor density
is high smaller stimulus element is
used than in periphery.
• The information can be summarised
in form of a 3-D plot, resembling hill
of vision.
• Use : Any disorder that affects retinal
function.
 Clinical applications
1. Vitamin A deficiency & xerosis.
2. Retinitis pigmentosa & allied diseases e.g.
(a) Congenital Night Blindness.
(b) Oguchi's Disease.
(c) Retinitis punctate albicans.
3. Prognosis in Cataract.
4. Prognosis in Glaucoma.
5. Detachment of retina.
6. Systemic & retinal vascular conditions.
7. Macular diseases.
8. Malingering
 Eog
• Measures changes in corneo-
retinal potential of the eye under
varying conditions of illumination.
• 2 electrodes are placed on the skin,
1 at lateral canthus & other at medial
canthus. Pt is asked to shift fixation back &
forth between 2 red lights that turn on & off
sequentially in an alternating fashion.
• Several measurements are taken every min for
total of 15 min in darkness & then 15 min in light.
• Plot of average amplitude value for each min
against time normally shows a min trough value
during dark period & a max peak value in light.
• Dark trough - integrity of pigment epithelial outer segment region.
• Light rise - function of mid-retinal layers + outer retina-pigment epithelial
complex.
• Light peak/dark trough ratio - reliable parameter of retinal function.
• N - >185%.
• Arden ratio : calculated by taking ratio of(max light adapted to min dark
adapted response)*100.
• EOG is a reflection of generalized retinal responsiveness. So, abnormal in most
of those conditions in which ERG is abnormal.
• Except Best’s Vitelliform macular dystrophy, Butterfly dystrophy, fundus
flavimaculatus & generalized drusen. Here, ERG -N, EOG -abnormal.
 v.e.r.
• Measure of the electrical
potential generated in
response to a visual stimulus.
• It is recorded with scalp electrodes
placed over occipital lobe region,
a cortical area with primarily a
macular representation.
• Diffuse light stimulus flashes
intermittently-in suspected
monocular pathology.
• Patterned stimulus-alternating
dark and light bars in form of a
sinusoidal grating.
• Checkerboard pattern stimulator with alternation of dark and light
checks.
• Then average potential is calculated by a computer.
• USES: monitoring of visual function in babies, macular pathway
function & inv of optic neuropathy(demyelination).
• Though VER is predominantly a foveal response, it represents
integrity of entire visual pathway from retina to occipital lobe.
• Limitation : cant differentiate macular from an optic n/cortical
pathology.
 Foveal Flicker Sensitivity
• A small flickering test light (0.5-2*) is
superimposed on a constant background
luminance.
• The luminance of the flickering test light is so
modulated; that the mean luminance of the test
light is equal to that of the surround.
• For a given frequency value, minimum
modulation depth at which test spot is barely
perceived to be flickering is defined as
threshold modulation, reciprocal of which is
sensitivity. Flicker sensitivity curve
• Comparison with normal patients yields is then plotted for a
given point on retina as
information about presence of macular a function of flicker
pathology. frequency.
 perimetry
• Perimetry can also test the retinal
function.
• N useful for defects of peripheral
visual fields careful STATIC of
central 2-4* - early maculopathy.
• FLICKER PERIMETRY.
• Scanning Laser ophthalmoscope.
• Macular disease is sometimes part
of a generalized pathologic
process & in such cases peripheral
field may also show
abnormalities.
SCANNING LASER
OPHTHALMOSCOPE
Thank you!