Test For Macular Pigment

USERS MANUAL
METROVISION - 4 rue des Platanes 59840 PERENCHIES FRANCE

Tel: +33 3 20 17 19 50
export@metrovision.fr
Version 05/01/2015
Fax: +33 3 20 17 19 51
http://www.metrovision.com
2015 Metrovision
TABLE OF CONTENTS
INTRODUCTION ........................................................................................................................................................... 5
EXAMINATION BASICS................................................................................................................................................. 7
MACULAR PIGMENT AND AGE RELATED MACULAR DEGENERATION ............................................................................ 8
MACULAR PIGMENTS AND NUTRITION .......................................................................................................................... 8
MACULAR PIGMENTS AND NUTRITION .................................................................................. ERREUR ! SIGNET NON DEFINI.
REALIZATION OF EXAMS ........................................................................................................................................... 11
PATIENT'S INSTALLATION ............................................................................................................................................. 12
QUALITY CONTROL ....................................................................................................................................................... 14
EXPLOITATION OF RESULTS ....................................................................................................................................... 15
ACCESS TO RESULTS ...................................................................................................................................................... 16
MACULAR PIGMENTS ANALYSIS ................................................................................................................................... 16
OTHER ANALYSIS ........................................................................................................................................................... 16
PATIENT'S INFORMATION ............................................................................................................................................. 19
STORING THE RESULTS ................................................................................................................................................. 19
PRINTING THE RESULTS ................................................................................................................................................ 19
TECHNICAL SPECIFICATIONS ...................................................................................................................................... 21
CLINICAL EXAMPLES .................................................................................................................................................. 23
NORMAL VALUES ...................................................................................................................................................... 25
INFLUENCE OF DIET ....................................................................................................................................................... 26
INFLUENCE OF AGE ....................................................................................................................................................... 26
EDITION OF PROCEDURES ......................................................................................................................................... 27
BIBLIOGRAPHY .......................................................................................................................................................... 29
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Copyright 2015 Metrovision
Macular pigments
4 / 30
Introduction
INTRODUCTION
This document describes the use of the Test for macular pigment density application available on the Vision Monitor
system.
Before reading this document, you should be familiarized with the general information related to the
hardware and software of the Vision Monitor.
These information are available in the following documents:
DOCUMENT
5 / 30
CONTENU
The Vision Monitor Introduction and

general operation
General functions of the Vision Monitor software
Recommendations for the installation of

Vision Monitor Systems
Recommendations for the installation of equipment
Installation of MonPack3 system

Installation of MonCv3 system
Installation and safety of the equipment
Macular pigments
6 / 30
Examination basics
EXAMINATION BASICS
7 / 30
Macular pigments
MACULAR PIGMENT AND AGE RELATED MACULAR DEGENERATION

The fovea region of the retina has a yellow color due
to the high concentration of a non-bleachable pigment
called the macular pigment.
This pigment has a filtration effect of blue light. On
average it absorbs 60 percent of the blue light, but
inter-individual variations are very large.
(WALD, 1945)
It has been shown that the pigment density is
maximum at the fovea and that it decreases sharply
with eccentricity to reach a rather constant value at
about 4 degrees.
(SNODDERLY & al, 1984)
Photographs of a cross section of the central retina in
primate retina under green (top) and blue (bottom)
illumination. Dark areas correspond to absorption of
light by pigment.
(SNODDERLY & al, 1984)
The macular pigment is believed to reduce the effect

of glare and to minimize chromatic aberration, so
improving visual acuity and contrast sensitivity.
(WHITEHEAD & al, 2006)
In relation with age related macular degeneration, the
blue light filtering effect may play a protective role
against oxidative retinal damage.
(WHITEHEAD & al, 2006)
It has been shown that dietary modification can
change the macular pigment density.
(HAMMOND & al, 1997)
MACULAR PIGMENTS AND NUTRITION
It has been shown that a change in alimentary diet or

the use of nutritional supplements may change the
density of macular pigments.
(HAMMOND & al, 1997, DESMETTRE, LECERF& SOUIED,
2004)
MEASUREMENT OF THE MACULAR PIGMENT DENSITY

Several psychophysical techniques have been
proposed to estimate the spatial distribution of
macular pigment optical density.
One technique is the hetero chromatic flicker

technique (STABELL & STABELL, 1980) which is
frequently used in recent research studies.
They have a common basic principle which is to

compare the sensitivity of the patient to blue light to
his/her sensitivity to another wavelength such as red
light which is not absorbed by the pigment.
It consists in alternating rapidly two lights of different

colors (blue and red for example). This alternation is
perceived as a flicker. The luminance
of one of the two sources is then
8 / 30
Examination basics
adjusted to obtain a minimum perception of flicker,

which corresponds to an equal luminance of the two
sources.
The hetero chromatic flicker technique allows faster

measurements but appears to be very difficult for
patients with little experience.
Another technique is using differential thresholds

(WILLIAMS & al, 1981) which consists in comparing
differential thresholds obtained with blue and red light.
It is similar to the classic visual field test except for
the use of chromatic stimuli.
The differential threshold technique is found to be

more reliable for clinical applications and for this
reason has been selected on the Vision Monitor.
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Macular pigments
10 / 30
Realization of exams
REALIZATION OF EXAMS
11 / 30
Macular pigments
PATIENT'S INSTALLATION
First step:
Second step:
Click on
to access to the identification
of the patient and examined eye.
Click on the icon which corresponds to the selected

examination protocol.
Enter the birth date to allow the program to

determine the age of the patient.
Adjust the height of the seat and of the electric table

(if available) to achieve the best possible comfort for
the patient.
This data is very important because it is used to

adjust the starting value of the tests and to compute
the normal values of thresholds.
Place an occluder over the non-tested eye.
If the birth date is not entered, the program will

assume that the patient is 20 years old.
Place the optical correction for near vision (1 ft).

The optimal refractive correction takes into account
the correction for distance vision (sphere and cylinder)
with an addition depending on the age of the patient:
Age (years)
Addition to the far vision

correction
< 30
30-39
+0.50
40-44
+1.00
45-49
+1.50
50-55
+2.25
> 55
+3.00
The correction used for the exam can be computed
Notes:
automatically by clicking on button

identification of the patient.
(1) The correction for astigmatism is taken into

account by adding half the value of the cylinder
correction to the spherical correction.
during the
Enter the sphere and cylinder for distance vision and

the program automatically fills the Correction with
the value to be used during the exam.
(2) When the pupils are dilated with a mydriatic agent

that paralyses the accommodation, refractive
correction does no longer depend on age. In that case,
select the option dilated pupils.
(3) The correction value given by the program
corresponds to the nearest correction available in the
set of large field lenses provided by Metrovision.
However, it is possible to obtain the exact spherical
correction putting in the configuration file the
following lines:
[REFRACTION]
metrovision=false
12 / 30
Realization of exams
Adjust the vertical position of the chin rest with

command button 1 so that the examined eye is at the
level of the eye marks 2.
Second step: measurement of peripheral thresholds

for red and blue
The visual stimulator displays a central fixation dot.
On the video control, the tested eye should be within

the rectangular control area.
First step: measurement of the foveolar threshold for

red and blue
The visual stimulator displays a circle, in the middle of
which blue and red stimulus will be presented.
The patient must fixate the central dot and use the
press button every time a point appears in the
periphery.
If the fixation dot is not clearly visible, press on button
to increase its size.
Click on the
presentation of stimuli.
button to start the
Automatic fixation control

If the device is equipped with the option automatic
fixation control, initialize it by clicking on button
.
If its not equipped with this option, the fixation

control is made by presentation of tests inside the
blind spot.
Explain the patient that he/she will have to press the
button every time a stimulus will be presented.
Click on the
presentation of stimuli..
13 / 30
button to start the
The program measures the direction of the glance that

will be used as reference to detect the patients
fixation errors. A message superposed on the eye
image will appear to indicate the initialization results.
If the initialization is successful the
patients responses will be invalidated
Macular pigments
in case of fixation errors. If it fails, repeat the

command or click on button
that will
detect eye movements in the process of the exam.
You can also measure the pupil by clicking on button
on the right side of the video control window.
Duration between the presentation of

tests
This duration is displayed on button
.
It can be modified in the process of the exam by
clicking on this button if the rhythm of the test
presentation is too quick for the patient.
QUALITY CONTROL
The information bar down the exam window enables a
quick evaluation of the exam in process. The items are
green when the results are of good quality and red in
case of problem.
The number of validated measures regard to the

number of measures programmed enables to
evaluate the progress of the exam.
The patients attention is periodically controlled

with the presentation of fake tests which are not
seen.
The responses to these fake tests are counted as
attention losses (here 2) compared to the number
of control tests (here /22).
If the patients response times are abnormally fast,
it will also be posted as attention losses.
The quality of the patients fixation is indicated by

the number of fixation losses (here 1) compared to
the number of control tests (here /19).
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Exploitation of results
EXPLOITATION OF RESULTS
15 / 30
Macular pigments
ACCESS TO RESULTS
Results are accessible directly at the end of each examination or can be accessed from the hard disk when they have
been recorded.
MACULAR PIGMENTS ANALYSIS
Result from a subject with a normal optical density of

macular pigments
This graph shows up the attenuation of blue

thresholds by the macular pigment.
The estimated value for the optical density of macular
pigments is displayed under the graph.
The deficit corresponds to the difference between the
result obtained on the patient and the average of a
reference group of subjects with a recommended diet
(refer to chapter on normal values).
A positive deficit shows that the pigments optical
density is lower than this average. The value of the
deficit is followed by the statistical value of the result
when compared to a group a subjects with a
recommended diet.
For each result, the graph above shows the absolute

threshold values versus the eccentricity measured
with red tests (red curve) and blue tests (blue curve).
Each curve is obtained from the foveolar threshold,
the average of measured thresholds at 2 degrees of
eccentricity and the average of measured thresholds
at 10 degrees of eccentricity.
The graph on the right shows the relative thresholds,
that is to say the threshold difference between fovea
and periphery (at 10 degrees of eccentricity).
It enables to eliminate the eventual influence of
absorption of the blue by the crystalline lens which is
supposed to be identical for central and peripheral
measures.
Result from a subject with an abnormally low macular

pigment optical density
OTHER ANALYSIS
Several analyses can be performed:
the visual field analysis
the follow-up analysis
the comparison with the image of the eye

fundus
Easy way: the different analysis can also be selected

directly from the results' menu.
16 / 30
Visual field analysis

This analysis allows visualizing the threshold of the
tested points.
The results are displayed in blue for blue tests and in
red for red tests.
Superposition of the visual field and eye

fundus
This analysis allows the superposition of visual field
map on the image of the patient's eye fundus.
The superposition method is that proposed by Pr BEK
(BEK T. Accurate superimposition of visual field data
onto fundus photographs, Acta Ophthalmol.
1990,68,11-18).
Follow-up analysis
This analysis allows the evaluation of the evolution of
the patient over several consecutive exams.
The program automatically searches on the hard disk
all the exams performed with the same patient's name,
with the same tested eye and the same birth date.
When the analysis is started, a new window entitled

"SUPERIMPOSE IMAGE OF EYE FUNDUS" is displayed
with a map of the values of measured points.
Note: this map is reversed "upside down" with
respect to the visual field map so that it can be
superimposed over the image of the eye fundus.
The program displays the list of exams in chronological

order.
Evolution of indices
This graph represents the evolution in time of each of
the indices:
sensitivity at the fovea for blue and red

stimuli
sensitivity in the periphery for blue and red

stimuli
macular score
17 / 30
The next step is to acquire the digital image of the

eye fundus.
One click on button
opens a menu
allowing you to select the image file from the results
database.
Macular pigments
Perform
Note: use the
button in the control bar of the
Vision Monitor program to import a photograph in
the results database.
The photograph can be imported either through a
computer network or from a storage media such as a
USB key, a CDROM, etc
the
same
operation
with
button
and the corresponding point of the

image.
The program automatically adjusts the image and

displays the result of the superposition:
The program is compatible with the major image file

formats: JPEG, BMP, etc.
The image of the eye fundus should then appear in the

superposition window.
The next step is to define the position of the fovea and

the papilla that are used as references for a precise
superposition of the visual field map.
An additional click on button

allows
the restoration of the red component of the image.
Corrections:
In order to better identify these features, the red

component of the image can be eliminated by clicking
on button
- The position of the eye fundus image can be finely

adjusted with the arrow keys of the keyboard
"up", "down", "right" and "left".
- The magnification of the eye fundus image can be

finely adjusted by pressing simultaneously the
"SHIFT" key and the arrow keys of the keyboard
"up", "down", "right" and "left".
-
The image can also be rotated by pressing the

keys "page up" and "page down".
Axis:
Axis and parallels (every 5 degrees of eccentricity) can
be added with a simple click on button
Click on button
and then click on
the corresponding point of the image.
18 / 30
Printing the results, exporting the results to other

applications
To print the final result, click on
To
save
the
result
, or on
image
click
on
button
to make a copy in the
clipboard
PATIENT'S INFORMATION
This command gives access to the patient's

information. It can be useful for adding comments
before recording or printing the result
STORING THE RESULTS

Click on button
on the hard disk.
to store the results
The reference number of the record appears on top of
the screen.
The crossed sign on the button indicates that the
result has been stored.
PRINTING THE RESULTS

The print command allows printing the visual field
result and the different analysis.
Easy way: you can also print the results and the
different analysis directly from the results' menu.
The crossed sign on the button indicates that the

result has been printed.
19 / 30
Macular pigments
20 / 30
Technical specifications
TECHNICAL SPECIFICATIONS
The tests are presented over a white background with a luminance of 10 cd/m2.
The size of the chromatic tests is equivalent to Goldmann size III.
The reference luminance (0 dB) corresponds to 65 cd/m2 for the red tests and 27 cd/m2 for the blue tests.
21 / 30
Macular pigments
22 / 30
Clinical examples
CLINICAL EXAMPLES
23 / 30
Macular pigments
Subject with a normal optical density of macular pigments.
Patient with an abnormally low macular pigments density and a diet poor in lutein and zeaxanthin
24 / 30
Normal values
NORMAL VALUES
25 / 30
Macular pigments
INFLUENCE OF DIET
Source: CROCHET & al. Evaluation of macular pigment
optical density with a color perimetry technique.
Normal values and influence of diet. ARVO 2009.
Method:
Exams were performed on 54 subjects with normal
visual acuity, normal eye fundus and no ophthalmic
disease.
Subjects were interviewed about their dietary habits
by a questionnaire written for this study according to a
list of foods established by Pasteur Institute in Lille (Pr
Lecerf) and classified into two groups:
One with a recommended diet consisting of

more than 5 fruits and vegetables rich in
Lutein and Zeaxanthin and fat fish, omega 3
and no smoking habit.
Another group with the subjects who did not

match these criteria.
The figure hereby shows the distribution of the results

from the two groups.
The group with a
recommended diet has a significantly higher MPOD
(average value = 5.06 dB, standard deviation = 1.9 dB)
than the group with a poor diet (average value =
2.30 dB, standard deviation = 1.5 dB).
The difference between the 2 populations is highly
significant (p < 0.0001).
MPOD (dB)
Results: The average value of the macular pigment

optical density (MPOD) in the tested population was
3.49 db (0.349 log units) with a standard deviation of
2.0 dB.
Recommended
diet
Non recommended
diet
INFLUENCE OF AGE
Foveolar thresholds for blue and red chromatic tests
as a function of age
Between 20 and 60 years of age, the sensitivity
thresholds decrease with age by 5 dB for the red
stimuli and by 7 dB for the blue stimuli. The dispersion
of the results also increases with age.
26 / 30
Blue and red test thresholds in the peri foveolar area

Between 20 and 60 years of age, the sensitivity
thresholds decrease with age by 4.5 dB for the red
stimuli and by 6 dB for the blue stimuli. The dispersion
of the results also increases with age.
Edition of procedures
EDITION OF PROCEDURES
Not available at the moment.
27 / 30
Macular pigments
28 / 30
Bibliography
BIBLIOGRAPHY
29 / 30
Macular pigments
CROCHET M., ZANLONGHI X., CHARLIER J. Evaluation of macular pigment optical density with a color
perimetry technique. Normal values and influence of diet. Poster, ARVO 2009.
DESMETTRE T., LECERF J.M., SOUIED E.H. Nutrition et dgnrescence maculaire lie lge
Ophtalmol., 2004, 27, 9: 3S38-3S56.
HADDAD W.M., SOUIED E., COSCAS G., SOUBRANE G. Pigment maculaire et dgnrescence maculaire
lies lge. Implications cliniques. Bull. Soc Belge Ophtalmol. 2006, 301, 15-22.
HAMMOND B.R., JOHNSON E.J., RUSSEL R.M. & al Dietary Modification of Human Macular Pigment Density
Invest Ophthalmol. Vis Sc. 1997, 38:1795-1801.
ROUGIER M.B., DELYFER M.N., KOROBELNIK J.F. Le pigment maculaire et sa mesure in vivo. J Fr. Ophtalmol.,
2008; 31, 4, 445-453.
SNODDERLY D.M., AURAN J.D., DELORI F.C. The Macular Pigment. II. Spatial Distribution in Primate Retinas.
Invest. Ophthalmol. Vis Sc. 1984, 25, 674-685.
STABELL U, STABELL B: Variation in density of macular pigmentation and in short-wave cone sensitivity with
eccentricity. J Opt Soc Am 70:706, 1980.
WALD G. Human vision and the spectrum. Science. 1945,101, 653-658.
WHITEHEAD A.J., MARES J.A., DANIS R.P. Macular Pigment A Review of Current Knowledge. Archives
Ophthalmology. 2006, 124, 1038-1045.
WILLIAMS DR, MACLEOD DIA, and HAYHOE MM: Punctate sensitivity of the blue-sensitive mechanism.
Vision Res. 21:1357, 1981.
30 / 30
J. Fr.

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USERS MANUAL

METROVISION - 4 rue des Platanes 59840 PERENCHIES FRANCE

Copyright 2015 Metrovision

Copyright 2015 Metrovision

These information are available in the following documents:

The Vision Monitor Introduction and

General functions of the Vision Monitor software

Recommendations for the installation of

Recommendations for the installation of equipment

Installation of MonPack3 system

Installation and safety of the equipment

Copyright 2015 Metrovision

Copyright 2015 Metrovision

Copyright 2015 Metrovision

MACULAR PIGMENT AND AGE RELATED MACULAR DEGENERATION

The macular pigment is believed to reduce the effect

MACULAR PIGMENTS AND NUTRITION

It has been shown that a change in alimentary diet or

MEASUREMENT OF THE MACULAR PIGMENT DENSITY

One technique is the hetero chromatic flicker

They have a common basic principle which is to

It consists in alternating rapidly two lights of different

Copyright 2015 Metrovision

adjusted to obtain a minimum perception of flicker,

The hetero chromatic flicker technique allows faster

Another technique is using differential thresholds

The differential threshold technique is found to be

Copyright 2015 Metrovision

Copyright 2015 Metrovision

Copyright 2015 Metrovision

Click on the icon which corresponds to the selected

Enter the birth date to allow the program to

Adjust the height of the seat and of the electric table

This data is very important because it is used to

Place an occluder over the non-tested eye.

If the birth date is not entered, the program will

Place the optical correction for near vision (1 ft).

Addition to the far vision

The correction used for the exam can be computed

automatically by clicking on button

(1) The correction for astigmatism is taken into

Enter the sphere and cylinder for distance vision and

(2) When the pupils are dilated with a mydriatic agent

Copyright 2015 Metrovision

Adjust the vertical position of the chin rest with

Second step: measurement of peripheral thresholds

On the video control, the tested eye should be within

First step: measurement of the foveolar threshold for

button to start the

Automatic fixation control

If its not equipped with this option, the fixation

button to start the

The program measures the direction of the glance that

Copyright 2015 Metrovision

in case of fixation errors. If it fails, repeat the

Duration between the presentation of

The number of validated measures regard to the

The patients attention is periodically controlled

The quality of the patients fixation is indicated by

Copyright 2015 Metrovision

Copyright 2015 Metrovision

MACULAR PIGMENTS ANALYSIS

Result from a subject with a normal optical density of