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Primary Eye

A Comprehensive Guide
to Diagnosis
Jong-Soo Lee 

Primary Eye Examination
Jong-Soo Lee

Primary Eye
A Comprehensive Guide to
Jong-Soo Lee
Department of Ophthalmology
Pusan National University School of Medicine
South Korea

ISBN 978-981-10-6939-0    ISBN 978-981-10-6940-6 (eBook)

Library of Congress Control Number: 2018968146

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1 Visual Acuity Test����������������������������������������������������������������������������   1

Ji-Eun Lee
2 Refraction and Glasses Exam ��������������������������������������������������������  13
Ji-Eun Lee
3 Accommodation and Convergence ������������������������������������������������  31
Jae Ho Jung
4 Color Vision��������������������������������������������������������������������������������������  37
Jong-Ho Park
5 Ocular Alignment and Movement Exam ��������������������������������������  47
Hye-Shin Jeon, Jung-Yul Park, and Hee-Young Choi
6 Binocular Function Test������������������������������������������������������������������  71
Hye-Shin Jeon and Hee-Young Choi
7 Eyelid and Lacrimal System Exam������������������������������������������������  83
Jung-Yul Park and Hee-Young Choi
8 Slit Lamp Exam������������������������������������������������������������������������������� 101
Jong-Soo Lee
9 Conjunctiva and Cornea Exam������������������������������������������������������ 113
Jong-Soo Lee
10 Pupil Exam �������������������������������������������������������������������������������������� 137
Jae Ho Jung
11 Tonometry���������������������������������������������������������������������������������������� 149
Jong-Hoon Shin
12 Anterior Chamber Angle Exam������������������������������������������������������ 163
Keun-Heung Park
13 Optic Nerve Head and Retinal Nerve Fiber Exam ���������������������� 173
Keun-Heung Park
14 Visual Field Test ������������������������������������������������������������������������������ 179
Ji-Woong Lee

vi Contents

15 Fundus Examination������������������������������������������������������������������������ 209

Han-Jo Kwon and Sung-Who Park
16 Fluorescein and Indocyanine Green Angiography����������������������� 229
Ik-Soo Byon
17 Ultrasound Exam ���������������������������������������������������������������������������� 243
Young-Min Park and Seung-Min Lee
18 Optical Coherence Tomography ���������������������������������������������������� 263
Ji-Eun Lee, Je-Hyun Seo, and Young-Min Park
19 Electrophysiologic Test�������������������������������������������������������������������� 295
Jae-Jung Lee and Sung-Who Park
Visual Acuity Test
Ji-Eun Lee

The visual acuity test is the best way to show 1.1 Distant Vision Test
the status of eye. It includes uncorrected and
corrected visual acuity, distant and near visual 1.1.1 Indication
acuity, binocular and monocular visual acuity,
decimal and fractional visual acuity, visual acu- It is possible to examine at 3 years of age or older.
ity measured with one and parallel object, log- At 3–8 years of age, the visual acuity is measured
MAR (minimal angle of resolution) visual higher when using single object chart than the
acuity, and central and out-of-central visual parallel chart. That is, all persons who can read
acuity. In general, visual acuity is the central the target in the visual acuity chart are all
visual acuity when viewed from the foveola. candidates.
The visual acuity in ophthalmology refers to
the corrected visual acuity which is the cor-
rected visual acuity measured by refraction. If 1.1.2 Purpose
the uncorrected visual acuity is poor and the
corrected visual acuity is good, the refractive The causes of visual impairment include refrac-
error should be considered. If the corrected tive errors and eye diseases involving visual path-
visual acuity is bad, a pathology from the eye to way. The refractive error can be improved by
the central nervous system should be consid- correction, but for the cases of eye diseases, it is
ered. The appropriate visual acuity test should difficult to improve the visual acuity only by cor-
be selected and recorded according to the sub- recting the refractive error. Therefore, visual acu-
ject and purpose. If the patient has the history ity test can be a great help in determining the
of using contact lenses, cataract surgery, or cause of vision impairment.
LASIK surgery, record them on your visual
acuity chart.
1.1.3 Method How to Represent Visual Acuity

The minimum separable visual acuity represents
the ability to distinguish between two points or
two lines. The angle formed by these two points
or two lines on the eye is called minimum visual
J.-E. Lee, MD., PhD. (*)
Department of Ophthalmology, Pusan National angle and is indicated by visual acuity. In other
University School of Medicine, Busan, South Korea words, the angle formed by the two straight lines

© Springer Nature Singapore Pte Ltd. 2019 1

J.-S. Lee (ed.), Primary Eye Examination,
2 J.-E. Lee

The logarithmic visual acuity chart displays

a the visual acuity in logMAR, which is the loga-
b rithm of the minimal angle of resolution (MAR).
Each step of the visual acuity chart is at the same
b Q
interval, so an arithmetic average is possible to be
Fig. 1.1  The reciprocal of the minimum visual angle is The logarithmic visual acuity chart has five
visual acuity. If the visual angle Q is 2 minutes, the visual characters per line, and the left and right charac-
acuity is 0.5 ter spacing is a spacing of the size of each charac-
ter, and the size ratio of the large character and
from the two points of the object under consider- the lower character is kept at a constant ratio of
ation to the nodal point of the eye is referred to as about 5:4, respectively. The spacing between the
the visual angle, and the size of the retinal image upper and lower lines is the size of the character
is determined thereby. The closer the distance of in the lower row. They are arranged at the same
the same size object is from the eye, the closer interval at which the index is reduced by 0.1 by
the visual angle becomes. The larger the size of one logMAR at the top. This visual acuity chart is
the object at the same distance, the larger is the used at a distance of 4 m. It can measure up to
visual angle. Visual acuity is represented by the 20/957, that is, 0.02 at 1 m, which is useful for
reciprocal of visual angle, visual acuity = 1/visual patients with low vision.
angle (minute) (Fig. 1.1).
Decimal Visual Acuity Visual Acuity Chart This is the method of displaying the reciprocal of
The visual acuity chart includes a decimal visual the minimum visual angle as a decimal. That is,
acuity chart, a fractional visual acuity chart when the minimum visual angle is 1 minute, it is
(Snellen visual acuity chart), and a logMAR displayed as 1.0, and the index number (0.1, 0.15,
chart. The devices of the visual acuity chart 0.2, etc.) on the visual acuity chart is displayed as
include reflection type, transmission type, and it is.
projection type.
The decimal visual acuity is 0.1 intervals Fractional Visual Acuity
from 0.1 to 1.0 and 1.2, 1.5, and 2.0 afterward. It is widely used in Europe. Write the test dis-
Because it is expressed as a reciprocal of the tance on the numerator and the test number on
minimum visual angle, the arrangement does not the denominator. The character width of the
show the same interval. 0.1 and 0.2 and 0.9 and number 20 will have a visual angle of 1 minute
1.0 are both one step, but the visual angle is at 20 feet, and if you look at it at 20 feet, your
10  minutes and 5  minutes in the former and visual acuity will be 20/20, and you will have
1.1 minutes and 1 minute in the latter. The for- normal vision. The test distance is usually
mer is twice the difference, and the latter is 1.1 20  feet or 6  m. 20/40 is equivalent to 0.5, but
times, which does not represent the same differ- does not convert the fraction to a decimal. It is
ence. Therefore, if 0.125 and 0.16 are inserted an old custom to use fractional visual acuity in
between 0.1 and 0.2, 0.25 is inserted between 0.2 Europe.
and 0.3, and 0.7 and 0.9 are subtracted, the
arrangement of decimal visual acuity chart Algebraic Visual Acuity
becomes almost equal. In the United States, logMAR is used to display.
The fractional visual acuity (Snellen method) Decimal visual acuity (VA) is VA  =  1/MAR in
has the same arrangement of visual acuity, and which logMAR is the logarithm of MAR. In the
unlike the decimal visual acuity charts, it is pos- reciprocal relationship, the absolute value is the
sible to indicate by two-step visual acuity increase same, but “–” is added so that
or decrease. logVA = −logMAR.
1  Visual Acuity Test 3

Table 1.1  The comparison of distant visual acuity

Fractional visual
Decimal visual acuity acuity log MAR
0.10 (0.1) 20/200 6/60 +1.0
0.125 20/160 6/48 +0.9
0.16 20/125 6/38 +0.8
0.20 (0.2) 20/100 6/30 +0.7
0.25 20/80 6/24 +0.6
0.32 (0.3) 20/63 6/20 +0.5
0.40 (0.4) 20/50 6/15 +0.4
0.50 (0.5) 20/40 6/12 +0.3
0.63 (0.6) 20/32 6/10 +0.2
0.80 (0.8) 20/25 6/7.5 +0.1
1.00 (1.0) 20/20 6/6 0.0
1.25 (1.2) 20/16 6/5 −0.1
1.60 (1.5) 20/12.5 6/3.75 −0.2
2.00 (2.0) 20/10 6/3 −0.3 Fig. 1.2  ETDRS visual acuity chart

The logarithm is the logarithm of 10, and the but logMAR is calculated from the number of
decimal visual acuity comes from 10−logMAR. The characters the patient reads. The difference
minimum visual angle of 1 min (1/60°) is 1.0 in between each line in the ETDRS chart is 0.1 log-
decimal visual acuity and 0  in logMAR visual MAR, and there are five characters in each line,
acuity from log 1. Decimal visual acuity, frac- so one character corresponds to 0.02 log-
tional visual acuity, and logMAR conversion are MAR.  Therefore, it is possible to evaluate the
shown in Table 1.1. visual acuity five times as detail as the conven-
ETDRS (diabetic retinopathy study) visual tional visual acuity chart and is also useful for
acuity chart by Ferris has been used recently. measurement of low vision. At the time of 4  m
ETDRS (logMAR indication) visual acuity chart measurement, it is obtained by subtracting the
is carried out as follows. number of character or the number × 0.02. For
Sit at a distance of 1 m or 4 m to shield the left example, if five of five characters of +0.4 (deci-
eye. (Corrected visual acuity is measured after mal visual acuity of 0.4) line can be read and two
correcting refractive error using chart R). Have out of five characters at +0.3 (decimal visual acu-
an eye chart for the right eye (chart 1), one line at ity of 0.5) line can be read, logMAR is
a time, from top to bottom. For example, let’s +0.4 − (0.02 × 2) = +0.36.
read from left to right and then right to left. For low vision, test can be made at 3.2, 2.5,
Calculate the number of correct answers. In case 2.0, 1.6, 1.3, and 1 m, and the measured values​​
of low vision, test is performed at 1 m. Place the at these distances can be added to the logMAR
patient in a 1  m position and insert a +0.75D values at 4 m by adding 0.1, 0.2, 0.3, 0.4, 0.5,
spherical lens. As in the case of 4 m, calculate the and 0.6 respectively. For example, when 1 m is
number of character by reading the chart from the measured, it is obtained in the same manner as
top by one line. The visual acuity chart for the the 4  m measurement, and 0.6 is added to the
left eye (chart 2) is used to perform the same value. When logMAR is +1.0 at 1  m,
visual acuity test as the right eye (Fig. 1.2). +1.0 + 0.6 = +1.6.
Unlike the decimal visual acuity test, if the For the results, it is recommended to use a
patient reads four or more characters on one line, dedicated result sheet. Check the unread charac-
the next line is checked. If you only read three or ter with an X mark, and calculate the logMAR
less characters, the patient is stopped on that line. with the number of read marks. It is general to
The result is not determined from the line read, record the visual acuity results numerically, but
4 J.-E. Lee

sometimes the number of characters read is Illuminance of Visual Acuity Chart

recorded together. The test distance of ETDRS In general, the luminous intensity of the visual
chart is usually 4 m, but one character is added acuity chart is 500 ± 125 lux. If the illumination
when reading the largest character at 1  m. of the visual acuity chart is adjusted to about
Therefore, if 4  m is used, add 30 characters 500–1000 lux, it is good as a semi-standard chart
because reading at 4 m is the same as reading 30 apparatus.
Test Distance Standard Visual Acuity The distance vision test is performed at a distance
Measurement of 3–6 m. If a 5 m visual acuity chart is installed,
it is accommodated to 0.2 diopter in emmetropic
Type of Visual Target eye. Therefore, myopia of −0.2D is judged on
At the 1909 International Eye Society, the emmetropia. The test distance in foreign coun-
Landolt ring was defined as a standard character. tries is 6  m or 20  feet. At this time, the patient
The International Organization for faces the chart, and the height of the visual acuity
Standardization (ISO) agreements between 1980 chart is such that the index of 1.0 is the height of
and 1981 require the use of the Landolt ring as a the patient’s eye.
standard target (Fig. 1.3).
The 1.5 mm wide grating of the Landolt ring Indoor Lighting
with a diameter of 7.5 mm and a width of 1.5 mm Indoor illumination affects vision. For example,
is made to be 1 minute at a test distance of 5 m. if only the visual acuity chart is illuminated and
The visual acuity at this time is 1.0. Snellen “E” when the surroundings are dark, night vision will
is also designed with the same principle. occur, and the visual acuity will be decreased,
However, the character visual acuity chart is used and the influence of the pupil should be consid-
mainly for the purpose of quick examination of ered. The vision test is best measured in its natu-
clinical charts. This was determined by a com- ral state and should therefore be done in bright
parative experiment with the Landolt ring, which places in principle. The lighting should be evenly
can be used in semi-standard test equipment. brighter than 50 lux.

1' 5' 1' 5'

Fig. 1.3  Snellen E and Landolt ring

1  Visual Acuity Test 5 Measurement of Visual Acuity Table 1.2  International visual acuity chart
at 5 m Visual
Measure one eye at a distance of 5  m from the acuity Definition
chart. When a target of 0.1 is not visible at a dis- 1.0 Normal visual acuity, identifying the
interval of the standard Landolt ring
tance of 5 m, the target is approached to the posi- (visual angle of 1 minute) at 5 m distance
tion where the target of 0.1 can be seen. If the 0.5−2 The patient cannot read two of the
distance from the target is X m, the visual acuity characters at 0.5
is 0.1 × X/5. For example, if you read a 0.1 target 0.06 Visible to identify the largest target at 3m
at 2 m, your visual acuity will be 0.1 × 2/5 = 0.04. distance
If the target of 0.1 is not readable at a distance of FC/30 cm Finger count at 30 cm, also known as CF
(counter finger), when the patient cannot
1 m, the number of the target is set by the exam- read the largest target even at a distance
iner’s finger in front of the eye. For example, if of 50 cm
the number of fingers is adjusted to 30  cm, the HM Although the number of fingers cannot be
finger is counted as “FC (finger count)/30 cm.” If visible, the patient can notice the hand
moving (hand movement or hand motion)
you cannot count your fingers, but you can only
LP When the patient do not recognize hand
see the motion of your hand shaking in front of motion, you can determine if there is
your eyes, then your vision is recorded as hand light in the darkroom
movement (HM). When the patient do not know LP/proj The patient can recognize the brightness
the movement of your hand and notices the light or direction of the light
at darkroom, you should write light perception LP/no The patient can notice whether there is
proj light or not, but cannot the direction of
(LP). The light is projected to the eye in the up, light
down, left, and right directions, and it is asked 0 The patient cannot detect the light
about the projection direction. If you answer this
accurately, it is said that light projection is good.
When the light direction is clear, it can be recommended to keep the patient eyes open so
assumed that there is no significant change in the that you do not frown.
retina. If there is no light perception, the visual When the pupil enlargement is performed, a
acuity is written as zero. This is a strict definition 3 mm pinhole plate can be used. If the pinhole is
of blindness. used, the depth of focus is deepened to increase
the visual acuity. If the pinhole visual acuity is
decreased, the corneal opacity, cataract, vitreous
1.1.4 Interpretation opacity, or macular abnormality is suspected.
Children under 8 years old, especially children
The subject’s visual acuity is used as the visual under 6  years old, are precisely measured with
acuity number when reading more than half of using a stand-alone basis visual acuity chart. When
the acuity charts. If the number is less than half, observing the progress of visual acuity change, it
it means that the visual acuity is partially shown, should be done under the same conditions as before.
but the visual acuity value of “p” cannot be
applied when writing in the paper. According to
ISO, if you fail to read more than two, the visual 1.1.5 Record of Visual Acuity
acuity of the preceding step is taken as the visual
acuity of the eye (Table 1.2). Uncorrected visual acuity refers to visual acuity
You must check the printability of the target, without wearing glasses or contact lenses, but
the brightness of the visual acuity chart, and the radial keratotomy, PRK (photorefractive keratec-
standard of indoor illumination. Be careful not to tomy), laser in situ keratomileusis (LASIK) and
squeeze the patient’s eyes when the patient cov- laser epithelial keratomileusis (LASEK), pseudo-
ers the eyes. If the patient has strong light stimuli, phakia with intraocular lens implantation, or pha-
check after about 5 minutes. During the test, it is kic IOL insertion should be recorded.
6 J.-E. Lee

The right eye is recorded as VOD, RV, or vd, Hyperopia

and the left eye is recorded as VOS, LV, or vs. In case of latent hyperopia having good distant
Both eyes are recorded as OU. visual acuity, it is easy to think that prescription
VOD: 0.8  ×  IOL (1.2  ×  −1.50 D): 0.8 with of glasses is unnecessary. However, the patient
pseudophakia and 1.2 with adding glasses needs great accommodation effort for near target
VOS: 0.5 × LASIK (1.0 × −0.5 D): 0.5 with and does not like reading or complains of asthe-
LASIK surgery and 1.0 with adding glasses nopia. In the case of mild hyperopia, the specta-
Contact lenses, RK, PRK, LASEK, and pha- cle lens can cause near visual impairment when
kic IOL are also recorded in the same manner. prescribing only for the distant vision. It is wise
Vcc or VAcc is used for recording the corrected to decide the lens power that focuses on near
visual acuity, and VAsc is used for recording the vision even if it is a little overcorrected at a
uncorrected visual acuity. distance. Patients in Bed

1.1.6 Pinhole (PH) Visual Acuity If the patient is unable to perform a distant visual
acuity test, the visual acuity can be roughly deter-
It is used for the purpose of determining whether mined by measuring the near visual acuity in a
vision loss is correctable by glasses. Focal depth lying state.
is deepened and retina image is cleared by using
pinhole. If the patient’s visual acuity improves Amblyopia
more than two lines, there is a high possibility of According to the Moore-Johnson method or the
refractive error. When using glasses and having near penalization method, atropine is instilled in
visual acuity of 20/30 or less, the pinhole visual the normal eye, and the near vision is made into
acuity test method should be performed and is as the amblyopia to optically shield the normal eye
follows. One eye is covered, and a pinhole plate at near vision. At this time, check that the degree
with a diameter of less than 2.4 mm is placed in of near vision in the normal eye is suppressed
front of the other eye to measure the distant enough and worse than the near visual acuity of
visual acuity. Record the visual acuity of pinhole amblyopic eye.
after corrected distant visual acuity. For
example: Assessment of Visual Acuity for
VAcc OD: 0.4+2 PH: 0.6
visually handicapped
VAsc OD: 0.5+1 PHNI: When there is no It is based on the reading and writing ability, and
improvement in visual acuity (no it is the evidence data to choose the public school,
improvement) the school for amblyopia, or the school for

1.2 Near Visual Acuity

1.2.2 Method
1.2.1 Indications and Purposes
Using a near vision chart, measure visual acuity Accommodation Disturbance at the distance of 30 cm. The bright indoor level
due to Presbyopia is enough to be tested, and the illuminance should
Near visual acuity should be tested for the be 400–800 lux. If the largest target cannot be
purpose of measuring the degree of near read, the test distance should be shorter. For
vision disturbace, determining whether the example, if a target of 0.1 is read at 15 cm, the
near vision glasses are suitable, and prescrib- visual acuity becomes 0.1 × 15/30 = 0.05, which
ing the lens power suitable for the near vision is not a near visual acuity of the original meaning
glasses. but a visual acuity indicating at least how many
1  Visual Acuity Test 7

Table 1.3  The comparison of near visual acuity acuity measures the ability of the eye to resolve the
Decimal Fractional Jaeger Point fine objects, but does not adequately represent the
method method method method ability to see objects with low contrast. In visual
1.0 20/20 J1 N3 abnormalities such as cerebral abnormalities, optic
0.8 20/25 J2 N4 neuritis associated with multiple sclerosis, glau-
0.5 20/40 J4 N6 coma, diabetic retinopathy, and amblyopia, visual
0.2 20/100 J13 N14
acuity is close to normal, but contrast sensitivity
0.1 20/200 J16 N30
decreases. For example, the VCTS, CSV-1000,
Regan letter chart, Vistest picture test, and Pelli-
characters can be read. At this time, the record Robson letter sensitivity chart are examples of
should be written in 0.1 (15 cm). A large target of devices that can test the spatial frequency.
0.1 or less should be prepared as the maximum
1.3.1 Indication and Purpose

1.2.3 Interpretation The purpose is to find out the causes of visual dete-
rioration that cannot be found in visual acuity test.
When reading 3/4 or 4/5 or more characters, it is When the contrast sensitivity of a normal person is
regarded as a visual acuity (Table 1.3). measured, the contrast becomes higher as the spa-
It is important to strictly set the test distance to tial frequency increases, highest as the spatial fre-
30 cm, and it is necessary to define the distance quency reaches the middle, and lower as the spatial
between the eyes and the target in a ruler or a frequency increases again. This spatial frequency
thread. The chart made in Europe and United is established under the optical system of the eye,
States should be careful because the test distance the intraretinal processing system, the neurotrans-
is set to 1/3 m (33 cm). Generally, the visual acu- mission system, and the information processing
ity chart printed on ordinary paper has a deterio- system of the visual cortex, so the specific pattern
ration of contrast sensitivity due to discoloration of contrast sensitivity represents the area where
due to years, so it is necessary to change it to a the defect happened. For example, a decrease in
new one every 3 years. The standard should have the contrast sensitivity in the high frequency
a contrast sensitivity of 85% or more. means a decrease in the visual acuity itself, and a
decrease in the maximum height means a decrease
in the retinal inhibitory effect. If the visual acuity
1.3 Contrast Sensitivity Test and fundus examination are both normal and the
contrast sensitivity of low frequency is decreased,
An object does not have the same brightness. a lesion that gives pressure on visual pathway such
This change of brightness is expressed as con- as optic neuritis, multiple sclerosis, or Parkinson’s
trast. Contrast sensitivity refers to how to distin- disease can be considered. However, spatial fre-
guish objects with different contrasts from one quency does not have diagnostic value to accu-
another. For example, there is a strong contrast rately determine the area of ​​the defect.
between the face and hair, but there is less con-
trast between the nose and mouth. The visual
acuity is related to the sensitivity of the retina. 1.3.2 Method
The amount of light and the background play a
more important role than the size of the object. The VCTS has a distance (3  m) and near test
That is, you can see stars in the middle of the charts which have approximately 1.5° size of the
night, but you cannot see them during the day. circle with 8 horizontally, 5 vertically, and 5
Snellen acuity has 100% contrast sensitivity blank vertical targets and a total of 45 targets.
and is completely black on white paper. Visual The target is arranged such that the contrast is
8 J.-E. Lee

Fig. 1.4  VCTS chart

decreased from left to right or the spatial fre- whether the contrast sensitivity of low frequency
quency is increased from the top to the bottom. area, the highest value area, or high frequency
High-contrast examples are shown for the pur- area is decreased.
pose of indicating that there are three kinds of
stripes with vertical, 10° right angled and 10° left
angled (Fig. 1.4). 1.4 Glare Test
There is a set containing one check sheet for
each of distant and near and a set containing three 1.4.1 Indication
sheets for each. In the 3-sheet set, the arrange-
ment of the patterns that can be placed on the 40 It is necessary to determine the surgical indica-
marks of each test chart is changed so that the tion of a case with media opacity such as cataract,
patient cannot memorize the direction of the after cataract, or corneal opacity or to observe
­target. Show the patient a sample of the mark on after the corneal refractive surgery.
the bottom of the checklist, and make a full
understanding what the check is. Begin the
examination from the top most target with the 1.4.2 Purpose
smallest spatial frequency. First, ask the patient
whether the direction of the stripe is vertical or Glare is the decrease of contrast sensitivity on the
whether it is tilted slightly to the left or right. If retinal image due to scattering of light in the eye.
the answer is correct, ask the direction of the tar- When there is opacity, the light is sometimes
get with low contrast on the right side, and repeat scattered when the light passes, so the patient
this until the patient cannot answer. Perform this sometimes complains of photopia, and the visual
procedure for the next four groups. Write the acuity in the strong and bright light is worse than
contrast sensitivity at each spatial frequency on the visual acuity measured by the normal visual
the recording paper (Fig. 1.5). acuity test.
The glare test measures the degree of glare
that cannot be checked by conventional visual
1.3.3 Interpretation acuity test, and it is the main purpose to deter-
mine the indication of cataract surgery. This is
The normal value displayed on the attached paper the example of the test using the Miller-Nadler
is compared with the recorded result to determine glare tester.
1  Visual Acuity Test 9

Fig. 1.5 VCTS CSV-1000 Contrast sensitivity

recording paper
8 b

7 b
8 t
6 t 8 t
7 b
5 t 7 t
6 b
4 b 6 b
5 b
3 t } 5 b 8 t
4 t
2 b } 20/50 4 t 7 b
3 t
1 b } 20/70 3 b 6 t
2 b
2 t 5 b
1 t
B } 20/100 1 b 4 t

3 b

X-OD C 2 t

1 t
Ages 60–69
Ages 70–80

3 6 12 18
Spatial frequency–(Cycles per degree)

Patient name Age Date

Functional acuity OD OS
Standard acuity OD OS


1.4.3 Method

The Miller-Nadler glare tester is a tabletop-­shaped

instrument that uses a projector to illuminate the
slides of the charts attached to the background
(Fig. 1.6). The target is a Landolt ring of 20/400
and is displayed in a 4 cm diameter circular back-
ground. It consists of 19 slides with a different
contrast between the target and the background
from 80% (No. 1 slide) to 2.5% (No. 19 slide).
The target is displayed in the center of the square
screen of the background light of 3200 lumens. Fig. 1.6  Miller-Nadler glare tester
10 J.-E. Lee

Fix the patient’s head at a distance of 36 cm a

from the projection plane. After correcting the
refractive error so that the patient can see well
at this distance, the target slides attached to the
background are projected onto the light source
from the No. 1 slide. Repeat the above proce-
dure by sequentially presenting slides with dif-
ferent contrast between the target and the
background. Obtain a glare disorder from the
contrast difference of the final slide that was

1.4.4 Interpretation b

The lower contrast slide (higher number slide) is

readable, the less glare disorder is. The glare dis-
order is expressed by the contrast value (%). For
example, if you read contrast value 80%, the
glare disorder is expressed as 80%. If the screen
illuminating the slide becomes dirty, the contrast
of the target will change, which can affect the test Fig. 1.7  The equipment of measuring optokinetic nys-
tagmus (OKN). (a) OKN inducing shaking drum. (b)
OKN inducing cloth pocket strip

1.5 Pediatric Visual Acuity 1.5.2 Method

1.5.1 Indication and Purpose Under 3 years old, it is possible to evaluate the
visual acuity through qualitative tests which
Pediatric patients can be tested with using include the reponse of the child, gaze, pursuit
Landolt ring from the age of 3 years old. In recent movement, eyelid reflex and optokinetic nystag-
years, screenings have been conducted in kinder- mus (OKN), and quantitative tests which include
gartens, so that visual development disorder in OKN, visual evoked potential, preferential look-
children can be detected in early stage. ing test, and grating acuity card. Landolt ring
The characteristics of visual acuity in children single object visual acuity test can be used for 3-
is better visual acuity because of using the to 7-year-old children, and Landolt ring parallel
Landolt ring instead of the character, the single visual acuity test for children over 8 years old.
object chart instead of parallel object chart, and
the near distance instead of 5 m distance. There is Response of Child
also a problem that it is difficult to interpret the When a child is suspected to have a visual dis-
result only by a single test. turbance, attention should be paid the child’s
Children cannot express their thoughts unlike expression, attitude, or behavior. Check whether
adults, so the cognitive ability of children can be the child is looking the eyes or the head by
tested through physical tests or electrocephalo- moving the milk bottle or the red target of the
gram. There are a number of tests that can be toys. Although there is a device such as Dayton
used to determine the development of visual acu- that uses nystagmus, OKN drum (Fig. 1.7a) or
ity in children. cloth pocket strip (Fig. 1.7b) is widely used. If
1  Visual Acuity Test 11

there is no response or no eye contact or no

response, check the eyelid blinking motion or
the light response by illuminating the pupil
with a pen light or strong light coming from the
side. Optokinetic Nystagmus OKN

It is a qualitative test that records the phenome-
non of nystagmus. This can record visual move-
ment response even in children who are not sure
to watch or respond. Rotate the belt with various
frequency bands (stripes) to cause nystagmus, Fig. 1.8  Preference looking test using TAC
and record the highest frequency band as a visual
looks into the hole in the middle of the two circu- Visual Evoked Potential lar targets. This test is simpler than OKN and
It is a method to see the reaction of the electroen- VEP and is for infant aged between 2–3 months
cephalogram by the stimulus coming from the and younger than 1 year.
eye by putting the electrode on the back part of If the child is able to talk, the examiner first
the head of the child, that is, the part where the shows a striped pattern and then displays a pat-
visual cortex is located. The visual stimulus uses tern less pattern. Make a child point in the direc-
western chessboard patterns, stripes, or stereo- tion of the screen by pointing the finger on the
scopic signs. When the pattern is seen, the brain screen.
wave is generated, and the size, thickness, or con- If the child is pointing at the target, the exam-
trast of the pattern becomes smaller. When the iner presents the target with the same width once
child cannot see, the brain wave is not generated. again. If the target is wrong, return the target with
Therefore, the visual acuity and stereoscopic bigger size. If the correct rate is over 75%, the
vision of the child are indirectly measured (see target value is regarded as a child’s PL visual
Chapter Electrophysiologic Test). acuity. If it is fully skilled, it takes about
5–10  minutes. Using the forced-choice method Preferential Looking (PL) Test and pointing method, it is possible to measure the
In 1962, Frantz performed the first visual acu- visual acuity from 2 to 3 months infant to 3-year-­
ity test for child, which used child’s interest in old child.
striped pictures. The device is a rear-project-
ing slide Awaya-Mohindra visual acuity test Grating Acuity Card
with two translucent circular windows with a In principle, it is the same as the preferential
diameter of 11° in the center of the screen, at a looking test. It is simpler and it is possible to per-
distance of 50  cm, projecting a stripe pattern form visual acuity test for premature infants and
and a uniform image from the back to the pro- newborn babies. Teller acuity cards (TAC), which
jector. The width of the stripe pattern varies are available from Vistech, are commonly used as
from 30.0 to 0.25 mm, the illuminance is about test cards (Fig. 1.8).
40 cd/m2, and the contrast sensitivity is about This shows the visual acuity card at a dis-
85–95%. tance of 38  cm and judges which side the
There are two methods, forced-choice and patient is looking at by eye movement. The
pointing. The forced-choice method shows a narrowest stripe target is regarded as a visual
black-and-white stripe pattern and a grayish-­ acuity. After confirming whether the child is
white uniform color to the child. The examiner staring at the card, the examiner can move the
12 J.-E. Lee

card about 15 cm from the center to the left or 1.5.3 Interpretation
right to judge the child’s eye movements. It
takes approximately 5 minutes and the success A 6-month-old infant has the same visual acuity
rate is reported as 80% for experienced as an adult with visual evoked potential test. The
examiner. preferential looking test shows that visual acuity
Measure the visual acuity by converting the reaches 20/20 of the adult at age 2. The preferen-
stripe spacing to visual angle. tial looking test records the visual acuity when
correct answer rate is 70% or more. If you do this Landolt Ring Vision Test way, it will take about 5–10 minutes to measure,
Because child from kindergarten to elementary and you will be less likely to miss the test. For
school is hard to read the parallel visual acuity Landolt visual acuity test, if three directions out
chart, especially in patient with amblyopia, it is of four directions are correct, it is regarded as a
recommended to use one object visual acuity visual acuity.
chart. If you repeat the parallel visual acuity
chart, the child may memorize all the visual acu-
ity charts, so it is better to use the one object Suggested Reading
visual acuity chart.
At first, binocular visual acuity is measured Bailey IL, Lovie JE.  New design principles for visual
acuity letter charts. Am J Optom Physiol Opt.
and then measure one by one. The infant does
not want to cover one eye, so measure the better Benjamin W.  Borish’s clinical refraction. 2nd ed. St.
one. At this time, when the eye is covered with Louis: Elsevier; 2006.
an occluder or black glasses, the child may turn Colenbrander A.  Measuring vision and vision loss,
Ch. 51. In: Duane’s clinical ophthalmology, vol. 5.
the eyes or head to look through the gap. So, it
Philadelphia: Lippincott Williams & Wilkins; 2009.
is better to patch one eye. Make a child watch a Davidson DW.  Visual acuity. In: Clinical procedures
0.1 target at a distance of 5 m. If the answer is in optometry. Philadelphia: Lippincott Williams &
not good at 5 m, reduce the distance and convert Wilkins; 1991.
Elliott DB, Whitaker D.  Clinical contrast sensitiv-
the visual acuity value. For child aged 3 years or
ity chart evaluation. Ophthalmic Physiol Opt.
older, make a child have a handle that mimics 1992;12(3):275–80.
the Landolt ring, and know the open direction. Fannin TE, Grosvenor T. Clinical optics. 2nd ed. Boston:
When the age increases, make a child point or Butterworth; 2002.
Garcia GE. Handbook of refraction. 4th ed. Boston: Little,
answer the open direction. If the answer is cor-
Brown and Company; 1989.
rect, change it to a smaller target, and record the Keirl A, Christie C. Clinical optics and refraction: a guide
visual acuity when answering more than three for optometrists, contact lens opticians, and dispens-
directions out of four directions. For a child who ing opticians. Edinburgh: Elsevier; 2007.
Macnaughton J.  Low vision assessment. Edinburgh:
cannot answer at initial visit, practice should be
Elsevier; 2005.
done at home and examine at next visit. If the Verweyen P.  Measuring vision in children. Community
difference between single and parallel target is Eye Health. 2004;17(50):27–9.
large, it is helpful to diagnose the amblyopic
Refraction and Glasses Exam
Ji-Eun Lee

It is an objective examination to check and cor- According to the refraction state of the eye, the
rect the refractive error (Fig. 2.1). reflected light is parallel in emmetropia, diverged
in hyperopia, and converged in myopia.

2.1 Objective Refraction Indication

Patients with refractive error, abnormal eye posi-
2.1.1 Skiascopy, Retinoscopy, tion, and asthenopia are candidates, and they
and Shadow Test should have retinal reflex.

When a light projects to the patient’s eye, the

light reaching the retina reflects out of the eye.

Fig. 2.1  The sequence Subjective refraction examination Objective refraction examination
of refraction
Spherical refractive error examination Skiascopy,
Correction with spherical lens
Astigmatic dial,
Cross cylinder lens

Correction with astigmatic lens

Re correction with spherical lens

Duochrome test,
Fogging method
Determination of refractive power

J.-E. Lee, MD., PhD. (*)

Department of Ophthalmology, Pusan National
University School of Medicine, Busan, South Korea

© Springer Nature Singapore Pte Ltd. 2019 13

J.-S. Lee (ed.), Primary Eye Examination,
14 J.-E. Lee

Fig. 2.2 Streak Reflective mirror Handle

Turn sleeves left and right

Move up and down

the retina in the pupil. Inspect the refractive Method error of the horizontal meridian. Then, turn the
There are a streak retinoscope, a spot retinoscope, sleeve of the retinoscope to the left or right to
and a specular retinoscope. The streak retino- select the horizontal light band, and move the
scope is the most commonly used method. retinoscope itself up and down to observe the
The descriptions of two methods are as fol- upward and downward movements of the light
lows: one for refraction test to keep the patient’s shadow to check the refraction of the vertical
point of view at a long distance and the other for meridian. There are three kinds of movement of
accommodation test to keep close at a near light shadow. If the moving direction of light
distance. shadows coincides with the insertion direction
The light band from the streak retinoscope of the light band, it moves “with movement.” If
(Fig.  2.2) can be used by turning the sleeve up it moves in the opposite direction, it is called
and down to adjust it to a light band of the paral- “against movement.” If the focus coincides with
lel, convergence and divergence. It is also possi- the position of the examiner’s eye, light shadow
ble to turn the sleeves to horizontal and vertical does not move, and this is called “neutraliza-
strips by turning them left or right. tion” (Fig. 2.3).
The following are the procedures using streak If the light shadow is “with movement,” it
retinoscope. means myopia less than −2 diopter (D), emme-
Prepare a streak retinoscope and trial lenses tropia, or hyperopia. Put a weak “+” lens in front
in a semi-darkroom. The examiner can have a of patient’s eye and observe the light shadow.
test distance of 50 cm, 67 cm, or 1 m with the Gradually increase the power of the “+” lens by
patient, but it usually sits at a distance of 50 cm. +0.5D and find the “neutralization” point. The
The patient should be in the state of accommo- power of lens at the time of switching from “with
dation free by viewing the point at least 5  m movement” to “against movement” means the
away from the back of the examiner. Examine neutralization point. If the test distance is slightly
the patient’s eye with the same eye as the exam- increased, it is possible to confirm the neutraliza-
iner’s eye. That is, when examining the patient’s tion, and it is also possible to make a fine adjust-
right eye, the examiner puts a retinoscope in his ment of the dioptric power (Table 2.1).
right eye and holds the lens with his left hand in In the case of “against movement,” it means
front of the patient’s right eye. While looking myopia of −2D or more. Start with a weak “−”
through hole of the streak retinoscope, move the lens, and gradually increase the power to find the
sleeve upward or downward to make the light neutralization point. The power of lens at the
divergent, and turn the sleeve to the left or right time of switching from “against movement” to
to make the light strip vertical. This vertical “with movement” means the neutralization point.
light passes through the patient’s pupil to the In the case of “neutralization,” the movement
left and right by turning the retinoscope itself to of the light shadow cannot be seen with the move-
the left and right. Observe the movement of the ment of the retinoscope, and it means myopia of
light shadows of the red reflexes reflected from −2D. If 2D is subtracted from the power of lens
2  Refraction and Glasses Exam 15

Focal point is far away

from the examiner


Focal point is located between

the patient and the examiner


Focal point is located

in the examiner


Fig. 2.3  Reflections from retinoscope

Table 2.1  Refraction according to motion of streak at not coincide with each other, this is referred to as
50 cm distance an off-axis, which means that there is oblique
Streak Refraction astigmatism. There are “with the rule astigma-
With movement Hyperopia, emmetropia, myopia tism,” “against the rule astigmatism,” and
under 2D
“oblique astigmatism” (Fig. 2.4).
Against Myopia more than 2D
If the light band does not coincide with the
Neutralization Myopia of 2D astigmatic axis, the break is eliminated by rotat-
ing the sleeve and aligning the axes. The angle at
at neutralization point, it becomes a refractive this time becomes the main meridian, and the
error. However, 2D is changed according to the perpendicular meridian becomes another main
test distance. If the test distance is 67 cm, 1.5D meridian. It is easy to find the astigmatic axis by
should be subtracted, and if it is 1 m, 1.0D should adjusting the light band as narrow as possible to
be subtracted. The test distance of 67 cm has less the pupil. If it is not sure, moving the light band
error. After finding the neutralization point in the will be helpful to notice, which is called skew
horizontal direction, turn the sleeve, and change (Fig. 2.5).
the light horizontally to find the neutralization When the light band coincides with the astig-
point in the vertical direction with the same man- matic axis, the width of the reflected light is the
ner. If the neutralization point in the horizontal thinnest, and as the axis deviates, the width
direction and in the vertical direction is different, increases (Fig. 2.6).
it means that there is astigmatism so that the When the light band coincides with the astig-
refractive indices in the two directions are calcu- matic axis, the reflection band shines most
lated in the same manner as above. Astigmatism brightly, and as the axis shifts, it becomes darker.
has two axes. The angle between the two axes is If the axis is not correct, the power is not also
always 90°. When the axis between the light band accurate, so there is a straddling test to confirm
of retinoscope and the light shadow of pupil does the axis. With wearing glasses, put the light band
16 J.-E. Lee

a b c

Fig. 2.4  Classification according to astigmatic axis. (a) With the rule astigmatism. (b) Oblique astigmatism. (c) Against
the rule astigmatism

Fig. 2.5  Break and a b

skew phenomenon. (a)
Light band
Break phenomenon. (b)
Skew phenomenon

Reflection band

Fig. 2.6  Incorrect axis. a b

(a) Incorrect axis. (b)
Correct axis

Thick Thin
reflection band reflection band

Light band

on the astigmatic axis, and turn it 45° to the left concave lens, astigmatic power is too strong if
and right. At this time, the left and right sides of the spherical axis (the axis that is perpendicular
the reflection should be the same. If one side is to the astigmatic axis) is first neutralized, and if
narrower and brighter, move the axis 5–10° to the astigmatic axis is first neutralized, astigmatic
opposite side until the left and right sides are the power is too weak.
same in the case of concave lens. Convex lenses
should be reversed (Fig. 2.7). Interpretation
If you think that the axis is perfect, move your For example, if there is with the movement with
body a little forward, and raise the sleeve so that +4.0D and against the rule with +4.5D at 50 cm,
the reflection becomes brighter. Move back the neutralization will be +4.25D.  The refractive
sleeve while pulling your body back, and com- error is calculated as +4.25  –  2  =  +2.25D.  In
pare the reflections of two axes. When using a astigmatism, if there is neutralization at +1.0D in
2  Refraction and Glasses Exam 17

Fig. 2.7  Straddling test 90°





a b c


–5.25 –3.0


Fig. 2.8  Recording of refractive error. (a) No astigmatism. (b) Astigmatism. (c) Oblique astigmatism

the vertical meridian and 0D in the horizontal Caution should be given when changing the
meridian, the refraction error will be −1.0D in divergent ray and the long convergent ray into a
vertical meridian and  −  2.0D in horizontal short convergent ray because with the movement
meridian. and against the movement are switched. When
To find the neutralization point in a vertical the refractive power is to be obtained, the pupil-
meridian, you have to move the light horizontally lary plane should be completely covered with a
up and down while moving it horizontally. To light band. Convergent light band does not com-
find the neutralization point in the horizontal pletely cover the pupillary plane, so it is neces-
meridian, you should move the light vertically, sary to check them with divergent light band.
and move left and right. When a short convergent light band is used in
If the 20° meridian is −1.0D and the 110° high myopia and a long convergence light band is
meridian is +3.0D, then record as shown in Fig. used in high hyperopia, the brightness of the light
4.9c, and write as +1.0D cyl 20°  =  −3.0D cyl band is increased, and it becomes easy to watch.
110° or +1.0D sph  =  −4.0 cyl 110° or −3.0D In high myopia, short convergent ray changes
sph  =  +4.0D cyl 20°. The recording method from with the movement to against the move-
shows the error of horizontal and vertical merid- ment, which makes it easier to distinguish the
ian as follows (Fig. 2.8). light shadow. There is also a way to check
18 J.-E. Lee

Table 2.2  Types and characteristics of cycloplegics

Time to pupil Time to reach the Time Degree of
Agents enlargement highest effect duration Residual time cycloplegia
Atropine 1% 30 min ~ 1 h 12~24 h 24 h 10~18 days +
Scopolamine 0.25% 30 min ~ 1 h 1 h 2 h 4~6 days +
Homatropine 5% 30 min 1 h 1–2 h 36–48 h +
Cyclopentolate 1% 20 min 20~45 min 30 min 6~8 h ++
Tropicamide 1% 20 min 20~35 min 15 min 2~6 h +++

o­ vercorrection of glasses by performing retinos- such as cataract, corneal opacity, or vitreous

copy with wearing glasses. opacity, it may not be tested or may have inac-
curate results. The measurable range differs from Cycloplegic Refraction model to model, but the maximum is ±25D in
In general, it is performed in hyperopic patients spherical power and ±18D in cylindrical power.
with excessive accommodation. Others included
mental retardation, children with low concentra- Purpose
tion, children with residual hyperopia, and It was developed for the purpose of measuring
patients with malignancy. After applying cyclo- refraction in a short time without the need for
plegics, perform the retinoscopy. Atropine is the skill. The spherical power and cylindrical power
most powerful cycloplegics with long lasting and axis can be measured quickly and printed in
effect. So cyclopentolate is commonly used. The numerical value.
types and characteristics of the cycloplegics are
shown in Table 2.2. Method
Place the patient in front of the autorefractome-
ter, move the chin rest up and down to be a com-
2.1.2 Autorefractometry fortable position, and raise the chin on the chin
rest. Keep the forehead fixed so that the head
It is a method to measure the refractive power of does not move while examining. The examiner
the eye by projecting a certain target on the fun- moves the adjustment knob to the front, back,
dus and adjusting the distance so that the target left, and right so that the focus is focused on the
marked on the retina can be seen clearly, which is center of the patient’s pupil. Take care not to
similar to the principle of the ophthalmoscope. blink the eyes. If the eyelids or eyelash blocks,
Although errors may occur when the patient pull the eyelids up, taking care not to press the
looks inside the machine, the error can be reduced eyes. Measure by pressing the button. If the
to a certain level by using various fog methods pupil is small, it may be possible to measure if it
and automatic tracking devices. A portable is dark. Measure several times to obtain repre-
autorefractor has also been developed and can be sentative value. Young patient with high accom-
measured regardless of patient position. modation, patient with abnormal eyeball
position (especially esotropia), or monitor Indication worker need cycloplegics. Multiple measure-
This is usually the case when a sitting position is ments and representative measurements are
possible and the face can be fixed to the chin rest. output.
If the pupil is small, if the patient absorbs the
infrared light during measurement (pseudopha- Interpretation
kia), if the patient is not able to watch well, if If there is no significant difference between
there is severe nystagmus, if the cornea has irreg- the measurements and the astigmatic axis
ular astigmatism, or if there is media opacity is stable, it is judged that the measurement is
2  Refraction and Glasses Exam 19

performed correctly. The reason why the reli- the patient’s glare which happens when using a
ability is low and unstable result is obtained manual keratometer. It is divided into automatic
is  as follows. In case that observation is not and manual keratometry.
maintained at the measurement, the pupillary
center is deviated from the center, or accom- Autokeratometry
modation relaxation is insufficient. When It is for patients who can place the chin on the
the  centers of measurement and pupil are chin rest in a sitting or standing position, espe-
­deviated, the power of cylindrical lens tends cially before and after cataract surgery, astigma-
to  become strong and that of the spherical tism correction surgery, refractive surgery, and
lens  tends to be weak. As a representative contact lens prescription and in corneal abnor-
value, it is preferable to select a hyperopic malities or suspected corneal astigmatism. It is
value in spherical lens and a lower value in performed to evaluate the effect of corneal
cylindrical lens. ­astigmatic power and axis on corneal abnormal-
ity, cataract surgery, astigmatism correction sur-
gery, or refractive surgery. Place the patient in
2.1.3 Keratometry front of the autokeratometer, and raise the chin
on the chin rest. Keep the forehead fixed so that
Most of the autorefractor measures refractive as the head does not move while examining. The
well as keratometric value. This device also uses examiner performs the test after the focus of
a non-visible infrared wavelength reflector and autokeratometer is focused on the pupillary cen-
detector, which is convenient because it reduces ter (Fig. 2.9).

Fig. 2.9  Record of

20 J.-E. Lee

Wrong Correct entire cornea marked with D can be converted

adjustment adjustment into the radius of curvature by the conversion
Normally, the refractive power of anterior cor-
nea is 43D, and the radius of curvature is about
7.8  mm. Corneal scars and corneal irregular
(+) is
combined astigmatism are suspected when the concentric
circles are not completely or partially visible.
When there is a difference between the horizontal
and vertical meridian, the difference is the degree
of astigmatism. If the value of the horizontal or
(–) is vertical line is less than 36D or 9.38 mm or 52D
combined or 6.49 mm or more, it cannot be measured and
indicates pathological refractive error.

Wrong axis Correct axis 2.1.4 Photorefraction Indication
It is useful for infants or children and the patients
who are not able to perform subjective refraction
test because of poor coordination or lack of atten-
Fig. 2.10  Manual refractometer method
tion. Especially, it is useful for group screening
of infants and children. Manual Keratometer
Place the patient in front of the manual kera- Purpose
tometry in the dark or semi-darkroom, and fix The reflected light from the cornea and fundus
the head with the chin rest and the forehead can be photographed to measure refractive error
rest. After covering one eye, adjust the reflector and the presence of strabismus.
to be reflected on the patient’s cornea through
the ophthalmoscope. Turn the focus screw for- Method
ward or backward so that the three circles are It is a method using a camera equipped with a
clearly visible. At this time, make sure that the light source. When a patient’s face is photo-
right lower circle is located in the center of the graphed by attaching a light source slightly lower
cornea and the “+” mark appears in the center than the lens of the camera, the patient’s pupil
of the right lower circle (Fig. 2.10a). Turn the becomes red due to reflex from the fundus. Here’s
knob (Fig. 2.10b) so that the right “+” mark of how to use MTI photoscreener: use Polaroid
left lower circle is overlapped with left “+” monochrome film, and shoot at a distance of 1 m
mark of right lower circle. Turn the vertical with an eccentricity of 1.2 mm between the lens
adjustment knob (Fig.  2.10c) so that the “−” entrance and the light source. At this time, the
mark of the bottom of the upper circle and the examiner makes an X mark exactly 1.25 inches
“−” mark of the top of the lower right circle are above the center of the pupil. Red light and sound
overlapped. If the “+” marks of the lower cir- generator are used to make a patient pay atten-
cles are not in the same position, it means that tion. In order to measure the astigmatism, the
there is astigmatism (Fig. 2.10d). The value of light source is rotated 90° vertically and horizon-
horizontal, vertical, and cylindrical axis is read tally, and the picture is taken in two directions to
and written, and the refractive power of the print on one film.
2  Refraction and Glasses Exam 21

a b

Fig. 2.11  Photo refraction method. (a) Myopia: Half-­ reflections appear on the bottom in the upper picture, on
moon reflections appear at the top in the upper picture and the right in the lower picture
at the left in the lower picture. (b) Primitive: Half-moon

forming this test, the patient should use bright and Interpretation clear targets so that they can watch the near vision.
In Polaroid photographs, there are two photo-
graphs, with a vertical axis picture at the top and
a horizontal axis picture at the bottom. If the Interpretation
patient is emmetropic, the fundus reflex appears The dioptric value at the near target point is sub-
to have a similar brightness as a whole. If the tracted from the dioptric value at the neutraliza-
patient is myopic, fundus reflex with half-­moon tion point, which is the accommodative lag. If the
shape appears on the upper side in the upper pic- neutralization point is further from the patient
ture and on the left side in the lower picture and than near target point, the value will be “+” and
vice versa. If the light source is mounted on the vice versa. The normal value is +0.25 ~ +0.75. If
top of the camera, half-moon reflex is observed at a greater positive value is obtained, it shows
the opposite location (Fig. 2.11). insufficient accommodation such as esotropia or
accommodative insufficiency, and if the value is
lower than normal or -, it indicates excessive
2.1.5 Dynamic Retinoscopy accommodation such as exotropia or accommo-
dative spasm. Indciation and Purpose
Patients with refractive error or accommodative
disorder can be candidate. This is for measuring 2.1.6 Ophthalmoscopy
the accommodative lag at a near distance in the
binocular state, that is, the distance gap between The degree of refractive error can be found. The
the near target and patient’s near target. emmetropic examiner focuses the patient’s ret-
ina through the lens by rotating the lens disc of Method ophthalmoscope. The power of lens indicates
A typical Nott method is as follows. Have the the patient’s refractive error. The green number
patient watch the near target at 40 cm after cor- of the lens shows + lens, and the red number
recting far vision. The examiner should perform shows − lens. If both the examiner and the
retinoscopy from the slightly outward and upward patient are emmetropia, they will look better
position, being careful not to cover the patient’s when the lens disc is at 0, but it is usually better
visual axis. Determine the neutralization point at −2 to –3D because of some accommodation
while moving backward or forward. When per- (see Chap. 15).
22 J.-E. Lee

2.1.7 Visual Evoked Potential (VEP) 90° from each other. Usually, 0.5D is used. When
using a cross cylinder lens, a circle of least confu-
In the case of a checkboard pattern, when the sion should be placed on the retina, corrected
focus is on the retina, visual evoked potential with spherical and cylindrical lenses.
waves become maximal. If the best correction This test can confirm the dioptric power and
trial lens is inserted in front of the eye, the maxi- axis of astigmatism. Calculate the spherical equiv-
mal wave is generated, which is used to deter- alent which is spherical lens power plus 1/2 cylin-
mine the refractive error (see Chap. 19). drical lens power and can obtain the best visual
acuity. In this case, the circle of least c­ onfusion is
placed on the retina. Check the a­ stigmatic axis by
2.2 Subjective Refraction comparing the visual acuity after placing the “–”
axis of cross cylinder lens at 45° or 135° in front of
It is used to correct the glasses prescription which the cylinder lens. If the latter is better than the for-
is obtained from objective refraction. mer, in the case of “−” cylinder lens, the axis of
the cylinder lens is rotated 5° to the “−” axis of the
cross cylinder lens when cross cylinder lens is
2.2.1 Astigmatism Examination positioned at the side where better visual acuity
was obtained, and then the visual acuity at 45° or Cross Cylinder Method 135° is compared over and over until the same
Cross cylinder lens is composed of a – cylinder visual acuity is achieved (Fig. 2.12).
lens on one meridian and + cylinder meridian on Check the astigmatic power by comparing the
the other meridian. The absolute dioptric values​​ visual acuity when the “−” axis of the cross cyl-
of two meridians are the same, and the axes are inder lens is overlapped on cylinder lens with the

Fig. 2.12 Determination
of astigmatism axis using b
a cross cylinder lens.
Place the “-” axis of
Power of cylindrical lens Cross cylinder lens
cross cylinder lens at .5
.5 –0
45°(a) or 135°(b) in front –0
of the -0.5 cylinder lens.
When the visual acuity
of b is better than that of
a, the axis of the cylinder
lens is rotated 5° to the Axis of cylinderical lens
right (to the “-” axis of
the cross cylinder lens
when cross cylinder lens When the visual acuity of b is better than that of a
is positioned at the side
where better visual
acuity was obtained). c
Astigmatic axis is rotated
over and over and .5
.5 5˚ –0
determined when the –0
visual acuity of c and d is

Astigmatic axis is determined when the visual acuity of c & d is same

2  Refraction and Glasses Exam 23

Fig. 2.13 Determination a b
of astigmatism power
using a cross cylinder Power of cylindrical lens Cross cylinder lens
lens. Overlap the “-“ .5 .5
(a) or “+”(b) axis of the –0 –0
cross cylinder lens on
the axis of -0.5 cylinder
lens. When the visual
acuity of a is better
than that of b, increase
the astigmatic power to Axis of cylinderical lens
-1.0 cylinder lens and
the repeat until the When the visual acuity of a is better than that of b
same visual acuity is
achieved. Astigmatic c
power is determined d
when the visual acuity
of c and d is same .0 .0
–1 –1

Astigmatic power is determined when the visual acuity of c & d is same

visual acuity when the “+” axis is overlapped. If Make a final spherical lens with fine adjust-
the former is better the latter, in the case of “−” ment. That is, check the highest “+” lens power or
cylinder lens, increase the astigmatic power, and the lowest “−” lens power having the best visual
then repeat until the same visual acuity is acuity after wearing the spherical and cylinder
achieved (Fig. 2.13). lens which are determined in the previous step.
Wear the cylinder lens, and measure the visual
acuity until the best visual acuity is achieved with
wearing the lowest “−” spherical lens or the 2.2.2 Reassessment Test
highest “+” spherical lens to determine the final
spherical lens power. Red-Green Test and Duochrome
Test Astigmatic Dial The principle is that chromatic aberration causes
It is used to check the presence and degree of light to focus on different retinal plane depending
astigmatism. With wearing spherical equivalent on the refractive status. In emmetropia, long
lens (spherical lens power +1/2 of cylinder lens wavelengths of red light are focused slightly
power), add +1.0D (fogging method) which behind the retina, and short wavelengths of green
makes compound myopic astigmatism. There is light are slightly before the retina (Fig.  2.15).
no astigmatism if there is no difference in all Therefore, the red and green marks look similar
directions. If there is a difference in the contrast of in emmetropia, but in the case of hyperopia, the
the lines in the astigmatism dial, place the “−” focal plane is placed behind the retina, so that the
cylinder lens at 90° to the direction that it is thick. green mark looks brighter, and in the case of
Slowly increase the power of cylinder lens until myopia, the focal plane is placed before the ret-
lines in all direction have same contrast (Fig. 2.14). ina, so that red mark looks brighter.
24 J.-E. Lee

Fig. 2.14 Astigmatic a b
dial. (a) Astigmatic dial.
(b) In this case, the axis
of astigmatism should
be horizontal

Hyperopia Myopia Emmetropia

Fig. 2.15  Principle of red-green test

The final spherical lens can be adjusted up to The objects are not limited to children but
1/8D. At first, examine at 5 m distance with wear- VDT workers over the age of 30 years. It is help-
ing final corrected lens. Make a look at the target ful to avoid overcorrection of myopia because of
with a black “+” sign on the red or green back- relaxation of accommodation.
ground. If both eyes are clearly visible, there is Both eyes wear the final spherical lenses with
no astigmatism. If the red light looks clearer, it adding +3.0D lenses for 20–40 min.
means myopic state which means undercorrec- Cover one eye, and make 0.5D decrements
tion of myopia or overcorrection of hyperopia from the previous +3.0D on the other eye. At this
and if the green light looks clearer, vice versa. time, 0.5D decrement lens is inserted, and then
the existing lens is removed. When the visual Fogging Method acuity becomes 0.5–0.7, make 0.25D decrements
A subjective refraction test should be measured until the visual acuity becomes 1.0. Check the
without accommodation. The fog method can lowest “−” lens or the highest “+” lens at which
reduce the accommodation by using a convex the best visual acuity is obtained. Calculate the
lens which does not make the image clear even spherical lens power as follows: the power
when the patient accommodates. In this state, obtained for the best visual acuity plus the power
regulation is eliminated in principle. No accom- of 1/2 of the astigmatism plus +1.0D (fogging
modation occurs in fogging method. method). With wearing this lens, the visual acuity
2  Refraction and Glasses Exam 25

becomes 0.5 which is appropriate to perform the When the accommodative power is decided,
astigmatic dial test. After wearing the spherical leave 1/3 or 1/2 of them, and use the rest of
lens determined above, have the astigmatic dial them for reading glasses. For example, if the
be seen. If there is a difference in the contrast of patient with accommodative power of 2D is
the lines in the astigmatic dial, place the “−” cyl- reading at 40  cm, 2.5D is needed for accom-
inder lens at 90° from the direction to be thick. modation. The patient’s accommodative power
The axis of cylinder lens determines the axis of is 2.0D, so leave 1D which is 1/2 of patient’s
astigmatism. Until the lines become thick in all accommodative power and prescribe 1.5D for
directions, increase the cylinder lens power. This reading glasses. Wear the prescribed lens,
cylinder lens power determines the power of measure the near visual acuity, and adjust the
astigmatism. With wearing the cylinder lens, lens power. It is better not to prescribe too
check spherical lens again. Find the lens of the strong because near vision does not have to be
lowest “−” lens power or the highest “+” lens 1.0. Reading glasses less than 0.75D are not
power at which the best visual acuity is obtained. usually prescribed. It is a principle to pre-
This spherical lens determines the final spherical scribe a reading glass according to the indi-
lens power. vidual patient.
The other eye is tested with the same manner.
Check if the patient is comfortable with final
lens. It is recommended to wear glasses for 2.3.3 Record of Glasses Prescription
15–20  min to determine the comfortableness.
Fine adjustment can be performed and then the Record the patient’s name, age, sex, and date
glasses are prescribed. of the test. Record spherical lens, cylindrical
lens, axis, and pupillary distance, and specify
the near or far use (Fig.  2.16). Prescribe
2.3 Prescription of Glasses prism  for phoria, strabismus, or convergence
2.3.1 Precautions for Glasses
2.3.4 Lens Replacement
Patients should be prescribed according to their
needs. Full correction is recommended for chil- Cylindrical lenses can be prescribed as “+” or “−”
dren and patients with strabismus. If there is no and can easily be changed with each other. At first,
strabismus, hyperopia should be 1/3–1/2 under- combine the cylindrical and spherical lens power.
corrected. Do not make much change compared Next, change the mark of cylindrical lens, and then
to the previous glasses. If the astigmatic axis add 90° to the astigmatic axis. For example, +2.5D
continues to be uncomfortable, set it to 90° or sph  =  +1.5D cyl 90° is substituted by +4.0D
180°. If it is not effective, adjust it with spheri- sph = −1.5D cyl 180°, and −2.0D sph = +1.0D cyl
cal aberration. Undercorrection is better than 90° is replaced by −1.0D sph = −1.0D cyl 180°. In
overcorrection. addition, +1.0D sph = −1.0D cyl 45° is substituted
by plano = +1.0D cyl 135°, and plano = −1.5D cyl
120° is replaced by −1.5D sph = +1.5D cyl 30°.
2.3.2 Reading Glasses Prescription

Calculate the accommodative power by knowing 2.3.5 Pupillary Distance

the near point of accommodation after correcting
to be an emmetropia. For example, if you can see It is necessary to measure the pupillary distance
a target of 1.0 at 33 cm in front of you, the accom- not only for prescribing glasses but also for mea-
modative power is 3D (1/0.33 = 3). suring angle of strabismus. Glasses that do not
26 J.-E. Lee

Fig. 2.16  Recording of sph

V∞ = 0.4 (1.0 × +2.0D – 1.0D cyl axis 90°) add + 2.0
glasses prescription

Visual acuity of right eye

Uncorrected visual acuity

Corrected visual acuity

Convex lens
Lens Power

Spherical lens

Connectio mark

Concave lens
Lens Power

Cylindrical lens

Axis of cylindrical lens

Degree of axis of cylindrical lens

Add for near vision

Convex lens

Lens Power
Prescription Glasses


Rt. D D ° ∆

Lt. D D ° ∆ mm


Rt. D D ° ∆

Lt. D D ° ∆ mm

measure the pupillary distance accurately will (Fig.  2.17a). In the same way, the distance
exhibit a prism effect. between corneal margin and pupillary reflex
can be also used. For Far Vision
In the darkroom, the examiner sits in a posi- For Near Vision
tion slightly lower than the front of the patient, Measure the pupillary distance at 33 cm which is
60  cm away from the patient, and holds the usually used for near work, with examiner’s one
ruler in the left hand and places it horizontally eye. The examiner’s eyes are placed in the center
under the line connecting the patient’s pupil- of the patient’s eyes, and the ruler is placed on the
lary center. The examiner closes the right lower eyelid 12  mm below the apex of the
eye and aligns scale of ruler 0 on the tempo- patient’s cornea. The patient then takes a look at
ral boundary of the patient’s right pupil, hav- the examiner’s one eye, and the examiner mea-
ing the patient watch the examiner’s left eye. sures the pupillary distance (Fig. 2.17b). If there
The examiner closes the left eye and performs is a high refractive error, record the distance
the same way. Measure the distance to the between pupillary reflexes at 33 cm to eliminate
nasal boundary of the patient’s left pupil the prism effect.
2  Refraction and Glasses Exam 27

a a b
b a b

12 mm

Examiner’s eyes

a b

d a b


Fig. 2.17  Pupillary distance measurement. (a) In the case of distant gaze. (b) In the case of near gaze. (c) In the case
of child. (d) In the case of strabismus (distance between a and b: pupillary distance)
28 J.-E. Lee For Children 2.4 Glasses Test

This method is used for children with unstable
visual line. The examiner faces the patient in To confirm the glasses have appropriate power or
front and places the ruler on the upper or lower the glasses are properly made as prescribed, the
eyelid. The examiner closes the right eye and power of the lens, the optical center, the principal
aligns the scale of ruler 0 on the temporal bound- meridian direction, and the prism power and the
ary of the patient’s right pupil, having the patient base direction are measured. There are analog
watch the examiner’s left eye. The examiner and digital systems. Analog systems include tele-
closes the left eye and performs the same way. scope type and projection type. Digital type is
Measure the distance to the nasal boundary of the display-only digital type or computer-integrated
patient’s left pupil. type (Fig. 2.18).
The analog method of telescope type lens For Patients with Strabismus meter is as follows:
The examiner faces the patient in front and Turn on the light source of the lensometer
places the ruler on the patient’s upper or lower (Fig.  2.18a), and focus on the “+” mark while
eyelid. Cover the patient’s left eye, have the looking at the eyepiece. Put the glasses on the
patient’s right eye watch the examiner’s left eye, lensometer, and fix them, and then turn the screw
and read the scale of ruler with examiner’s left to focus the circle with a yellow dot. Move the
eye. At this time, examiner closes the right eye. center of yellow dot vertically and horizontally to
Cover the patient’s right eye, have the patient’s match the intersection of the “+” mark which is
left eye watch the examiner’s right eye, and read the center of the field of view. Focus the yellow
the scale of ruler with examiner’s right eye. At point again and read the scale. When focusing,
this time, examiner also closes the left eye always turn the steering wheel slowly from the
(Fig. 2.17c). positive (+) side to the minus (−) side not to

a b

Lens holder

screw Circumferential


Fig. 2.18  Lensometer. (a) Analog lensometer. (b) Digital lensometer

2  Refraction and Glasses Exam 29

120 60


b c
90 90
60 120 60




Fig. 2.19  Viewing the lensometer. (a) With no astigmatism. (b, c) With astigmatism

induce the examiner’s accommodation. If you By moving the rotary screw, the long line of the
pass too much to the minus side, do not turn back “+” mark coincides with the direction of the cir-
to the plus side slowly, but return to the plus side cle of yellow point. Record the power and the
quickly, and start slowly again from the begin- angle in this direction (Fig.  2.19c). Turn the
ning. The dioptric power at this time is the refrac- screw again to focus in the direction perpendicu-
tive value (Fig. 2.19a). In the case of projection lar to the direction in which the yellow point
type, results can be stable since the examiner’s flows, and read the power at this time. Move the
accommodation is not involved. If the circle of pointing device at the center of the optical axis to
yellow point does not become an accurate circle, mark the optical axis of the lens. The glasses of
it means that there is astigmatism (Fig.  2.19b). the other eye are also performed in the same
30 J.-E. Lee

­ anner, and the distance between the centers of

m Cole RG, Rosenthal BP. Remediation and management of
two optical axes will be pupillary distance. In the low vision. St. Louis: Mosby; 1996.
Faye EE. Clinical low vision. Boston: Little Brown &
case of astigmatism, the numerical value obtained Company; 2000a.
by subtracting the smaller from the bigger is the Faye EE. The lighthouse ophthalmology resident train-
power of cylinder lens, and the numerical value ing manual: a new look at low vision care. New York:
of the smaller is the power of spherical lens. The Lighthouse International; 2000b.
Freeman PB, Jose RT. The art and practice of low vision.
axis is an angle in a direction in which the line Oxford: Butterworth-Heinemann; 1997.
having the larger absolute value flows. Jonathan Jackson A, Wolffsohn JS.  Low vision manual.
Edimburg: Butterworth Heinemann/Elsevier; 2007.
Jose RT. Understanding low vision. New York: American
Foundation for the Blind; 1983.
Suggested Reading Lueck AH.  Functional vision: a practitioner’s guide to
evaluation and intervention. New York: AFB; 2004.
Artal P.  Handbook of visual optics: instrumentation and Rosenthal BP, Cole RG.  Functional assessment of low
vision correction. Boca Raton: CRC Press; 2017. vision. St. Louis: Mosby; 1996.
Brown B.  The low vision handbook for eyecare profes-
sionals. Thorofare: Slack; 2007.
Accommodation and Convergence
Jae Ho Jung

3.1  ear Point of

N Range of accommodation refers the distance
Accommodation between the FPA and the NPA. These measure-
ments can be helpful in situations where accom-
The accommodation is a reflex action of the eye, modation abnormalities are suspected such as
in response to focusing on a near target, then presbyopia, hypermetropia, amblyopia, and
looking at a distance target (and vice versa), com- strabismus.
prising coordinated changes in vergence, crystal
lens shape and pupil size. The accommodation
amplitude meane the difference of refractive 3.1.1 Method (Fig. 3.1)
error between looking at near target and at dis-
tance target. Far point of accommodation (FPA) • Under correcting the refractive error, based on
refers to the farthest distance that a man can see looking a distance target, place the rule on the
something without accommodation, and the near patient’s noze.
point of accommodation (NPA) is the closest dis- • Target slowly approaching the from a distance
tance that can be clearly seen when the accom- to patient’s nose. The near point accommoda-
modation is maximized. tion rule is the point closest to the nose where
convergence and binocular single vision can

a b c

Fig. 3.1  Accommodative rules. (a) The RF rule. (b) The Krimsky-Prince Rule. (c) The Berens Rule.

J. H. Jung, MD., PhD. (*)

Department of Ophthalmology, Seoul National
University College of Medicine, Seoul, South Korea

© Springer Nature Singapore Pte Ltd. 2019 31

J.-S. Lee (ed.), Primary Eye Examination,
32 J. H. Jung

no longer be maintained as an object Table 3.1  The average amplitude of accommodation

approaches. Examiner select the target (usu- according to age
ally 20/40 target) that the patient can see Accommodation NPA of emmetropic
clearly at 0.4 meter, and fix it. This test started Age amplitude (D) eye (cm)
10 14 7.1
with monocularly and then binocularly condi-
20 10 10
tion. Binocular condition show the conver-
30 7 14.3
gence influences on accommodation. 40 4.5 22.2
• NPA is represented as centimeters. 45 3.5 28.5
• In case if the NPA is too far and so cannot be 50 2.5 40
measured within a distance of the near point 55 1.75 57
measuring system, NPA is checked with a 60 1 100
convex lens so that the nearest point moves 65 0.5 200
20–30  cm forward. That is, if the NPA is 70 0.25 400
­measured wearing the a diopter lens is at b m 75 0 ∞
with a diopter convex lens, the NPA is
b/(1 − a × b) cm.
• For young adult with normal vision, the near NPA
point is about 25  cm, and the far point is
between 25 cm and infinity.
a p
3.2 Amplitude
of Accommodation
∞ range of accommodation

The difference between the dioptic power

needed to focu at near point and far point is
p ∞
called amplitude of accommodation. This power
is measured in units called diopters (D) and is
calculated by dividing the NPA in centimeters Fig. 3.2  Range of accommodation
into 100. If a patient with an NPA of 25 cm has
an accommodative amplitude of 100/25=4 D). The range of accommodation is the distance
Specifically, amplitude of accommodation can bewteen the furtherest point an target of a certain
be calculated using following method. size is in clear sight and the nearest point at which
A = 1/p − 1/r, A diopter = amplitude of accom- the eye can maintain that celar vision. The range
modation, p meter  =  NPA, and r  =  FPA.  Also, of accommodation indicates the adjustable range
A  =  P  −  R, P  =  refractive error of NPA, and of accommodation, which is the range between
R = refractive error of FPA. In the emmetropic the NPA and FPA, is meaningful only in myopia
eye, r is infinite, so A = 1/p, that is, the ampli- (Fig.  3.2). For example, when we calculate the
tude of accommodation is the reciprocal number range of accommodation in emmetropia, −2D
of the NPA. myopia and +2D hypermetropia with 10D of
A  =  1/0.1–2  =  8D in −2D myopic eye with amplitude of accommodation, 10 = 1/p − 1/r in
10 cm of NPA, and A = 1/0.25 − (−2) = 6D in case of emmetropia where r is infinity, p is 0.1,
+2D hypermetropic eye with 25 cm of NPA. and the NPA is 10  cm. Therefore, the range of
Since the FPA is in the back of the retina in the accommodation is from 10 cm to infinity. In case
hyperopic, so ‘-’ sign attach. The amplitude of of −2D myopia, 10 = 1/p − 1/r; r is 1/2, that is,
accommodation decreases with age. The average 50 cm; and p = 0.125. Thus, the range of accom-
amplitude of accommodation according to age is modation is 12.5–50 cm, and only within this dis-
shown in Table 3.1. tance a clear image is formed in the retina.
3  Accommodation and Convergence 33

However, In hypermetropia, 10 = 1/p − 1/r and p get is blurred again so that the sum of the maxi-
is 1/2, that is, 50 cm, so r = −0.125. The control mum number of “+” lenses and the number of “−”
range is from 50  cm before the eye to 12.5  cm lenses can be the amplitude of accommodation.
behind the eye. Since accommodative convergence may work, it
The method of measuring the amplitude of should be tested in monocular environment.
accommodation is to measure the distance
between the NPA and FPA as described above,
but the method used in the clinic is as follows. 3.2.5 Binocular Amplitude
of Accommodation

3.2.1 Near Point Method Generally, amplitude of accommodation is larger

in binocular condition than in monocular condi-
While refractive error is fully corrected, the tion. Because, convergence works in
reciprocal number of the distance measured in accommodation.
meters in terms of distance from the point of
blurring to the nearest eye until the letter or target
is blurred The reciprocal number of the distance 3.3 Near Point of Convergence
of the point to appear blurred when you bring
your eye closer to the letters or targets until they Convergence is a vergence adduction move-
appear blurred in the unit of meter is amplitude of ment that increase the visual angle to permit
accommodation, of which the unit is diopter. single binocular vision during near viewing.
Convergence can be voluntary but need not be
no near stimulus need be present to elicit ver-
3.2.2 R
 ule Method with Distance gence. It is also reflexive and a co-movement in
Correction the near response. Convergence may be divided
in four groups: tonic convergence, fusional con-
Use the rule with the diopter and the “+” lens to vergence, accommodative convergence, and
adjust the NPA to within the range of the rule. For proximal convergence. The convergence
example, while refractive error is fully corrected, appears as synkinetic changes with pupil con-
if the NPA is 0.5 m with a +1.0D lens, the ampli- traction and accommodation. The near point of
tude of accommodation becomes 1D. convergence (NPC) is the distance between the
eye and the object when the convergence is
3.2.3 Rule Method Without maximized. It is normally located at the same
Distance Correction position as the nose and is similar to the inter-
pupillary distance (PD).
In myopia patients who do not know the refrac-
tive error, the difference between the diopters of
NPA and FPA. 3.3.1 Method

• Use an accommodative target (single 20/30

3.2.4 Spherical Lens Method letter) place in 33 cm in front of nose and keep
an eye on binocular condition. When the tar-
The amplitude of accommodation is the difference get is approached slowly toward the nose until
between the lowest value and the highest value of fusion is no longer maintained, or the eyes
the spherical lens to obtain clear visual acuity to abducted are measured. We should ask the
the near target. First, increase the power of the “+” patient to try to make the target one, so that the
lens until the target appear blurred, and add the nearest distance can be near point of
“−” lens again to increase the power until the tar- convergence.
34 J. H. Jung

• It can also be judged when the diplopia is mani- position of the eye convergence and divergence.
fested, the corneal reflex is deviated from the cor- The convergence amplitude is the range between
nea center, and miosis of near reflex disappears. limit point of the convergence and divergence.

3.3.2 Judgment 3.4.2 Rotating Prism

The normal range is usually 5~10 cm and is not Place the rotating prism based out, and set the
related to age. If it is more than 10 cm, it means scale to zero. The patient looks at a 5 m distance
convergence insufficiency. If it is not more than target and gradually increases the prism number
40–50  cm or convergence is not observed, it from zero. But it is possible to return to the single
means convergence paralysis. binocular vision by convergence soon when dip-
In normal subjects, there was no significant lopia occurs. The upper limit of the prism power
difference in the measurement results when using when the patients are aware of the diplopia is
the accommodative target, the optical chart, or referred to relative fusional convergence near
the optical chart with the red filter. However, point. In the same way, when the rotating prism
when there was a problem in convergence, the based in, the relative divergence occurred, and the
NPC can be determined more objectively, using amplitude of the prism when the patients aware
red glass over one eye and moving a light forward the diplopia is referred to relative fusional diver-
until the patient experience diplopia. gence far point.  The range of relative fusional
convergence near point and relative fusional
divergence far point is the fusion amplitude.
3.4 Fusional Convergence

Fusional convergence is a voluntary movement 3.4.3 Judgment

of the two eyes to obtain a binocular single vision.
The fusional convergence amplitude is measured Fusioanl vergence is classified according to the
by the maxinal response to stimulation when plae of eye movement. Fusional convergence
patient may cease to converge further and may eliminates bitemporal retinal disparity and
recognize diplopia, at the moment the examiner controls an exophoria. The normal value of the
can see the patient’s eye break from the point of fusion amplitude is −5° to +15° (“−” means
maximal convergence; this is called the fusion divergence, and “+” means convergence).
break point; the examiner then reduce the retinal When using a rotating prism, the normal value
image disparity by reducing the prism power is −10 △ to +30 △ (“−” means divergence,
until fusion is restored and the target is seen and “+” means convergence). When using the
clearly; this is the fusion restoration point. Bagolini linear lens, it is judged based on the
standard of rotating prism method.

3.4.1 Major Amblyoscope

3.5 Accommodation
Measurement should be done in no accommoda- Convergence/
tive condition by wearing a fully corrected lens. Accommodation (AC/A) Ratio
First, the ocular deviation (subjective deviation) is
investigated using the simultaneous pattern (het- Accommodative convergnece is the amount of
erogeneous pattern), and then the pattern is convergence elicited for a given amount of accom-
replaced with the pattern for fusion (homogeneous modation. The relationship between accommoda-
pattern). In the position of subjective ocular devia- tion and convergence is prism diopters (PD) to
tion, move the barrel slowly until the fusions are accommodation in diopters: the AC/A ratio
broken so that they begin to appear as two at the increase with age. Just as convergence can be
3  Accommodation and Convergence 35

stimulated by accommodation, so accommoda- measuring ocular alignment at near with and

tion can be stimulated by convergence. The ratio without a specific power lens, ocular align-
of convergence accommodation in diopters to ment is measured at distance and near, and the
convergence in PD is called CA/C ratio. difference in alignment in PD between dis-
tance and near viewing is divided by the fixa-
tion distance used for near viewing as
3.5.1 Method expressed in diopters. Ocular deviation should
be checked in condition of fully corrected Lens Gradient Method refractive errors fixing 5  m target by prism
It is a method to stimulate the accommodation by and alternative cover test. Next, move the tar-
keeping the fixing distance constant and chang- get to 33  cm, and measure the ocular devia-
ing the power of plus or minus lenses. An accom- tion by the same method. If deviation at
modative target must be used and the working distance  =  1Δ, deviation at near  =  2Δ, and
distance is held constant. Plus or minus lenses are PD = interpupillary distance in centimeter and
used to vary the accommodative requirment, and the reciprocal number of the near distance in
the difference between the ocular alignment with diopter (33 cm is 3D), AC/A ratio = PD + (Δ
and without the lens, divided by the power of the 2 – Δ1)/D. Marking “+” in esotropia and “−”
lens, is the AC/A ratio. in exotropia. For example, interpupillary dis-
For example, patient’s ocular alignment is tance is 6.0  cm, ocular deviation at near is
measured with the patient viewing the accom- 8△ of esotropia, and ocular deviation in dis-
modative target at a specific distance such as 33 tance is 2△ of exotropia, the AC/A
cm, and the patient is found to have an esotropia ratio  =  6.0  +  (−8−(−2))/3  =  4. This method
of 15 PD. A plus 3 D spherical lens is placed can be overestimated due to the near conver-
over each eye, and ocular alignment is again gence and depends on the interpupillary dis-
measured with the patient viewing the same tar- tance. The AC/A ratio of the normal person
get at the same distance. The patient is now obtained by this method is within PD ± 0.3.
found to have an esophoria of 0 PD. The differ-
ence between the ocular alignment with and Near-Distance Comparison
without the lens, divided by the power of the Method
lens, is the AC/A ratio and is (15-0)/3 (D)= 5. It is most often used in a simple way. A high
This means that when 3 diopter of accommoda- AC/A ratio can be presumed when the angle of
tion was reduced in this patient by placing a 3 D deviation is 10△ or more at a near distance than
spherical lens in front of the eyes, the patient’s the far distance, and the ratio is measured by the
convergence, measured at the same distance method mentioned above.
from the eyes, decreased from 15 to 0 PD. AC/A
ratio of this patient is 5, patient has high AC/A Fixation Disparity Method
ratio. In another patient viewing the clear target In this method, the AC/A ratio is measured indi-
at 5 m, and a change in deviation from an exo- rectly by using the change of the fixation dispar-
phoria of 2 PD to an esophoria of 10 PD when ity caused by the convergence induced by prism
minus 3 D spherical lens. The AC/A ratio then and the change of the accommodation caused by
would be (10−(−2))/3 (D) = 4. Lens gradient the spherical lens. This method is not used gener-
method has no difference between test distance, ally in clinical practice.
examiner can use 33 cm distance with plus lens
and 5 m distance with minus lens.
3.5.2 Results Heterophoria Method
and Geographic Method The normal AC/A ratio is between 2 and 5,
This method uses the distance-near relation- regardless of the method of testing that is
ship to determine the AC/A ratio. Instead of used. It should be noted, however, that the
36 J. H. Jung

AC/A ratio varies from person to person and dim illumination, or using a Gaussian target. In
from day to day or hour to hour in a given indi- this test, accommodation is measured as conver-
vidual depending on that person’s level of gence is produced using progressively stronger
fatigue or alertness. In addition, the AC/A base-out prisms. Unlike accommodation, conver-
ratio rises sharply after the age of 40 as accom- gence does not decline significantly with age.
modation begins to be lost but convergence Thus, just as the AC/A ratio increases with age,
remains stable. Nevertheless, values above 5 the CA/C ratio decreases with age. Recent study
usually indicate an excess of convergence per suggest that CA/A ratio may work in control
unit of accommodation, whereas values below intermittent exotropia. Measruing CA/A raio
2 suggest convergence insufficiency. An ele- may also important issue in strabismus patient.
vated AC/A ratio in a cooperative child is a
risk factor for the rapid onset of myopia, or is
risk for bifocal lens to treat accommodative Suggested Reading
Alpern M, Kincaid WM, Lubeck MJ.  Vergence and
accommodation: III. Proposed definitions of the AC/A
ratios. Am J Ophthalmol. 1959;48(1):141–8.
3.6  onvergence accommodation/
C Fincham EF, Walton J.  The reciprocal actions of
accommodation ratio accommodation and convergence. J Physiol.
(CA/A ratio) 1957;137(3):488–508.
Ittelson WH, Ames A Jr. Accommodation, convergence,
and their relation to apparent distance. J Psychol.
The CA/A ratio, needs the patient experience no 1950;30(1):43–62.
blur during the test. This can be accomplished by Von Noorden GK. Binocular Vision and Ocular Motility:
the use of a pin hole device, performing the test in Theory and Management of Strabismus. Mosby, 2002.
Color Vision
Jong-Ho Park

Color vision is a function of the retinal cone cell, and 4% of women have congenital color vision
which is the ability to distinguish the color of the defects.
object according to the wavelength difference During the test, daylight with cloud is consid-
among the visible light. In other words, the per- ered as standardized luminance of examination
ception of color is a sensory phenomenon, not a condition. It is recommended to use standardized
physical phenomenon. Color vision abnormali- illumination for the examination because it is
ties can be innate or acquired. greatly influenced by latitude difference, time
Every color that a normal person sees is repre- difference, and cloud thickness. Various color
sented by a mixture of three monochromatic vision tests have been developed for detection of
lights (red, green, blue). The incomplete function color vision abnormalities. There are two types
of one of the three types of cone cells is called a of inspection: a method using the color of the
trichromacy. And the incomplete function of two object and a method using the color light.
of the three types of cone cells is called a dichro- Correction of the refractive error is necessary,
macy. In reality, however, it is difficult to distin- and elderly person wears magnifying eyeglasses
guish between color weakness and color to match inspection distance.
blindness, so this classification has not been used
well in recent years. Depending on severity, it is
classified as mild, moderate, or high degrees, or it 4.1 Selection of Color Vision Test
can be classified the protan, deutan, and tritan
according to the cone cells with abnormalities The pseudoisochromatic plate (PIP) or Lantern
(Table  4.1). The monochromat is total color test is used in the screening test to detect cases of
blindness, and the object looks like a black-and-­ suspected color vision abnormality, but there is a
white photograph. In Koreans, 4.2–5.9% of men limit. In other words, it turn out false even if it’s

Table 4.1  Classification of color vision defects

Protan Deutan Tritan
Anomalous trichromat Protanomaly Deuteranomaly Tritanomaly
Dichromat Protanopia Deuteranopia Tritanopia
Monochromat Cone monochromatism, rod monochromatism

J.-H. Park, MD. (*)

Department of Ophthalmology, Pusan National
University Yangsan Hospital, Busan, South Korea

© Springer Nature Singapore Pte Ltd. 2019 37

J.-S. Lee (ed.), Primary Eye Examination,
38 J.-H. Park

normal, and a person with color vision abnormal- Methods

ity can get the right answer. It should be avoided The illumination in pseudoisochromatic plate test
to judge the degree of color abnormality as color uses natural light from the northward window or
weakness and color blindness. Be careful not to a fluorescent lamp for inspection to have a bright-
judge protan and deutan reversely. The anomalo- ness of about 200 lux. At a distance of 75 cm, one
scope is used to confirm the diagnosis. This test plate should be presented perpendicular to the
should be used in careers such as aircraft crew line of sight, and the inspection shall be carried
and policeman. out in accordance with the test rule. Test time is
The degree of congenital color vision abnor- within 3 seconds per page. If the color vision is
mality is checked with the Farnsworth dichoto- normal, it takes less than a second, but if run out
mous test panel D-15. However, this test cannot of time, a slight error is suspected even if you get
be used to determine the presence or absence of the correct answer. The normal person reads as 8,
color vision abnormality. Discrimination tests but a examinee who is a red-green color blind-
such as the panel D-15 and the Farnsworth- ness reads as 3. (Fig. 4.1).
Munsell 100 hue test are used for the detection of
the degree of color discrimination ability and the
confusion axis over the acquired color 4.2.2 Ishihara Test Charts
It consists of 25 plates in total. Only the presence
or absence of color blindness should be examined,
4.2 Screening Test and classification and degree judgment should not
be made. Plates 1 through 21 are checked; the
4.2.1 Pseudoisochromatic Plate detection plate is used to determine the presence
or absence of color abnormality. Plates 22 through
All diseases are subject to inspection, and this 25 consist of two digits. It is easier for the patient
test is used to detect, classify, and qualify color with protan to read to the right digit between the
blindness. It is easy to be confused by the dys-
chromatopsia because the letters and numbers are
drawn in the background of the rounded dots of
various colors in similar shape. It is widely used
in group test because it quickly and easily finds
the color abnormality. Ishihara and Hahn’s pseu-
doisochromatic plate tests are effective in identi-
fying normal and congenital color blindness, but
it is not sufficient to determine classification and
degree. The HRR pseudoisochromatic plate test
consists of three simple geometric forms instead
of numbers to determine the type and degree of
the disordered person. It is possible to divide the
degree by the degree of severity of color abnor-
mality, and it can also distinguish tetartanopsia.
However, it is not accurate to find out the red and
green color abnormalities. It is desirable to
inspect with the preexisting pseudoisochromatic
plate test. Fig. 4.1  Pseudoisochromatic plate test
4  Color Vision 39

two-digit numbers. However, it is easier for the 4.2.4 Hardy-Rand-Rittler (HRR)

patient with deutan to read to the left digit between Color Test
the two-digit numbers. More than 6 wrong
answers out of 14 plates are considered as abnor- It consists of 24 plates. Patients are asked to dif-
mal, more than 3–5 wrong answers are considered ferentiate between the three patterns of circles,
suspected color vision abnormality, and less than scissors, and triangles.
2 wrong answers are normal.
• Plates 1–4 identify color blindness.
• Plates 5–10 distinguish between the first and
4.2.3 Hahn’s Pseudoisochromatic second (red-green) and third (blue-yellow)
Plate Test color blindness defects.
• Plates 11–20 qualify the first and second (red-­
It consists of total 21 plates that 12 plates of part green) color defects with mild, moderate, and
1 (detection of color abnormality) and 9 plates of high degrees.
part 2 (degree classification of color • Plates 21–24 qualify the third (blue-violet)
abnormality). color-blind person with mild, moderate, and
If a tester reads Arabic number in about high degrees.
3  seconds or draws the curve straight in about
10 seconds, then it is considered to be normal.
Plates 1–12 are used to judge the presence or 4.3 Lantern Test (Fig. 4.2)
absence of color abnormality. The classification
and degree classification method of the color It was developed in the US Navy to screen sol-
blindness is determined by examining using the diers for color blindness. This has been widely
plate 13–18 indicated by numerals and the plate used as an aptitude test to identify the identifica-
19–21 indicated by curves. tion ability of traffic lights for railways, ships,

Fig. 4.2 Farnsworth
40 J.-H. Park

and aviation employees. This test detects con- nizes the color correctly that was incorrect when
genital color vision abnormalities sensitively, so the test distance is shortened. In addition to the
this test is aimed at those who are detected in inherent congenital abnormalities of color vision,
group screening and those who are suspected of it can also be used as a simple visual function
having color vision abnormalities. Since this test test. In acquired achromatism, even if the visual
uses color light, it can examine the condition of acuity is about 0.01, a examinee is often recog-
color vision more than one way. This test is nized correctly.
highly reproducible because of low individual
variation by the patient and the examiner, and it
also detects slight color defects. 4.4 Discrimination Test

4.4.1 Panel D-15 Test (Fig. 4.3)

4.3.1 Methods
This test is aimed at patients who have been
The tester consists of a main body and an operat- judged as a color vision abnormality by false
ing plate. Two holes are arranged vertically in a coincidence test. The degree of color blindness is
cover like a cylinder in front of the body. The divided into high (functional color blindness) or
combination of color light is presented as nine less than moderate. It is effective for the determi-
kinds of red-red, green-green, yellow-yellow, nation of the highly anomal type having the con-
red-green, green-red, green-yellow, yellow-­ genital color abnormality including the third
green, red-yellow, and yellow-red. It is carried color anomaly, but there is a limit in that a weak
out in a semi-dark room. It illuminates for 2 sec- color tone abnormality is not detected. This test is
onds each at 3–5 m inspection distance and extin- not a test to determine whether it is normal or
guishes for 2  seconds and displays nine kinds abnormal. It is also useful for various eye dis-
continuously. Let the examinee answer the name eases that cause acquired color vision abnormali-
of the color given at that time. Patient’s answer is ties other than congenital abnormalities, and this
written as: R for red, G for green, and Y for yel- is helpful in the observation of choroidal retinop-
low. If all nine answers are correct, end the test. If athy, optic nerve disease, etc. It is advisable to
there is a wrong answer, check again, and the perform this test if there is congenital color vision
number of incorrect answers will be the score. If deficiency.
red-green color is incorrect, 2 points is scored. If
yellow color test is incorrect, 1 point is scored. Method
Judgment is classified into pass and fail. The At the left end of the long box, the color of the
test result is considered as pass in the following reference color is fixed. There are 15 different
conditions: if the total number of points is scored color schemes; each color has a number on the
6 or less, or the number of incorrect answers is 3 back of it. And then take out 15 color plates and
or less for more than 2 times, and yellow color mix them in order. Ask the patient to find a color
test alone is incorrect and mistaken, red and tint most similar to the reference color tint, and
green tests are always correct, or patient recog- arrange the color tint next to the reference color

Fig. 4.3  Panel D-15

4  Color Vision 41

tint. And repeat the test in the same way. (Fig.  4.4a). If there is a change in the number
Inspection time should be 1–2  minutes, 5  min- after the line, a crossing line is partially drawn,
utes, or less. which is called a minor error and is regarded as a
Judgment of test consists of pass and fail. pass (Fig. 4.4b, c). Therefore, it does not check
the color discrimination ability of 15 colors. If
• Pass, mild abnormal findings there is one crossing line, it is one error, and the
judgment is passed. Normally, color numbers
After closing the box, turn it over, and read the 7–15 go straight from right to left and from 15 to
number of the color plate arranged toward the 8 are arranged upside down.
bottom. Connect the lines according to the num-
bers arranged in the picture on the recording • Fail, severe abnormality
paper. When arranged according to the total num-
ber, a circle with no error is drawn, which The occurrence of two or more transverse
includes normal and mild color abnormality lines crossing circles in a sequence is considered

a b c
3 4 5 2 3 4
4 5 1
6 2 3 p 5


p p 6





7 o



Sc 7
n n
Trita Trita Tritan
8 8 15
15 15
9 9 14
14 14 13 9
13 10 13 10
12 11 12 11 12 11 10

d e f
1 2 3 4
5 1 2 3 4 1 2 3 4 5
p p 5 p

6 6




7 7 7
Tritan Tritan Tritan

15 8 15 15 8
14 14 14 9
9 9
13 13 13
12 11 10 12 11 10 12 11 10

2 3 4 5
1 6



15 9
14 10
13 12

Fig. 4.4  Result of panel D-15 test. (a) Normal (b) Minor error (c) One error (d) Protan (e) Deutan (f) Tritan (g) Rod
42 J.-H. Park

as fail and is judged to be a high degree of color 5 and chroma level 5 are numbered from 1 to 85
vision abnormality. When the line of intersection on the back of the color plate and divided into 4
coincides with the axis of the protan, deutan, and wooden boxes. Two standard color plates are
tritan, which are the leader lines printed on the fixed to the ends of each wooden box, and all 8
recording paper, they are diagnosed as abnormal- colors are fixed colors, so they are made up of 93
ities of the first, second, and third color vision colors (Fig. 4.5).
abnormality (Fig. 4.4d–f). If there is ambiguity or In the first box, 84 and 22 color patches are
one crossing line, reexamination is carried out. fixed on both ends, and there are 85 to 21 move-
The three-color hue passes the most of them, but ment color patches between them. In the second
some fail, which means a severe abnormality. box, 21 and 43 are fixed, and there are 22 to 42
The two-color hue and three-color hue altitudes moving colors. In the third box, 42 and 64 are
are combined and classified as severe color fixed, and there are 43 to 63 moving colors. In the
abnormality. Rod monochromatism represents fourth box, 63 and 85 are fixed, and there are 64
the scotopic axis, the intermediate deutan axis, to 84 moving color patches, each of which
and the tritan axis (Fig.  4.4g). In the case of removes the moving color separately. From the
acquired color abnormality, the blue line abnor- first box, pick the color of the most similar color
mality appears as a transverse line parallel to the based on the fixed color of both ends, and place it
tritan axis. beside the fixed color. Next, select the color plate
that is closest to the color plate you placed, and
arrange it next to it. Repeat these operations to
4.4.2 Farnsworth-Munsell 100-Hue arrange all 22 color schemes in color order. The
Test above process is also carried out in the second,
third, and fourth wooden boxes to arrange all of
It is aimed to measure the degree of color dis- them, and the inspection is finished.
crimination ability and the nature of color confu- Close the lid of the box, and actually examine
sion by dividing 85 groups of different colors into the number of the recording paper, fill in the
four groups. It is often used to detect minor number displayed after the arranged color dis-
anomalies in acquired color vision defects rather play, and calculate the difference from the neigh-
than congenital color vision defects and to deter- boring number. The recorded score is combined
mine the course and treatment effects. with the neighboring number again to calculate
the deviation value (Fig. 4.6). This score is writ- Method ten on a radial chart, which is a recording plate,
Eighty-five colors with almost similar color dif- and connected by a line to judge the pattern. The
ference visually in 100 colors of brightness level total error score is the sum of the values obtained

Fig. 4.5 Farnsworth-­
Munsell 100-hue test
4  Color Vision 43

Fig. 4.6  A method of 9 10 11 12 13 14 15 16 17 18 19 Number of regular colors

calculating the deviation
value corresponding to 9 10 12 14 15 11 13 16 18 20 17 Number of actual color arrangement
each color according to
the inspection result 1 2 2 1 4 2 3 2 2 3 Difference between actual number
and neighbor number
3 4 3 5 6 5 5 4 5 Error score

a b c

Fig. 4.7  Result of Farnsworth-Munsell 100-hue test. (a) Protan. (b) Deutan. (c) Tritan

by subtracting 2 from each deviation value. It is 4.5 Color Matching Test

used as a reference value in evaluating the color
discrimination ability and as a data in evaluating 4.5.1 Nagel’s Anomaloscope
the disease progression in the acquired color
vision abnormality. It is diagnosed as blue-yel- It is based on principle that the color and bright-
low color abnormality, red-green color abnormal- ness are recognized as the standard yellow light
ity, and confusion of full color depending on the when the red light and the green light are prop-
total score difference and the area (pole) with erly mixed.
wrong answer on radial diagram. In protan, the Basically, this test is used when it is necessary
scores are increased near 19 and 65. In deutan, to judge whether the congenital protan or deutan
the scores are increased near 15 and 59, and the or determine the degree of recognition of trichro-
scores are increased from 1 to 46  in the tritan macy or dichromacy. A case in which the pres-
(Fig. 4.7). However, since it is often difficult to ence or absence of color hue is not confirmed by
judge the type, it is desirable to judge the type in another color hue test such as a pseudoisochro-
a numerical form together with the total score matic plate is also an object of inspection.
difference. The normal range of the total score It is not a screening test and is used to confirm
varies according to the age. The 20s have the the type and degree of color abnormality.
smallest total score difference around 50–90, and Acquired color vision abnormality, the tritan
the 50s have the total score difference around (green-yellow) is not subject to be inspected
160. It takes long to conduct and analyze the test, basically.
and it is difficult to judge the abnormality.
Although there is a difficulty in group examina- Method
tion, it is possible to accurately evaluate the Under natural light conditions, the each eyes are
degree of color vision abnormality and to apply it examined separately not to interfere with color
to the follow-up of acquired achromatosis. vision. Let the patient see the eyepiece and align
44 J.-H. Park

the optic axis of the patient with the visual axis of presentation time should be within 3 seconds. At
the patient to see if there is a circular visual field that time, let the patient watch the light adapta-
of the upper and lower semicircles. The lower tion plate for more than 5  seconds. The results
semicircular light is yellow; rotating the mono- obtained in this way are used for diagnosis in
chrome screw changes the contrast. If the mono- absolute equality. In the case of a color-blind per-
chrome screw scale is 0, it is dark, and nothing is son, first look at the circular field of view in the
visible; raising the scale gradually brightens. The vicinity of the normal range of uniformity, and
upper semicircular color light is green when the then calculate the uniform range by adjusting the
scale is 0 and red when the scale is 73 with rotat- color mixing screw and the monochrome screw
ing the color mixing screw. The scale of mixed according to the reaction.
two colors is between 0 and 73. The color vision abnormalities are classified
To obscure other eyes and to avoid color adap- into five types, protanomaly, protanopia, deuter-
tation, let the patient see light adaptation plate anomaly, deuteranopia, and normal, according to
just for 5–10 seconds. the result of color mixing scale. When the color
The examiner turns the color mixing screw mixing screw scale is around 40 and the mono-
and adjusts the color mixing scale from 0 to chrome screw scale is around 15, it is judged as
10 units. Then, the patient turns the monochrome the normal neutral point where the color and
screw to find the monochrome scale where color brightness of the upper and lower semicircles
and brightness are the same (Fig. 4.8). When you synchronized each other. The range of neutral
find a place where the patient feels the same, point is less than 5. For protan, color mixing
record the monochrome scale value at the point. scale is neutralized at the point smaller than nor-
At this time, the mixed scale and the monochro- mal neutral point. If the color mixing scale is
matic scale are referred to as an equal point. If neutralized at the point larger than normal neutral
you cannot find the same point, record it as “not point, it is considered as deutan.
found.” The protanopia is diagnosed when the color
Repeat the above test by raising the color mix- mixing screw scale is 40 and the monochrome
ing screws by 10 units. Since the equal range is screw scale is near 15; the color mixing screw
extended as a result of a long examination, the scale is 0 and the monochrome screw scale is

Fig. 4.8 Nagel’s
4  Color Vision 45

Fig. 4.9  Judgment of color

abnormality in Nagel’s
anomaloscope. 1 + 5 + 2,
protanopia; 2, protanomaly; 3,
deuteranomaly; 3 + 5 + 4,
deuteranopia; 5, normal

near 20; and the color mixing screw scale is 73 recording paper, it is considered as protan. If the
and the monochrome screw scale is near 4. In neutral point is in the range of green color, it is
protanomaly, color mixing screw scale increases considered as deutan.
between 40 and 73, and corresponding mono-
chrome screw scale decreases. The deuteranopia
is diagnosed when the color mixing screw scale Suggested Reading
is between 0 and 73 and monochrome screw scale
is near 15. The patient with deuteranomaly feels Baylor DA.  Photoreceptor signals and vision. Invest
Ophthalmol Vis Sci. 1987;28:34–49.
the same color and brightness of upper and lower International Standard. ISO 8596 Ophthalmic optics,
semicircles when the color mixing screw scale is visual acuity testing, standard optotype and its presen-
between 0 and 40 and monochrome screw scale tation. 1994(E). p. 1–4.
is near 15. It is easy to determine the type of color Linksz A. The development of visual standards: Snellen,
jaeger, and Giraud-Teulon. Bull N Y Acad Med.
abnormality by recording the neutral points and 1975;51:277–85.
drawing the line between neighboring points on Newell FW. History and interpretation. In: Ophthalmology
the recording paper as shown in Fig. 4.9. If the principles and concepts. 8th ed. St. Louis: Mosby;
neutral point is in the range of red color in the 1996. p. 139–48.
Ocular Alignment and Movement
Exam 5
Hye-Shin Jeon, Jung-Yul Park,
and Hee-Young Choi

5.1 Measurement of Deviation If there is constant deviation, the deviation is

shifted when the normal eye is covered. The
5.1.1 Qualitative Examination direction of the deviation is opposite to the direc-
tion in which the eye moves (Fig. 5.1).
The target is selected according to the purpose of
the test. If it is necessary to test in accommodative Cover-Uncover Test
environment, a small accommodating target should Uncover the occluder and observe the movement
be used. And a large target or a light source may of the covered eye.
be used if the accommodation is to be eliminated. It is possible to diagnose phoria and tropia,
In the case of infants, a target that can induce the and it is possible to discriminate whether it is
interest of the infant is used. Cover test can only be alternating or mono fixating. Uncovered eye is
performed on patients who have enough visual acu- moving in case of phoria. In case of tropia,
ity and concentration ability to look at the target. In uncovered strabismic eye is not moving, but fix-
addition, the results are inaccurate even when there ing eye is moving when uncovered after
is an abnormal retinal correspondence and extrafo- occluding.
veal fixation. The eye level of the examinee should
be the same as the patient and be careful not to Alternating Cover Test
occlude the target by the examiner. Since the head Observe the movement of the eyes that were cov-
position of the patient may affect the rest position, ered alternating the two eyes. It should be noted
examination is required at the right head position. that the occluding time should be sufficient for
1.5–3  seconds, and the time to move the cover Cover Test should be faster. In the case of phoria and tropia,
Make the patient look at the target 30 cm and 6 m there is eye movement when the occluder is
distance, and observe the eye movement covering moved to another eye. Phoria and tropia could
the opposite eye. not be distinguished.

H.-S. Jeon, MD., PhD. · J.-Y. Park, MD.

Department of Ophthalmology, Pusan National 5.1.2 Quantitative Examination
University Hospital, Busan, South Korea
H.-Y. Choi, MD., PhD. (*) If the cover test indicated that there is abnormal
Department of Ophthalmology, Pusan National ocular deviation, the amount of deviation should
University School of Medicine, Busan, South Korea
e-mail: be measured.

© Springer Nature Singapore Pte Ltd. 2019 47

J.-S. Lee (ed.), Primary Eye Examination,
48 H.-S. Jeon et al.

a d

b e

c f

Fig. 5.1  Cover test. (a) The resting position. (b) There is no is covered, the right eye moves outward in esotropia. (e)
deviation in the right eye because the right eye’s eye move- When the left eye is covered, the right eye moves inward in
ment does not occur when the left eye is covered. (c) There exotropia. (f) When the left eye is covered, the right eye
is no deviation in the left eye because the left eye does not moves downward in hypertropia. (g) When the left eye is
move when the right eye is covered. (d) When the left eye covered, the right eye moves upward in hypotropia Prism and Cover Test The total deviation can be known in the fusion-­
It is possible to measure the amount of deviation blocking state.
most accurately in various test distances and reli-
abilities in children and adults with good binocu-Simultaneous Prism and Cover Test, SPCT
lar function and cooperation. Keep two eyes fixating the target, and observe the
movement of the deviating eye, placing the prism
Alternating Prism and Cover Test, APCT at the deviating eye while the fixing eye is
Keep two eyes fixating the target, and place the occluded. The prism diopters is increased or
prism in front of an eye, and cover the two eyes decreased until there is no movement. It can be
alternately; increase or decrease the prism used in the examination of the monofixation syn-
diopters until the eyeballs do not move drome. There could be little or no deviation when
(Fig. 5.2). using simultaneous prism cover test, in patients
The direction of the prism should be base-out with relatively large deviation measured with
in esodeviation, base-in in exodeviation, base-­ alternating prism cover test. This means that the
down in the hyperdeviation, and base-up in the fixation disparity is present in the microtropia
hypodeviation. That is, the apex of the prism may and monofixation syndrome. The latent deviation
be directed toward the side having the deviation. is difficult to measure.
5  Ocular Alignment and Movement Exam 49

a d

b e

c f

Fig. 5.2  Alternating prism and cover test. (a) Right eso- right eye moves outward but less than in B. (e) Place the
tropia. (b) When the left eye is covered, the right eye prism with the higher diopters on the right eye and cover.
moves outward. (c) When the cover is trasferred to the (f) Transfer of cover to the left eye and no eye movement
right eye, the left eye moves outward. (d) Put the prism occurs in  the right eye. This prism diopter is consistent
base-out in front of the right eye and cover the left eye; the with ocular deviation

Fig. 5.3  Position of

prism in eccentric gaze

Comments When two prisms are overlapped in the same

Because prisms can cause variations depending direction, it is not the same as the sum of two
on how they are placed, we need to know the prisms. If two prisms are measured separately,
manufacturer’s standards. In the case of plastic the measured prism diopter must be corrected
prisms in general use, they should be placed in a (Table 5.1).
minimum deviation position or a frontal plane In case of wearing glasses and measuring the
position. When measuring from side gaze, make angle of deviation, The angle may be less than the
sure that the back of the prism is perpendicular to original deviation in the convex lens, and larger
the viewing direction (Fig. 5.3). in the concave lens. In the naked eye, it is ­possible
50 H.-S. Jeon et al.

Table 5.1  The actual angle of deviation when the prism is placed in both eyes individually in the horizontal direction
Prism in the left eye Prism in the right eye
10 12 14 16 18 20 25 30 35 40 45 50
10 20 22 24 26 29 31 36 41  47  52  58  63
12 22 24 26 29 31 33 38 44  49  55  60  66
14 24 26 29 31 33 35 40 46  52  57  63  69
16 26 29 31 33 35 37 43 48  54  60  66  72
18 29 31 33 35 37 39 45 51  57  63  69  75
20 31 33 35 37 39 42 47 53  59  65  71  78
25 36 38 40 43 45 47 53 59  66  72  79  86
30 41 44 46 48 51 53 59 66  73  80  87  94
35 47 49 52 54 57 59 66 73  80  87  95 103
40 52 55 57 60 63 65 72 80  87  95 104 113
45 58 60 63 66 69 71 79 87  95 104 113 123
50 63 66 69 72 75 78 86 94 103 113 123 133

to observe eye movements in the horizontal reflex is not at the center of the pupil, keep
direction 1–2 △, in cyclovertical direction 2 △. patient fixing the target with target placing away
from the position of the light source. The angle Major Amblyoscope between the light source and the target when the
It is used to examine sensory and motor abnor- corneal reflex is in the pupil center is the kappa
malities such as subjective and objective devia- angle (Fig. 5.4).
tion measurements, fusion, retinal
correspondence, suppression, stereopsis test, and • Subjective method
training of binocular function in patients with
suspicion of abnormal ocular deviation, binocu- Place the slide as shown in Fig.  5.5 on the
lar dysfunction, or abnormal eye movement amblyoscope, and let the patient fix the center of
disorder. the slide (dog). If the corneal reflex is not at the
center of the cornea, move the handle so that it is Corneal Reflex Test at the center of the cornea, and then ask for the
symbol or picture. The position of this symbol or
Measurement of Angle Kappa figure is the kappa angle.
The corneal reflex is not located at the center of When the corneal reflex point is located at the
the cornea, and there is a slight difference indi- center of the pupil, the kappa angle is zero. The
vidually, which is called the kappa angle. positive kappa angle refers to the case where the
Therefore, correction of Kappa angle is neces- corneal reflex point is located inside the pupil.
sary for analysis when performing amblyoscopy, The negative kappa angle refers to the case where
Hirschberg test, and Krimsky test which measure the corneal reflex point is located outside the
the angle of deviation by corneal reflection pupil. The positive kappa angle below 5° is
method. Measure the angle formed by the two regarded as normal and cornea reflex point
axes: visual axis and pupil axis. located at 0.5 mm on the nasal side in most peo-
ple. Positive kappa angle seems to be exotropia,
• Objective method and negative kappa angle seems to be esotropia.
If a large positive kappa angle and esotropia are
Let the patient see the examiner’s eye; place present, or if a large negative kappa angle and
the patient’s and the examiner’s eye on the same exotropia are present, strabismus may not be seen
axis. Position the light source coincident with or overlooked. If a patient has a large positive
the axis, and then observe whether the corneal kappa angle, fundus examination should be per-
reflex is in the center of the pupil. If the corneal formed to check for retinal abnormalities.
5  Ocular Alignment and Movement Exam 51

f f


Positive Negative
Angle Kappa Angle Kappa

Pupil axis Visual Axis




Fig. 5.4  Kappa angle. K Kappa angle, L light source, f fovea

Fig. 5.5  Amblyoscope slide for the measurement of Kappa angle

Hirschberg Test the light spot at a 33 cm or 6 m in front of the eye,
It is used mainly for infant and mental retardation and observe the location of the corneal reflex point.
child who are difficult to cooperate, poor fixation If the corneal reflex point is in the pupil mar-
due to low visual acuity, or for patients with eccen- gin, 15° deviation (30△); if it is between the
tric fixation. In a dark room, make patient look at pupil edge and the limbus, 30° deviation (60△);
52 H.-S. Jeon et al.

Fig. 5.6 Hirschberg a
test. (a) Normal. (b)
Esotropia of 15o. (c)
Esotropia of 30o.
(d) Esotropia of 45o

and if it is in the corneal margin, 45° deviation Let the patient fix the light spot. Looking the
(90△) is expected (Fig. 5.6). deviating eye, place the prism in front of the fix-
The distance from the normal kappa ing eye (base-out in esodeviations and base-in in
angle should be measured, not the distance from exodeviation). The prism is increased or
the pupil center. It can  not distinguish between decreased until the corneal reflex of the deviated
phoria and tropia. If there is difference in devia- eye is at the center of the cornea (Fig. 5.7).
tion according to the fixing eye, incomitant stra- The prism diopters when the corneal reflex
bismus, eccentric fixation, or macular dragging, comes to the center of the pupil are the deviation
accurate measurement is difficult in this method. angle, and correction for the kappa angle is nec-
Errors may occur if there is a difference in the essary. It is difficult to measure the angle of devi-
corneal diameter of the infant or if the position of ation when there are abnormal kappa angles,
examiner changes. macular dragging, and eccentric fixation.

Krimsky Test Photographic Method

It is used to measure manifested ocular deviation In infant and young children, the angle of devia-
when it is difficult to perform the prism cover test tion can be measured using photographs. It con-
because of poor visual acuity or poor coopera- sists of three horizontally arranged flashes and a
tion. More accurate measurements can be camera with a small fixating light source. The
obtained than Hirschberg test. pupil reflex from the first and fourth Purkinje
5  Ocular Alignment and Movement Exam 53

b c

d e

Fig. 5.7  Krimsky test. (a) The Hirschberg test in strabis- the base-out prism on the right eye which is the fixing eye.
mic patient. Corneal reflexes are located on the nasal side The corneal reflex which is located in the temporal side of
of the pupil (+0.5 mm) in the right eye and on the tempo- the left eye (a), is observed at the nasal side, and is the
ral side of the pupil (−1.0 mm) in the left eye. Suspicion same position as the kappa angle of the left eye. (e)
of left esotropia. (b) Kappa angle of the right eye. Corneal Modified Krimsky test. Place the base-out prism in front
reflex in the right eye is present in the same position of the deviated left eye. Corneal reflex at the temporal side
(+0.5  mm) as in binocular environment (a). (c) Kappa (a) is moved to the nasal side and is located at the same
angle of the left eye. If right eye is covered, corneal reflex position as the Kappa angle of the left eye. (f) Actual pic-
of the left eye is moved to the nasal side (+0.5 mm), and ture of a child
the left eye seems to be deviated. (d) Krimsky test. Place
54 H.-S. Jeon et al.

images of each light source is taken to determine better-looking eye. Maddox cross can be used
the angle of deviation. Accuracy is about 2.0–4.5 together to measure the angle of deviation
△, which is more accurate than Hirschberg test; (Fig. 5.8).
error can be made because of accommodation. Maddox Rod Test
Brückner Test Maddox rod is a red lens with a rod of circumfer-
It is used to diagnose strabismus in infants using ential lens in parallel. When the light source is
the position of cornea reflex and the brightness of viewed through the lens, a red line appears in the
light reflected from the fundus. In the half-dark vertical direction of the rod. Phoria, monofixa-
room without mydriasis, the pupil, the bright tion syndrome, intermittent exotropia, and para-
light of the direct ophthalmoscope, is illuminated lytic strabismus could be indicated of this test.
at 1 m from the patient’s two eyes. The position manifest strabismus with suppression is difficult
of the cornea reflection and the color of the light to test.
reflected from the fundus are observed through Place a light spot at a distance of 33 cm and
the ophthalmoscope. The difference in the bright- 6 m in front of the patient, and place the Maddox
ness of binocular reflexes is important, and the rod according to the horizontal or vertical devia-
fixing eyes are slightly darker than the strabismic tion; placing the direction of the rod horizontally
eye. in horizontal deviation and vertically in the verti-
It is useful for identifying children who could cal deviation. Ask for the positional relationship
not cooperate or moderate strabismus. between the red line and the light spot seen
Asymptomatic fundus reflection could be through the lens (Fig. 5.9).
observed until 10  months of normal develop- When the red line passes through the light
ment; there may be false positives in non-­ spot, it is orthotropic. If direction of the red line
strabismic children. It should be noted that there is crossed to the light spot, it is exotropia or exo-
may be differences in brightness due to anisome- phoria. And if it is in the same direction, it is the
tropia, pupil abnormality, retinal abnormality, or esotropia or esophoria. Vertical deviation is also
media opacity. determined by the same method. Prism diopters
can be increased or decreased so that the red line
is at the center of the light spot. The prism direc-
5.1.3 Subjective Tests tion should be base-in when the red line inter-
sects with the light spot and should be base-out if Red Glass Test it is in the same direction.
It is a test to determine the degree of strabismus The patient should have visual acuity good
and deviation by subjectively expressing the dual enough to distinguish the light through the
image of the foveal image in the fixing eye and Maddox rods and the ability to distinguish
parafoveal image of the deviating eye. It should between left, right, top, and bottom. There is no
be performed to the patients who can cooperate at distinction between tropia and phoria, and the
least 4 years old. Red glasses are placed in front deviation measured by this method may not be
of one eye to separate the two eyes and darken to accurate. When there is abnormal retinal corre-
the extent that nothing other than faint red light is spondence, the angle of deviation is measured
visible. Let the patient look at the small light differently.
source, and describe where the red light is rela-
tive to the white light. Position of the red light Maddox Wing Test
relative to the white light is related to the eyeball It is a method to quantitatively measure the devi-
deviation. ation at near fixation by dissociating the two eyes
The red glasses should be placed in front of (Fig. 5.10). In patients who complain of astheno-
the fixing eye generally since the red glasses pia during near work, the subjective deviation
make the sight dark, so it is better to look with can be measured easily and can be used in
5  Ocular Alignment and Movement Exam 55

Fig. 5.8  Maddox Cross a

test. (a) Perform at a 3
distance of 5 m (1 m can 2
also be used with a
smaller number). The 76 5
patient has 4 △ 5m 1 1 2 3
esotropia. (b) If the 1
patient has normal
retinal correspondence, 2
the red light overlaps the 3
number of the fovea in
the deviated eye. In the
case of this patient,
the red light overlaps b 4 ∆ Esodviation
the number 4. (c) 5
Non-crossing diplopia in 4
patient with 4△ 3

esotropia (or esophoria)

6 5 4 3 2 1 1 2 3 4 5 6 7 6
4 1
6 5 4 3 2 1 1 2 3

OS OD Patient’s view

No Horizontal deviation

Exodeviation Fig. 5.10  Maddox wing test

patients who are suspected of small angle vertical
Esodeviation or cyclodeviation.
Holding the Maddox wings with hands, you
can see the horizontal and vertical scale on left
Fig. 5.9  Maddox rod test (a) The madox rod lens is eye and the horizontal and vertical arrows on
placed in front of right eye horizontally. (b) No strabis- right eye. The white arrows point to horizontal
mus. (c) Exodeviation. (d) Esodeviation
56 H.-S. Jeon et al.

scale which indicates the vertical deviation, Methods

and the red arrows indicate the vertical scale • Place the patient in a dark room and 50  cm
and horizontal deviation. If the horizontal line away from the Hess screen, and fix the head so
is not ­parallel to the horizontal scale, it indi- that the center of the screen is at the patient’s
cates that there is cyclodeviation. If the patient eye level. The spacing between each line of the
moves the arrow by himself until the patient Hess screen is 5°, and it colored red at 15° and
feels horizontal, the value of cyclodeviation is 30° where vertical and horizontal lines meet.
obtained. There are 8 red spots on the inside squares and
The visual acuity should be above the value of 16 red spots on the outside squares.
which the number and the arrow are clearly visi- • Put on red and green glasses, and watch the
ble, and the relaxation of the accommodation center of the screen with the eyes of red eye-
may lead to an increase in the exotropia and a glasses, and hold a pointer where the green
decrease in the esotropia deviation, resulting in target is projected.
inaccurate results. • Move the fixing point on the screen to the top
and clockwise from the center of the pattern. Lancaster Red-Green Test The examiner marks the positions indicated
Two subjects are visualized in each eye, and the by patient on the small card with reduced copy
two subjects are stimulated to the fovea of the of the screen (Fig. 5.11).
individual eyes. Patients with normal retinal cor- • The chart on the right shows the right eye
respondence are indicated. Using a screen with a deviation when fixing with the left eye, while
square of 5 cm at a distance of 1 m, let the patient the chart on the left shows the left eye devia-
wear red and green glasses that can be changed tion when fixing with the right eye.
each other. Prepare two linear streaks of light,
green for patient and red for examiner. The exam- Interpretation
iner projects the red light on the screen, fixes the Comparing the left and right deviation (chart),
patient’s head, and let the patient to match the red the eyes showing the reduced size of the eye
line light with the green line light. If the patient movement square become the eyes with
has normal retinal correspondence, the two
streaks formed are separated objectively  on the
screen according to the amount of strabismus.
The angle of cyclodeviation can also be exam-
ined according to the tilted angle of line. It is
most useful for examining the paralytic strabis-
mus, but it is inaccurate in intermittent
strabismus. Hess Screen Test

It can be examined if abnormal oculomotor
function or paralysis is suspected in patients
with normal retinal correspondence. This is a
subjective measurement method that can mea-
sure qualitatively and quantitatively the devia-
tion hyper- or hypoactivity of each extraocular
muscle by measuring the direction of the nine
gaze directions. This method is effective in find-
ing paralysis and paralysis of the extraocular
muscles. Fig. 5.11  Hess screen test
5  Ocular Alignment and Movement Exam 57

FIELD OF LEFT EYE(fixing with right eye) FIELD OF RIGHT EYE(fixing with left eye)

temp nasal temp

Green before left Eye Green before Right Eye

Fig. 5.12  Clinical example of Hess screen test. Right superior oblique palsy

reduced motion (paralyzed eyes), and the Methods

paretic eye is the one which direction of In the dark room, place a red rod filter in the eye
movement is most diminished from normal suspected to have cyclodeviation and a white rod
range. The direction in which most enlarged filter in the opposite eye, perpendicularly to the
than the range of normal value is the direction eyeglass frame, and then let the patient look the
of the yolk muscle of paralyzed muscle light spot on the front. Ask the patient if the red and
(Fig. 5.12). white lines are parallel. If they are not parallel,
make them parallel by rotating the handle of the red
rod by patient (Fig. 5.13). In right superior oblique
5.1.4 Diagnosis of Cyclodeviation palsy, a red rod filter is worn on the right eye. Qualitative Inspection by Interpretation

Position of Double Vision The right eye is excyclodeviated in right superior
For inspection, place a horizontal ruler in front oblique palsy if the red line of the right eye is
of the lower half of the midline of the eye, seen to be tilted to the nasal side. The two lines
shielding the eyes alternately, and check are perceived parallel only after the patient
whether the eye deviated. The slope of the reti- extorts the right rod (Fig. 5.13a). The angle of the
nal image is opposite to the slope observed by rotation done by the patient becomes the cyclode-
the patient. For example, if the line is tilted viation angle (Fig. 5.13b).
toward the nasal side, it is excylodeviated. If there is no vertical deviation, it is conve-
Retinal images are tilted as paralyzed muscles nient that the base-out 6△ prism is located in
act alone. front of an eye to separate the two horizontal
lines. Since the results vary depending on the fix- Double Maddox Rod Test ing eye, the opposite eye of the paralyzed mus-
It is a subjective test that can measure quantita- cles can be judged as having cyclodeviation.
tively the cyclodeviation. However, it is impossi- Although it is possible to accurately measure the
ble to differentiate between cyclotropia and cyclodeviation, it disadvantageously dissociates
cyclophoria. the two eyes to eliminate cyclo-fusion, which is
58 H.-S. Jeon et al.

40 35 30 25 25 30 35 40
105 90 75 5 90 75 6
20 60 0 10 0
1 45 12 45







50 0

Patients’s view Lt Rt

40 35 30 25 25 30 35 40
90 75 5 90 75 6
0 105 60 0 10
12 45 12 0


180 165

16 15


50 01

Patients’s view Lt Rt


Fig. 5.13  Maddox double rod test (a) In suspicious of that the red line is incyclotorted. (b) Rotate the red filter
right superior oblique palsy, red filter in the right eye and outward to find the point where the two lines become
White filter in the left eye are placed. The patient may feel parallel

the most important compensation mechanism of that can qualitatively measure the degree of
cyclodeviation. cyclodeviation. Patients who are suspected to
have cyclodeviation such as paralytic strabis- Maddox Double Prism Test mus, inferior/superior oblique overreaction or
Maddox double prism, attaching two prisms underaction, or A- or V-type strabismus are
with 4△ at the bottom, is a subjective method indicated.
5  Ocular Alignment and Movement Exam 59

Methods Methods
In a room of normal brightness, place a double Fovea is located below 0.3 disc diameter of the
prism in front of the opposite eye to be examined, geometric center of the optic nerve.
and look at the white paper with a horizontal line. This is the point passing through the middle of
Three lines including a straight line seen from the the lower half of the optic nerve head when the
strabismic eye appear at the center of two parallel imaginary horizontal line is drawn at the fovea.
lines of the double prism fitted in the opposite
eye. Interpretation
If the fovea is located higher, there is incyclotro-
Interpretation pia. If it is located lower, there is excyclotropia.
If all three lines are parallel, there is no cyclode- There may be difference between two eyes in
viation. If the center line is tilted to the outside, normal person, but vertical differences more than
incyclotorsion exist. If it is tilted inward, the 0.25 DD can be regarded as abnormal.
excyclotorsion is expected.
It is easy to examine the presence of cyclotor- Visual Field Test
sion and has the advantage of not having to turn The change of blind spot position on the visual
off the light of the room. However, if the prism is field test can discriminate the cyclodeviation. The
not set correctly, it can be misdiagnosed as hav- blind spot moves upward for incyclotorsion while
ing a cyclodeviation in the normal eye, and it moves downward for excyclotorsion.
cyclodeviation cannot be quantitatively
5.2 Duction and Version Test Bagolini Striated Glasses Test
It is used to qualitatively evaluate the For strabismus patients and those complaining
cyclodeviation. of diplopia or abnormal eye movement, such as
eye movement restriction, movement of one or
Methods both eyes should be measured 30° from the nine
Similar to the Maddox rod test, the stripe lens directions of primary gaze (front), secondary
make vertical line of light. Insert the stripe lens to gaze (upper, lower, left, and right), and tertiary
be perpendicular each other, turn them until gaze (upper right, lower right, upper left, and
fusion occurs, and read the angle. lower left). By testing eye movement, hyper-
functioning or hypofunctioning of muscles and
Interpretation the direction of decreased movement are
The direction and angle of the deviation should confirmed.
be interpreted to be the degree to which it has
been rotated.
The test can be performed while fusion is 5.2.1 Methods
maintained. If cyclodeviation is positive in dou-
ble Maddox rod test, but negative in Bagolini stri- Duction Test
ated lens test, it is possible that the patient has The movement of the tested eye is observed while
cyclo-fusion or compensates the strabismus by covering the other eye.
viewing the surrounding environment. If the patient can comply, ask the patient to see
a visual acuity chart of appropriate sizes or a pen Fixation Ophthalmoscopy light in the direction to be tested. For children,
and Fixation Fundus use stuffed toys or objects that make noises to
Photography gain their attention.
It is an objective test to be used to diagnose the After confirming the position of the patient’s
cyclodeviation. eye in primary gaze, limitation or enhancement
60 H.-S. Jeon et al.

of eye movement should be tested in each direc- The distance between the edge of the cornea
tion. Here, the patient should be asked to move of both eyes should be measured. Eyeglasses
the eyeball as much as possible. should be taken off when testing the periphery.
When mild abnormalities are observed, com- Care must be taken due to individual differ-
parisons should be made with the other eye. ences in the shape of the eyelids. Limitation or
enhancement of eye movement should be deter- Version Test mined and recorded in association with the main
The chart should be moved in each direction direction of action of each extraocular muscle.
from the central line between the two eyes. Figure  5.15 shows the normal range of eye
Hyperfunctioning of each extraocular muscle is movement.
scored as +1 to +4, whereas hypofunctioning is
scored as −1 to −4. Hyperfunction often appears Adduction
secondary to weakening of antagonistic muscle Perpendicular line at the lower punctum should
of the same eye or yoked muscle of the other eye pass through the line between the inner 1/3 and
(Fig. 5.14). outer 2/3 of the cornea.

Fig. 5.14  Version test.

The markings show
varying degrees of –4
hypofunction of the
lateral rectus of the left
eye in leftward gaze (0,
normal; −4, maximum




5  Ocular Alignment and Movement Exam 61

Fig. 5.15  Break point

in the range of eye

Adduction Abduction

Elevation Depression

Elevation in Depression in
adduction adduction

Elevation in Depression in
abduction abduction

Abduction 5.3 Vergence Test

The edge of the cornea should meet the outer cor-
ner of the eye. Eye convergence can be divided into tonic ver-
gence, fusional vergence, accommodative ver-
Elevation gence, and proximal vergence. Fusional vergence
The edge of the cornea should be above the line arises to allow an image to form on correspond-
connecting the inner and outer corners of the eye. ing points on both retina and is also called motor
fusion. In general, vergence test used in clinic
Depression measures fusional vergence.
The edge of the cornea should be lower than the line
connecting the inner and outer corners of the eye.
The distance moved by the eyeball using the edge of 5.3.1 Using a Prism
the cornea as the measurement point can be mea-
sured with a transparent ruler. Normal eye move- Methods
ment falls around 10 mm in convergence, divergence, Using a prism bar or rotating prism, the patient is
and lowering and around 5–7  mm in lifting. The asked to look at a target that does not cause
range of eye movement is around 50° in each direc- accommodation. The target is placed at a far dis-
tion, and aging leads to decreased upward gaze. tance (5 m) and a short distance (33 cm).
62 H.-S. Jeon et al.

The bottom of the prism is placed temporally 5.3.2 U

 sing a Major Amblyoscope
when measuring the convergence amplitude and (See Chap. 6)
toward the nose when measuring the divergence
amplitude. Examination of sensory and motor abnormalities
Placing the prism on one eye, the patient is asked such as subjective and objective deviation mea-
to look at the prism while making sure to not see surements, fusion, retinal correspondence, sup-
two targets. The prism refracting power is increased pression, stereopsis test, and training of binocular
gradually starting at a low strength, and the patient function in patients with suspicion of abnormal
is asked whether they are seeing two objects. ocular deviation, binocular dysfunction, or
The break point is the point where the patient abnormal eye movement disorder.
fails to fuse the images and sees two images.
Here, the prism refracting power is gradually
reduced again, and the point at which the patient 5.3.3 Using Bagolini Striated Lenses
sees one image again is the recovery point.
Caution is required to increase the prism The patient is asked to look at a bright visual acu-
refracting power gradually. If it is increased too ity chart through Bagolini striated lenses, and
rapidly, the fusional amplitude is measured to be tests are conducted using a prism. Since the target
lower than actual. is seen smudged, it is difficult to achieve a con-
If the divergence amplitude is measured sistent accommodation. However, binocular
immediately after measuring the convergence vision can be tested by confirming whether the
amplitude, the divergence amplitude is measured two lines formed by light cross perpendicularly
to be lower due to aftereffects. Therefore, the and patients can easily answer upon subjective
measurement should continue after causing verti- realization.
cal fusion. Therefore, vergence should be mea-
sured in the following order: convergence
amplitude, vertical fusional amplitude, and diver- 5.4 Head Tilt Test
gence amplitude.
Since diplopia may not be present due to sup- The test is used to diagnose rotating vertical
pression of the deviating eye in some patients, strabismus.
changes in the position of the eyeball should be
monitored in these patients.
5.4.1 Methods Interpretation
Various normal ranges have been reported. In Changes in vertical-oblique deviation mea-
general, when looking far away, the convergence sured when tilting the head left and right are
amplitude is around 20△, divergence amplitude observed while conducting an alternating
around 6–8△, and vertical convergence ampli- cover test. Deviation is small and continuous
tude around 3–4△. Horizontal fusional ampli- with binocular vision at habitual head posi-
tude is shorter when looking far away than tions. However, when tilting the head in the
closely. Even with normal visual function in opposite direction, deviation increases, and
both eyes, various fusional amplitudes can be diplopia or suppression is observed. Paralyzed
measured from different individuals. The recov- muscles are diagnosed according to the fol-
ery point is usually 2–4△ lower than the break lowing three steps.
point. In some patient, the recovery is never
achieved even when the prism refracting power • In which eye is hypertropia observed when
is very low. Such cases are observed when recov- looking straight into the front?
ery rarely occurs once the fusion breaks, such as • Does vertical deviation increase when looking
in intermittent strabismus. with right eye or left eye?
5  Ocular Alignment and Movement Exam 63

• Does vertical deviation increase when tilting 5.5 Forced Duction Test
the head left or right?
5.5.1 Methods

5.4.2 Interpretation Whether decreased movement of extraocular

muscles is restrictive or paralytic can be diag-
Since the above three-step test is difficult to use nosed in patients with eye movement restriction.
in clinic unless the doctor is experienced, it is Apply sufficient amounts of topical anesthetic
easier to understand if the procedure is summa- eye drops, such as 0.5% proparacaine and 4%
rized as shown below in the figures. lidocaine, and open the patient’s eyes with eyelid
speculums in a supine position.
Step 1: Hypertropia of the right eye is caused by Ask the patient to look at the direction with
hypofunction of depressor muscles of the right decreased movement (Fig. 5.17a, b).
eye, including right inferior rectus or right Hold the conjunctiva and episclera near the
superior oblique, or hypofunction of elevator limbus opposite to the direction of decreased
muscles of the left eye, including left inferior movement with a toothed forceps, and pull in the
oblique and left superior rectus. In contrast, direction of decreased movement (i.e., direction
hypertropia of the left eye is caused by hypo- opposite to the suspected direction of mechanical
function of elevator muscles of the right eye, duction) to observe the presence and strength of
including right superior rectus or right inferior resistance (Fig. 5.17c).
oblique, or hypofunction of depressors mus- When testing oblique muscles tightness, hold
cles of the left eye, including left superior the conjunctiva at the 3 o’clock and 9 o’clock posi-
oblique and left inferior rectus. Therefore, tions with two toothed forceps, and press the eye-
mark the two suspected extraocular muscles ball posteriorly. For superior oblique  muscle,
as shown in the figure (Fig. 5.16a). move eyeball  inward  and upward, and move
Step 2: If hypertropia worsens in right gaze, it is inward and downward for inferior oblique. Due
caused by right gaze verticals, including right to the tension of the oblique muscle, the eyeball
superior rectus, right inferior rectus, left inferior pops up across the tendon during this maneuver.
oblique, and left superior oblique. If hypertropia
worsens in left gaze, it is caused by paralysis of
left gaze verticals, including left superior rectus, 5.5.2 Interpretation
left inferior rectus, right inferior oblique, and
right superior oblique (Fig. 5.16b). For rectus muscles, no resistance indicates decreased
Step 3: If hypertropia worsens when tilting the movement from paralytic strabismus, whereas the
head right, it is caused by right eye intortors, presence of resistance indicates decreased move-
including right superior rectus and right supe- ment due to the contracture of antagonistic muscles
rior oblique, or by left eye extortors, such as or other mechanical causes. For superior oblique,
left inferior oblique and left inferior rectus. In anatomical abnormalities in the insertion site of the
contrast, if hypertropia worsens when tilting superior oblique can be suspected if no tension can
the head left, it is caused by left eye intortors, be felt in duction test conducted in patients with
such as left superior rectus and left superior paralysis of the superior oblique. The test can also be
oblique, or by right eye extortors, such as right useful in investigating the inferior oblique function
inferior oblique and right inferior rectus after inferior oblique surgery.
(Fig. 5.16c). For duction test of the rectus muscles, it is
accurate to conduct the test after slightly pulling
Final diagnosis: The muscle with three circles the eyeball to the front. If duction tests are con-
from the three steps can be suspected to be para- ducted while pushing the eyeballs posteriorly, the
lyzed (Fig. 5.16d). muscles may relax, leading to false-negative
64 H.-S. Jeon et al.

a Rt. Hypertropia b Increase in Rt. gaze c Increase in Rt. Tilt

Lt. IO Lt. SR
Rt. SR Lt. IO
Rt. SR Lt. IO

Rt. SO Lt. IR
Rt. IR Rt. SO
Rt. IR Lt. SO Or
Or Increase in Lt. Tilt
Lt. Hypertropia Or
Increase in Lt. gaze

Rt. SR Rt. IO Rt. IO Lt. SR

Rt. IO Lt. SR

Rt. IR Lt. SO
Lt. SO Lt. IR Rt. SO Lt. IR

d Rt. IO Palsy

Rt. SO Palsy

Rt. IR Palsy Lt. SO Palsy

Fig. 5.16  Markings in head tilt test (a) direction of the hypertropia at primary position. (b) Change of vertical deviation
when looking horizontally. (c) Change of vertical deviation when tilting head. (d) The muscle with three circles from
the three steps can be suspected to be paralyzed

results. If duction does not decrease even when oblique muscles tense and rectus muscles relaxed.
the eyeball is pushed posteriorly, adherence syn- Moreover, the conjunctiva at 90° to the direction
drome or Brown’s syndrome, rather than paraly- of suspected mechanical resistance (12 o’clock
sis of the rectus muscle, should be suspected. For and 6 o’clock positions in movement limitations
oblique muscles, the test should be conducted of medial rectus or lateral rectus) can be held
with the eyeballs pushed posteriorly, with the with two toothed forceps for tests. When the
5  Ocular Alignment and Movement Exam 65

Fig. 5.17 Forced a
duction test. (a) An
esotropia patient with
divergence disorder of
the right eye is asked to
fixate on the right as
much as possible. (b)
Holding the nasal edge
of conjunctiva and
episclera of the right eye b
with toothed forceps, the
patient is asked to
diverge softly in the
beginning and then
strongly from the
median plane. If
resistance is felt without
sufficient divergence,
mechanical duction is
present. (c) If no
resistance is felt with
complete divergence, c
there is no mechanical
traction, and lateral
rectus paralysis is

patient does not comply or in young children, the asked to look at the direction of action of para-
test should be conducted under general anesthesia. lyzed muscle, while the tester quantitatively
Depolarizing muscle relaxants, such as succinyl- feels the power of the paralyzed muscle. For
choline, contract the extraocular muscles for instance, in a patient with paralysis of left lat-
approximately 20  minutes, making the test eral rectus, the patient is asked to adduct the left
difficult; therefore, non-depolarizing muscle
­ eye. The tester then holds the 3 o'clock position
relaxants should be used. of the limbus with forceps and then asks the
patient to abduct the left eye to test the muscular
5.6 Active Force Generation Test

5.6.1 Methods 5.6.2 Interpretation

This test investigates the recovery of paralyzed In lateral rectus paralysis, active muscle power of
extraocular muscles and is important in deter- the lateral rectus suggests that the function of the
mining surgical approach for paralytic strabis- paralyzed muscle has recovered and recession of
mus. After local anesthesia, tissues surrounding the medial rectus and resection of the lateral rec-
the cornea are held with forceps. The patient is tus are considered. If only passive movement is
66 H.-S. Jeon et al.

present, transposition is considered. Moreover, 5.7.2 Interpretation

since very strong forces for abduction indicate
contracture of the medial rectus, it can be cor- Table 5.2 shows the normal ranges. However,
rected only through recession of medial rectus. there are individual differences, and aging leads
to decreases in test results.

5.7 Field of Fixation

5.8 Measurement of Head
Patients with eye movement restriction or Posture
enhancement are tested. Field of monocular fixa-
tion test quantitatively measures the range of Patients who may have head posture abnormali-
monocular movement, whereas field of binocular ties are tested, such as those with paralysis of eye
fixation test measures the range of movement muscles, incomitant strabismus, comitant strabis-
allowing for binocular vision without diplopia. mus, nystagmus, supranuclear pathway disorders
in eye movement, ptosis, anomalies of refraction,
or abnormalities of visual field.
5.7.1 Methods Head posture abnormalities can cause not
only esthetic problems, but also orthopedic prob- Field of Monocular Fixation Test lems, such as facial asymmetry. If they are caused
A kinetic perimeter, such as a Goldmann perime- by ophthalmological reasons, they should be
ter, is used. After fixing the head, the tested eye is treated in ophthalmology. The test can be divided
placed in the center, and the other eye is covered. into face turn, head tilting, and chin elevation/
Among visual acuity charts that can be clearly depression.
seen by the patient, the darkest and smallest chart
is moved from the center to the edge of the
perimeter. 5.8.1 Methods
The patient looks at the chart, and break points
at which the chart cannot be seen are measured in Qualitative Tests
each direction. Natural head posture is observed with both eyes
open. Photographs of the upper body are taken Field of Binocular Fixation Test from the front, sides, and above, and pre-­
After fixing the head, the bridge of the nose in treatment and posttreatment photographs are
between both eyes is set as the center of the compared. The observation follows the same
perimeter. An object that can be clearly seen is methods with one eye covered. In compensatory
moved in each direction while confirming head posture abnormalities arising from incomi-
whether binocular vision without diplopia is pos- tant strabismus, the abnormalities decrease or
sible. The patient looks at the object with both disappear when one eye is covered. In otorhino-
eyes, and the points at which the object appears laryngological or orthopedic head posture abnor-
as two are marked. malities, covering the eye does not exert any

Table 5.2  Normal ranges in field of monocular fixation and field of binocular fixation tests
Field of monocular fixation test Field of binocular fixation test
Left eye Right eye Left eye Right eye
Lifting 44° 42° 28° 28°
Depression 45° 45° 45° 45°
Divergence 39° 45° 20° 21°
Convergence 48° 44° 35° 34°
5  Ocular Alignment and Movement Exam 67

a b c

Fig. 5.18  Measurements of head posture (a) During face necting the external auditory meatus and inferior border
turn, the protractor is placed on the center of the head, and of the orbit is obtained. (c) During head tilting, the pro-
the angle between the tip of the nose and the gaze target is tractor is placed on the front, and the angle between the
obtained. (b) During chin elevation or depression, the midline of the face and perpendicular line is obtained
angle formed by the horizontal surface and the line con- Quantitative Tests genital nystagmus, acquired oculomotor nerve

Head posture abnormalities can be quantified paralysis, retraction syndrome, acquired nystag-
using protractors. mus, alternating periodic nystagmus, and Möbius
During face turn, the protractor is placed on syndrome.
the center of the head, and the angle between the Chin elevation and depression are seen in pto-
tip of the nose and the gaze target is obtained sis (progressive external ophthalmoplegia and
(Fig. 5.18a). congenital fibrosis), A- and V-type strabismus,
During chin elevation or depression, the angle bilateral trochlear nerve palsy, double elevator
formed by the horizontal surface and the line palsy, and Brown’s syndrome. Head tilting is
connecting the external auditory meatus and infe- observed in superior oblique palsy, dissociative
rior border of the orbit is obtained (Fig. 5.18b). heterophoria, and ocular tilt reaction.
During head tilting, the protractor is placed on Abnormal movements of the head are observed
the front, and the angle between the midline of in congenital nystagmus, Parkinson’s disease,
the face and perpendicular line is obtained multiple cerebral infarction, spastic ectropion,
(Fig. 5.18c). and eye ataxia. Consideration
5.8.2 Interpretation It is sometimes difficult to observe natural head
posture abnormalities when patients are nervous in
Face turn abnormalities appear in paralysis of doctor’s office. Therefore, it is important to hear
nerves for divergence, esotropia in children, con- from family members about head posture abnor-
68 H.-S. Jeon et al.

Table 5.3  Abnormal head postures seen in external ophthalmoplegia

Paralyzed muscle Turning Tilting Chin elevation Chin depression
Medial rectus Direction of normal eye
Lateral rectus Direction of paralyzed eye
Superior rectus +
Inferior rectus +
Superior oblique Direction of normal eye +
Inferior oblique Direction of paralyzed eye +

malities seen at home when the patient watches the nously, and responses are observed for 60  sec-
TV or reads books. Moreover, it is also important onds. If symptoms, such as ptosis, disappear or
to observe head posture in daily lives through pho- improve, the test is stopped. If no response is
tographs. In patients  with paralytic strabismus, observed, 1–2  mg of the drug is injected every
patients rotate their face in horizontal strabismus 60  seconds, and the response is monitored. In
to avoid diplopia. In vertical or torsional strabis- cases of severe side effects, such as hypotension,
mus, patients tilt their head or lift or depress their bradycardia, and arrhythmia, 0.5–1.0 ml of atro-
chin, so confirming head posture abnormalities pine is injected into the muscle.
can be important in diagnosis of paralytic strabis-
mus. Although Table 5.3 shows head postures seen
in different types of strabismus, it should be noted 5.9.2 Neostigmine Methylsulfate
that they do not always hold true. (Vagostigmin®)

In adults, 1  ml (0.5  mg) is injected subcutane-

5.9 Anticholinesterase Test ously or intramuscularly. Recovery is observed
10 minutes after injection.
In myasthenia gravis, an autoimmune disease,
abnormalities in neuromuscular junctions pre-
vent acetylcholinergic excitation from reaching 5.9.3 Neostigmine Bromide
the muscular tissues, thus leading to abnormal (Prostigmin®)
movements of orbicularis oculi and extraocular
muscles. Here, cholinesterase breaks down ace- Responses are observed 15–30  minutes after
tylcholine, leading to weakening of muscles. intramuscularly injecting the drug into the deltoid
Therefore, differential diagnoses of paralytic muscle. 0.5–1.5  mg for adults and 0.04  mg/kg
causes are required in ptosis and extraocular (maximum 1.5 mg) for children are injected intra-
muscle movement disorders. If positive results muscularly. When neostigmine bromide injection
are obtained after administration of anticholines- into children may interfere with future examina-
terases, myasthenia gravis can be diagnosed. tions, a dose of 5 mg per day is divided into three
Responses are especially fast for ptosis, and doses per day, and children aged 2–3  years are
patients sometimes do not respond in cases of eye asked to orally ingest the drug for a week.
movement disorders.

Suggested Reading
5.9.1 Edrophonium Chloride
(Tensilon®) Archer SM, Sondhi N, Helveston EM.  Strabismus in
infancy. Ophthalmology. 1989;96(1):133–7.
Bahill AT, Brockenbrough A, Troost BT. Variability and
This is one of the most commonly used methods. development of a normative data base for saccadic eye
The adult dose is 1 ml (10 mg); in the beginning, movements. Invest Ophthalmol Vis Sci. 1981;21(1 PT
0.2  ml (2  mg) is very slowly injected intrave- 1):116–25.
5  Ocular Alignment and Movement Exam 69

Beard C. Ptosis. St. Louis: CV Mosby; 1981. genital nystagmus. J Pediatr Ophthalmol Strabismus.
Biedner BZ, Marcus M, Yassur Y, et al. Stereopsis testing: 1987;24(2):87–93.
at the beginning or the end of the orthoptic examina- Noorden GKV.  Burian-von noordenis binocular vision
tion. Binoc Vis Q. 1992;7:37–9. and ocular motility. St. Louis: C. V. Mosby; 1985.
Bixenman WW, Von Noorden GK.  Apparent foveal dis- Paliaga GP.  Linear strabismometric methods. Binoc Vis
placement in normal subjects and in cyclotropia. Q. 1992;7:134–54.
Ophthalmology. 1982;89:58–62. Parls MM.  Isolated cyclovertical muscle palsy. Arch
Chung WS, Kim SY. Analysis of the causes of ptosis. J Ophthalmol. 1989;24:162–5.
Korean Ophthalmol Soc. 1995;36(10):1649–54. Pensyl CD, Benjamin WJ. Chapter 10: Ocular motility. In:
DeRespinis PA, Naidu E, Brodie SE.  Calibration of Benjamin WJ, editor. Borish’s clinical refraction. 2nd
Hirschberg test photographs under clinical conditions. ed. St. Louis: Butterworth-Heinemann-Elsevier; 2006.
Ophthalmology. 1989;96(7):944–9. Roper KL, Bannon RE.  Diagnostic value of monocular
Guyton DL.  Exaggerated traction test for the oblique occlusion. Arch Ophthalmol. 1944;31:316–20.
muscles. Ophthalmology. 1981;88(10):1035–40. Ruttum MS, Shimshak KJ, Chesner M.  Photographic
Helveston E, Bick SE, Ellis FD.  Differential intraocular measurement of the angel of strabismus. In: Campos
pressure as an indirect measure of generated muscle EC, editor. Strabismus and ocular motility disorders.
force. Ophthalmol Surg. 1980;11:386–91. Basingstoke: Macmillan; 1990.
Hess WR.  I. Ein einfaches messendes Verfahren zur Song WS, Lee SJ, Kim YH. Morphologic study of upper
Motilitätsprüfung der Augen. Ophthalmologica Journal contour and functional evaluation of levator palpebrae
international d’ophtalmologie International Journal superioris muscle in adult and young people. J Korean
of Ophthalmology Zeitschrift fur Augenheilkunde. Ophthalmol Soc. 2001;42(11):1523–9.
1916;35:201–19. Striph GG, Miller NR. Disorders of eyelid function caused
Hofmann FB, Bielschowsky A.  Die Verwertung der by systemic disease. In: Bosniak S, editor. Principles
KopfneigungzurDiagnoseder Augenmuskellmungen and practice of ophthalmic plastic and reconstructive
aus der Heber und Senkergruppe. Graefes Arch Clin surgery. Philadelphia: WB Saunders; 1996. p. 72–93.
Exp Ophthalmol. 1900;51:174. Tongue AC, Cibis GW.  Brückner test. Ophthalmology.
Lancaster WB. Terminology in ocular motility and allied 1981;88:1041–4.
subjects. Am J Ophthalmol. 1943;26:122–32. von Noorden GK, Campos EC. Binocular vision and ocu-
Lancaster WB.  Refraction correlated with optics and lar motility: theory and management of strabismus.
physiological optics and motility limited to heteropho- 6th ed. St. Louis: Mosby Inc; 2002. p. 168–210.
ria. Springfield: Thomas; 1952. Von Noorden G, Maumenee A. Atlas of strabismus. 3rd
McCord CD, Tenenbaum M, Nunery WR.  Oculoplastic ed. St. Louis: Mosby; 1983.
surgery. 3rd ed. New  York: Raven Press; 1995. Worth CA, Chavasse FB. Worth’s squint, or, the binocu-
p. 175–220. lar reflexes and the treatment of strabismus. London:
Mitchell PR, Wheeler MB, Parks MM.  Kestenbaum Baillière, Tindall and Cox; 1939.
surgical procedure for torticollis secondary to con-
Binocular Function Test
Hye-Shin Jeon and Hee-Young Choi

Binocular vision means both binocular single 6.1 Worth Four-Dot Test
vision and vision in both eyes recognized as
monovision, and visual acuity, anisometropia, This test is objected for patients with suspected
and ocular deviation are involved in binocular strabismus  who can  distinguish  numbers. The
vision. Therefore, binocular function test presence and degree of suppression, the presence
should be performed during the diagnosis and of the dominant eye, diplopia, and abnormal reti-
treatment of the strabismus, amblyopia, and nal correspondence can be tested.
aniseikonia. The binocular function test exam-
ines the stereopsis, fusion and suppression, and
abnormality of retinal correspondence, to 6.1.1 Methods
assess whether and how much the two eyes are
integrated into single vision. Because the Worth four-dot box and red-green glasses are
degree of dissociation of the two eyes differs required, and the examination room should be
according to the individual test, careful inter- dark enough to recognize the Worth four dots.
pretation is required. Patients wear glasses with the red and green filter
Several stereopsis tests are divided accord- in the individual eyes. Generally red filter on the
ing to the target age: the test used for a wide age right eye and green filter on the left eye are
range from children over 2 years old to adults applied. Patients see the Worth four-dot box
and the test that is easy to perform for infants. which present four points (two green lights in the
They may be also classified by the principle of left and right sides, red light in the upside, and
inspection or by considering qualitative or white light in the downside). Identify the number
quantitative examination. Polarizing glasses or and position of the lights of which the patient
red-eye glasses can be used to separate the two recognizes.

6.1.2 Judgment

H.-S. Jeon, MD., PhD. In patients with normal binocular function, the
Department of Ophthalmology, Pusan National four lights are arranged well. But if the four lights
University Hospital, Busan, South Korea are observed well-arranged when manifested
H.-Y. Choi, MD., PhD. (*) strabismus is observed, it indicates that there is
Department of Ophthalmology, Pusan National abnormal retinal correspondence (Fig. 6.1a).
University College of Medicine, Busan, South Korea

© Springer Nature Singapore Pte Ltd. 2019 71

J.-S. Lee (ed.), Primary Eye Examination,
72 H.-S. Jeon and H.-Y. Choi

Fig. 6.1  Judgment of

Worth four-dot test. Red a b c
filter in the right eye,
green filter in the left eye
(a) normal or manifested
strabismus with abnormal
retinal correspondence
(b) left eye suppression
(c) right eye suppression
(d) crossed diplopia,
abnormal retinal
correspondence in
esotropia, normal retinal
d e
correspondence in
exotropia (e) uncrossed
diplopia, normal retinal
correspondence in
esotropia, abnormal
retinal correspondence in

If the left eye is suppressed, the patient can 6.2  our-Prism Diopter Base-Out
recognize two red lights on up- and downside Prism Test
(Fig.  6.1b). If the right eye is suppressed, the
patient can recognize only three green lights Central suppression scotoma can be examined in
(Fig. 6.1c). strabismic patients. It is useful in measuring the
If the patient sees two red lights in the left degree of suppression in small strabismus and
side and three green lights in the right side, it helps to assess the binocularity in patients who
means crossed diplopia, abnormal retinal corre- maintain orthophoria after surgery.
spondence in case of esotropia, and normal reti-
nal correspondence in case of exotropia
(Fig. 6.1d). 6.2.1 Methods
If the patient sees three green lights in the
left side and two red lights in the right side, it With patient looking at the distant target, place
means uncrossed diplopia, normal retinal cor- four-prism diopter base-out prism in front of one
respondence in case of esotropia, and abnor- eye, and observe the movement of the other eye.
mal retinal correspondence in case of exotropia Put the prism on the other eye, and observe the
(Fig. 6.1e). movement of the contralateral eye in the same
The distance between the points varies way.
depending on the distance between the subject
and the illumination, which can be used for
analysis. For example, the distance between 6.2.2 Judgment
the points is 1.25° at 6  m while 6° at 33  cm.
Since it is a subjective test, the patient’s com- In a normal eye, when four-prism diopter base-­
prehension and age may influence the out- out prism is placed at one eye, the eye is dis-
come. Refractive errors should be corrected placed by 2–4 prism diopters nasally, and the
because decreased visual acuity can make other eye moves temporally, but temporary diplo-
false results. pia may occur, and the latter eye returns to its
6  Binocular Function Test 73

Fig. 6.2  Judgment of

4-prism base-out test.
The arrow indicates the
movement of the eye
and the point indicates
no movement. 1, 2
Normal, 3 left eye
suppression, 4 right eye
suppression 1

original position to avoid diplopia. In case of sup- strabismic eye in the vertical direction. Patient
pression on the eye without prism, both eyes can see a positive afterimage which appears as
move to the opposite side of the base by 4 PD, bright vertical and horizontal lines with empty
and if there is suppression on the eye with prism, center in a darkened room or with the eyes closed.
there is no movement of both eyes (Fig. 6.2). Negative image(dark lines) can be observed in a
lighted room or with the eyes open. Ask patient to
describe the positional relationship between hori-
6.3 Afterimage Test zontal and vertical lines.

Horizontal and vertical light stimulate the indi-

vidual fovea of the two eyes separately. Vertical 6.3.2 Judgment
light should be stimulated in the strabismic/non-
dominant eye, because suppression is less severe Check the foveal fixation by visuoscopy. If the
in vertical than horizontal stimulation. It is also patient has eccentric fixation, the test result
important to stimulate the nondominant eye later becomes unreliable. If the patient has normal reti-
to reduce the time to suppression. Retinal corre- nal correspondence, the two lines cross at midline
spondence could be examined by positional rela- since the two eyes make the afterimage at the fovea
tionship of the residual image in the two eyes and (Fig. 6.3a). If a vertical afterimage appears on the
subjective relation of the two eyes, regardless of right or left side of the area where the horizontal
the objective angle of ocular deviation. afterimage is broken, it means the two foveae have
a different direction and there is an abnormal reti-
nal correspondence. In the left esotropia, the verti-
6.3.1 Methods cal afterimage is shifted to the right, and the fovea
of the two eyes does not have the common visual
Have the patient sit in the dark room and place the direction because of abnormal retinal correspon-
afterimage tester in front of the patient. Occlude dence (Fig. 6.3b). In the left exotropia, the vertical
the strabismic eye and stimulate the fixing eye by afterimage is shifted to the left and abnormal reti-
the light in the horizontal direction. Stimulate the nal correspondence exists (Fig. 6.3c).
74 H.-S. Jeon and H.-Y. Choi

a b c

Lt eye Rt eye

Fig. 6.3  Judgment of afterimage test. R the image of the right eye, L the image of the left eye. (a) Normal retinal cor-
respondence. (b) Abnormal retinal correspondence in esotropia. (c) Abnormal retinal correspondence in exotropia

6.4 Bagolini Striated Glasses Test

Both suppression and abnormal retinal corre-

spondence can be evaluated by examining
whether the fovea of one eye and the peripheral
retina of one eye have a common direction. The
test is done under conditions close to normal con-
ditions of seeing.

6.4.1 Methods

A Bagolini lens, glasses frame, and a light source

are needed. Refractive errors should be corrected
before the examination.
The direction of the Bagolini lens should be View of left eye View of right eye
45° and 135° at the individual eye. Generally, 45°
Fig. 6.4  The shape of the line through the Bagolini lens
in the right eye and 135° in the left eye are applied
(Fig. 6.4).
Look at the light source at a distance of 6 m 6.5 Major Amblyoscope
and 33 cm.
Have the patient draw the number and location Examination of sensory and motor abnormalities
of the lines. such as subjective and objective deviation mea-
surements, fusion, retinal correspondence, sup-
pression, stereopsis test, and training of binocular
6.4.2 Judgment function in patients with suspicion of abnormal
ocular deviation, binocular dysfunction, or
Judge as shown in Fig. 6.5. abnormal eye movement disorder.
6  Binocular Function Test 75

Fig. 6.5  Judgment of a b c

Bagolini lens test. 45° in
right eye, 135° in left
eye. (a) Abnormal
retinal correspondence if
there is manifested eye
deviation. (b) Normal
retinal correspondence
with exodeviation. (c)
Normal retinal
correspondence with
esodeviation. (d) Central
scotoma of the left eye. d e
(e) Suppression of the
left eye Ocular Deviation

Two simultaneous test slides (e.g., birds and
cage) that do not have sameness are needed. Put
small target slides (birds) with small target size
on the dominant eye and slides with large target
(cage) on the deviated eye. Rotate the horizontal
rotary screw little by little and observe the move-
ment of the deviated eye by alternately blinking
the two targets. The numerical value when the
eyeball is not moving is the objective ocular devi-
ation. When you change the slit of the left eye
and the right eye and measure the deviation in the
same way, if the deviation is more than ten prism
diopters, it is an incomitant strabismus.
Fig. 6.6 Anomaloscope Binocular Vision

6.5.1 Methods Two simultaneous test slides (e.g., birds and cage)
that do not have sameness are needed. Fix the lens
Slides are selected according to the purpose.
barrel, with small-sized target slide in the fixing
Slides are used for alignment, fusion, stereo-
eye, at 0°. Move the barrel of the large target slide
scopic, and Kappa angle.
(cage) at the angle of deviation to the left or right
First, adjust the patient’s pupil distance, and
to ask whether the two slides overlapped (whether
place the slides on the left and right slide barrels
the bird enters the cage). When two slides are
individually according to the purpose. Second,
overlapped, there is binocular vision, and the
place the patient’s face on the exact place and fix
angle of the barrel is subjective ocular deviation.
the forehead. Third, make sure that all adjustment
If two slides do not overlap and disappear instantly
screws are at zero and refractive errors are cor-
while approaching and appear on the opposite
rected (Fig. 6.6).
side, there is suppression on the deviated eye.
76 H.-S. Jeon and H.-Y. Choi Retinal Correspondence not. Move both horizontal barrels to the outside
Perform an angle deviation test which is an objec- (abduction direction) and exam when the two
tive deviation test and the binocular vision test rabbit start to appear, the point where the fusion
which is a subjective deviation test. Compare the breaks, to record the fusional amplitude. Move
results of the two tests. If both the subjective and the barrel inside (adduction direction) and record
objective deviations are consistent, the patient the point where fusion starts. Continue moving
has normal retinal correspondence (Fig. 6.7a). In inside and record the point at which fusion is bro-
other cases, there is an abnormal retinal corre- ken again, the convergence fusional amplitude. If
spondence. If the picture overlaps with the handle two targets are found to be completely consistent,
angle of the machine to 0, subjective deviation is there is fusion.
0 and the ocular deviation corresponds to the
objective deviation and the sensory adaptation is Stereoacuity
complete, which is the harmonious abnormal Insert the stereoscopic slide into the barrel.
retinal correspondence (Fig.  6.7b). When the Ask for stereopsis. Stereopsis of normal adult
observed angle is smaller than the objective devi- is recorded as 40 arc seconds.
ation, it is called unharmonious abnormal retinal
correspondence (Fig. 6.7c). Fusion
For first-degree fusion, ask whether the two Fusion and Fusional Amplitude phases overlap by using the slide of the first-­
Two targets with the same size and shape, but degree fusion slide (Fig. 6.8a). For second-degree
with partial defects, are required. fusion, after fitting the amblyoscope to the sub-
Place the two slides in each barrel (e.g., a jective deviation, ask whether the image of the
flowerless rabbit and a tailless rabbit, Fig. 6.8b), slides is made as a complete image (Fig.  6.8b).
and move the barrel to make it a complete rabbit. For third-degree fusion, the slide for third-degree
Ask to see if a complete rabbit with a tail and fusion is inserted, and the patient is asked whether
flower is visible and record whether it is fused or it looks three dimensional (Fig. 6.8c).

a b c





15 5 15

10 10

20 15 15 20 20
25 25 2


Lt eye Rt eye

Patient’s view Patient’s view Patient’s view

Fig. 6.7  Retinal correspondence test by anomaloscope. (a) Normal retinal correspondence. (b) Harmonious abnormal
retinal correspondence. (c) Unharmonious abnormal retinal correspondence
6  Binocular Function Test 77

a b c

Fig. 6.8  Fusion test by anomaloscope. (a) First-degree fusion. (b) Second-degree fusion. (c) Third-degree fusion

6.6 Red Filter Test 6.7 Prism Test

Suppression, abnormal retinal correspondence, Prisms can be used to detect the size of the sup-
diplopia, and strabismic angle can be measured pression scotoma. Patients may not notice dip-
in strabismus patients. lopia when they put red glasses in front of their
eyes. The examiner may put the prism in front
of the eyes and find the prism diopter in which
6.6.1 Methods the patient notice diplopia. The fixing light
should be small, and it may be stimulated on the
Apply a red filter to one eye (mainly the domi- location outside the scotoma which is not sup-
nant eye). Instruct the patient to open eyes and pressed, and thus the patient feels diplopia.
see the light. Ask the patients what they see. The size of suppression scotoma may be pre-
sumed by prism diopters, and the direction of the
base needs to make diplopia (Fig. 6.9). For exam-
6.6.2 Judgment ple, if the right eye is esotropic, place the red fil-
ter in front of the left eye to see the light, and then
When two lights are visible, the fixing eye and place the base-out prism on the right eye to
the strabismic eye have normal retinal correspon- increase the angle until crossed diplopia occurs.
dence that considers the red light and the white Then, put the base-in prism on the right eye to
light separately. make an uncrossed diplopia; the horizontal diam-
If a red filter is placed on the right eye, a red eter of the suppression scotoma is the sum of
light is shown on the right side in esotropia, and the diopters of the two prisms.
on the left side in exotropia. Sometimes the direc-
tion of diplopia is reversed to that of strabismus.
This is because, if the abnormal retinal corre- 6.8 Stereoacuity Test
spondence in the long-lasting esotropia develops,
the abnormal retinal correspondence acts as a It is test for evaluating the presence and degree of
fovea even after the surgery becomes orthophoria stereopsis and hence the effect of strabismus
or undercorrected. treatment and the expected treatment outcome.
78 H.-S. Jeon and H.-Y. Choi

Fig. 6.9  Prism test to

measure the size of the a
suppression scotoma
(a) red glass is placed in
front of left eye the
patient who has Patient’s view
suppression scotoma
in his right eye may
not feel diplopia
(b) place the base out
prism on the right eye
to increase the angle
until crossed diplopia
occurs (c) place the base
in prism on the right eye Suppression scotoma
to make an uncrossed Left eye Right eye

Red Filter


Separate the left eye and right eye and have the 6.8.1 Titmus Test
patient see a parallax picture. If it looks stereo-
scopic, it is normal and normal stereoacuity is The polarizing filter separates the two eyes, and
40 seconds of arc. the two targets are polarized at 90° that matches
6  Binocular Function Test 79

Fig. 6.10  Titmus test

the filter. Circles and animals are in the left page

and fly is in the right page (Fig. 6.10). It is the
most widely used stereoacuity test because it is
simple and easy. However, because of monocular
clue, it is not suitable for screening test. Methods
Wear polarized glasses at a distance of 40  cm.
Have the patient hold the fly using the thumb and
index finger. Pick a circle floating in the air
among the four circles arranged in a rhombic
shape. If the patient gets the correct answer, go to
the next step. Pick an animal floating in the air
among the five animals. If the patient gets the
correct answer, go to the next step. Judgment Fig. 6.11  Random dot E test

The threshold of the fly represents 3000 seconds
of arc. If the patient holds the wing in the air, it is
judged as having stereopsis. Each animal plate of horizontal disparity produces stereopsis, if the
A, B, C represents stereoacuity threshold of 400, patient finds a stereoscopic picture during the
200, and 100  seconds of arc, respectively. The plate is turned 90°, the patient might have used a
nine circles indicate stereoacuity thresholds rang- monocular clue.
ing from 800 to 40 seconds of arc. So, it is pos-
sible to quantitatively measure the stereoacuity
threshold based on the last picture which the 6.8.2 Random Dot E Test
patient figures out correctly. The test can be per-
formed turning the plate as 90° to evaluate It contains a polarizing filter glasses and random
whether the patient is actually able to see stereo- dot stereogram. It can be used for the screening
scopically or is using monocular clue. Since only of the stereoacuity since there is little monocular
80 H.-S. Jeon and H.-Y. Choi

clue; the stereoscopic disparity varies depending to the next step. Pick an animal floating in the air
on the examination distance (Fig. 6.11). among the five animals. If the patient gets the
correct answer, go to the next step. Have the Methods patient answer the shapes such as circles, stars, E,
Wear polarized glasses at a distance of 50  cm. squares, triangles, and crosses in four squares.
Show one polarized card containing E that does
not have stereoscopic ability but confirm the Judgment
shape of E. Ask the patients of which side the E One animal among the five was imaged dispa-
character to be seen between the cards consisting rately of which thresholds are 400, 200, and
of only random numbers without a stereoscopic 100 seconds of arc, respectively. The circles were
image and a polarizing card with an E-shaped imaged disparately with thresholds ranging from
stereoscopic image. 400 to 20  seconds of seconds of arc. The right
side is divided into upper and lower and consisted Judgment of four squares individually. The upper part
The stereoacuity of 500  seconds of arc can be shows circle, star, and E shape of which stereop-
judged at a distance of 50 cm, and 50 seconds of sis is 500 seconds of arc. The lower part is con-
arc can be judged at 5 m. sisted of a square, triangle, and cross shape with
stereopsis of 250 seconds of arc. It is possible to
quantitatively measure the stereoacuity on the
6.8.3 Randot Stereo Test basis of the degree of disparity of the last picture
which the patient figures out correctly.
The polarized glasses are used to separate the two
eyes to see the random dot pattern, the shape of
the animal, and the specific shape. The test book 6.8.4 TNO Test
is similar to Titmus test (Fig. 6.12).
TNO test can be used to evaluate the presence of Methods stereopsis and suppression in patients with stra-
Wear polarized glasses at 40 cm. bismus and screen examination for stereopsis and
Pick a circle floating in the air among the three quantitative measurement of stereopsis by sepa-
circles. If the patient gets the correct answer, go rating the two eyes using red-green filter.

Fig. 6.12 Randot
stereoacuity test
6  Binocular Function Test 81

Fig. 6.14  Lang test

stereopsis ranging from 480  seconds of arc to

15 seconds of arc, so the TNO test can determine
stereoacuity threshold in the most detailed quan-
titative manner.

6.8.5 Lang Test

It used the random dot, but the cylinder gratings

Fig. 6.13  TNO test are on the surface individually, so the object
appears to be stereoscopic even without glasses. Methods Therefore, it can examine the stereopsis easily by
The plate is placed perpendicular to the gaze at separating the two eyes without using glasses in
40 cm with the green filter on the right eye and children aged 2–3  years who refuse to wear
the red filter on the left eye (Fig. 6.13). glasses (Fig. 6.14).
Ask a question about the number and location
of butterflies in Panel I. Ask a question about the Methods
largest circle and the smallest circle in Panel Place the exam plate perpendicular to the line of
II. Ask a question about the position of the figure sight at a distance of 40 cm.
of five shapes including circle, triangle, square, Have the patient say what he sees among cat,
rhombus, and cross in Panel III. In the plate IV, star and car.
there is a large circle on both sides of one small
circle. If only two circles are visible, let the Judgment
patient tell where the big circle is. Plates V, VI, The cat represents stereopsis of 1200 seconds of
and VII have a circular sector defect. Let the arc, the star indicates 600 seconds of arc, and the
patient answer the direction of the defect. car signifies 500 seconds of arc. If all three are
met, it is judged as normal. Judgment
Panels I, II, and III represent stereopsis of
1980  seconds. In plate IV, the patient sees  two 6.8.6 Frisby Test
circles in the right side on the green glass and two
circles in the left side on the red glass, and three The test tool consists of three plastic plates with
circles with both eyes so the examiner can check thicknesses of 6 mm, 3 mm, and 1.5 mm. Each
the inhibition and see which eye the patient plate has a random square and circle arranged on
is using. Plates V, VI, and VII have six levels of the front and back. Each inspection panel ­consists
82 H.-S. Jeon and H.-Y. Choi

of four-square sections, one of which actually Bagolini B. Sensorial anomalous in strabismus (suppres-
looks like a round shape. Since the actual depth is sion, anomalous correspondence amblyopia). Doc
Ophthalmol. 1976;41:23.
known, examination glasses are not necessary. Burian HM.  Normal and anomalous correspondence.
Paper presented at: strabismus ophthalmic symposium Methods 1950.
Lift the plastic plate so that is perpendicular to Frank JW, France TD, Harrington J.  The Worth four
dot test: is it really “worthless”? Am Orthopt J.
the patient’s view. Make sure that you find a rect- 1981;31(1):68–71.
angle with a round shape protruding out of the Irvine SR.  A simple test for binocular fixation: clinical
four-square areas printed. application useful in the appraisal of ocular domi-
nance, amblyopia ex anopsia, minimal strabismus, and
malingering. Australas J Optom. 1944;27(12):536–47. Judgment Jampolsky A. The prism test for strabismus screening. J
When examined at a distance of 30 cm, the 6 mm Pediatr Ophthalmol Strabismus. 1964;1(1):30–4.
plate indicates a stereoacuity of 600  seconds of Lovasik JV, Szymkiw M.  Effects of aniseikonia, aniso-
arc, the 3 mm plate demonstrates a 300 seconds metropia, accommodation, retinal illuminance, and
pupil size on stereopsis. Invest Ophthalmol Vis Sci.
of arc, and the 1.5 mm plate signifies a 150 sec- 1985;26(5):741–50.
onds of arc. Noorden GKV.  Burian-von noordenis binocular vision
and ocular motility. St. Louis: C. V. Mosby; 1985.
Romano PE, Von Noorden GK.  Atypical responses
to the four-diopter prism test. Am J Ophthalmol.
Suggested Reading 1969;67(6):935–41.

Bagolini B.  Anomalous correspondence: defini-

tion and diagnostic methods. Doc Ophthalmol.
Eyelid and Lacrimal System Exam
Jung-Yul Park and Hee-Young Choi

7.1 Eyelid Exam shape of the eyelids, changes in the skin, the eye-
brows, and the palpebral fissure are observed; if
Eyelid exams can be divided broadly into eye- any particular abnormalities are detected, that
brow and eyelid examinations. Located where the area is examined in more detail under magnifica-
frontalis and orbicularis oculi muscles meet, the tion and local illumination.
eyebrows provide support to the eyelids. When If necessary, further examinations are per-
examining the position of the eyelids, it is essen- formed by scraping or palpation.
tial to check the position of the eyebrows.
These examinations focus on diseases that Brow Ptosis Test
cause blepharoptosis of congenital, neurological, First, the height and shape of the eyebrows is
muscular, external injury or mechanical etiology, observed. In males, the eyebrows are in level
with the aim of differentiating eyelid edema and with the superior margin of the orbit and have
tumors and determining treatment plans in a relatively straight shape; in females, the eye-
patients with blepharoptosis. brows are positioned approximately 1 cm supe-
rior to the superior margin of the orbit and show
a slight rise in the lateral direction. The relative
7.1.1 Methods positions of the eyebrow and the superior margin
of the orbit can easily be verified by palpation General Examination with the thumb and index finger. If the distance
The patient is examined while sitting straight or from the middle of the upper eyelid to the inferior
lying on a bed. When examining blepharoptosis margin of the eyebrow is ≤10 mm in the primary
or abnormalities of eyelid position, it is preferable eye position, this indicates brow ptosis, which
to perform the assessment in a seated position. can also be detected based on the lack of confor-
The patient’s overall condition is observed mity in the angles of forehead wrinkles. The tail
under diffuse illumination. The position and of the eyebrow often develops ptosis with aging,
since it is not connected to the frontalis muscle. Blepharoptosis Test

J.-Y. Park, MD.
Department of Ophthalmology, Pusan National In the case of unilateral blepharoptosis, the
University Hospital, Busan, South Korea severity can be determined by comparison with
H.-Y. Choi, MD., PhD. (*) the contralateral eye. However, in bilateral
Department of Ophthalmology, Pusan National blepharoptosis, this can be determined by
University School of Medicine, Busan, South Korea inspecting the amount of the cornea covered by

© Springer Nature Singapore Pte Ltd. 2019 83

J.-S. Lee (ed.), Primary Eye Examination,
84 J.-Y. Park and H.-Y. Choi

the upper eyelid during primary gaze. It is neces- Table 7.1  Blepharoptosis severity based on the palpebral
sary to assess the vertical height of the palpebral fissure
fissure, the position of corneal reflex, and the Relation between the pupil and
function of the levator palpebrae superioris Blepharoptosis severity the lid margin
Mild 2 mm The lid margin is superior to
(LPS) muscle. During the examination, the
the pupil margin
patient should be instructed to keep their eyes Moderate 3 mm The lid margin slightly
open comfortably without using the frontalis covers the pupil margin
muscle; to facilitate this, the examiner should Severe ≥4 mm The lid margin covers more
press gently on the patient’s forehead while con- than half the pupil margin
ducting the examination.

Method Based on Measurement blepharoptosis (Table  7.1). This method can be

of the Palpebral Fissure Height affected by abnormalities of the lower eyelid,
The patient is instructed to focus on a distant such as ectropion or retraction, which can result
point without looking to the side or trying to in inaccuracies.
deliberately open the eyes wider. In this position,
the examiner measures the distance, in mm, from Method Based on Measurement
the middle of the upper eyelid to the middle of of the Marginal Reflex Distance (MRD)
the lower eyelid (Fig. 7.1). The marginal reflex distance-1 (MRD1) is the
distance from the corneal reflex to the middle of
Interpretation the upper eyelid in the primary eye position. A
The palpebral fissure height of typical individu- normal value in Western individuals is 4–5 mm,
als is 7–8 mm in Koreans and 9 mm in Westerners. and this is slightly smaller in Asians, at 3–4 mm.
Normally, the corneal diameter is approximately The extent of blepharoptosis can be calculated
11  mm, and the upper eyelid covers the upper by subtracting the patient’s MRD1 measurement
1.5–2 mm of the cornea. Thus the amount of the from 4 to 5 mm. To measure the marginal reflex
cornea covered by the upper eyelid can be sub- distance-2 (MRD2), the patient and examiner
tracted from 1.5–2 mm to determine the extent of have their eyes at the same height, the patient

Fig. 7.1 Measurement
of the vertical height of
the palpebral fissure
(assuming that 8 mm is
a normal value)

2 mm

1 mm Eyelid ptosis

7  Eyelid and Lacrimal System Exam 85

fixates on a distant object, and the examiner Interpretation

measures the distance from the corneal reflex to Normal values are in the range 12–16 mm. Values
the middle of the upper eyelid in the primary eye ≥13 mm are classified as “excellent,” and among
position while shining a light at the same height abnormal values, 8–12  mm is classified as
as the patient’s eyes. A typical measurement is “good,” 5–7 mm as “fair,” and ≤4 mm as “poor.”
5.5 mm, and this increases in cases of lower eye- Blepharoptosis patients may require frontalis
lid retraction. During the measurement, it is sling or levator resection, depending on levator
important to make sure that the patient is not function.
using the frontalis muscle to open their eyes
wider (Fig. 7.2). Iliff Sign
Following upper eyelid eversion, if the eyelid Levator Function Test (Berke does not return to its proper position when the
Method) patient shifts their gaze upward, this indicates
reduced levator function.
A ruler is placed vertically in the midline of the Margin Crease (Lid Crease)
palpebral fissure, and the distance moved by the Distance (MCD)
upper eyelid is measured, while the patient shifts
from downward gaze to upward gaze. Here, in Method
order to prevent frontalis muscle activity, the After instructing the patient to look down-
brow should be pressed firmly with the examin- ward, the examiner uses their hand to lift the
er’s thumb (Fig. 7.3). upper eyelid and measures the distance from

4 mm 2 mm

Fig. 7.2  Measuring marginal reflex distance 1

Fig. 7.3 Examination
of levator palpebrae
superioris function
86 J.-Y. Park and H.-Y. Choi

the middle of the upper eyelid to the middle of Lower Lid Horizontal Laxity Test
the lid crease using a ruler (Fig. 7.4).
Snap Back Test
Interpretation The examiner pulls down on the lower eyelid
Normal values are 8–10 mm for Western adult with their fingers (Fig.  7.5a) and then observes
females and 6–8  mm for Western adult males. how quickly the eyelid returns to its original posi-
These values are smaller in Asian individuals, tion after it is released (Fig. 7.5b).
and the lid crease is absent in many cases. If the lower eyelid does not return immedi-
ately to its proper position and requires the
patient to blink, this indicates the presence of
lower lid horizontal laxity.

Grade I: The eyelid immediately returns to its

original position.
Grade II: The eyelid returns to its original posi-
tion slowly but spontaneously.
Grade III: The eyelid does not return to its origi-
nal position spontaneously but does return
after blinking.
Grade IV: The eyelid does not return to its origi-
MCD nal position even after blinking.

Pinch Test (Distraction Test)

The lower eyelid is distracted anteriorly, and the
length of distraction from the eyeball is mea-
Fig. 7.4  Lid crease test. The examiner uses their hand to sured. Normally, the eyelid cannot be distracted
lift the upper eyelid with the patient looking downward beyond 6  mm. If the lower eyelid can be dis-

Fig. 7.5  Snap back test

to evaluate the lower lid
a b
horizontal laxity
7  Eyelid and Lacrimal System Exam 87

tracted more than 6–8 mm from the eyeball, this iner checks for clear improvement in ocular
indicates the presence of lower lid horizontal symptoms such as ptosis or diplopia.
laxity. Following intravenous infusion of edropho-
nium chloride 5–10 mg (Tensilon test), the drug
Medial and Lateral Canthal Tendon Laxity starts acting within 30–60  s, and the effect
Test wears off within 5 min. Following intramuscu-
Normally, when the lateral canthus is pulled lar injection of neostigmine methylsulfate
toward the nose or the medial canthus is pulled 0.5 mg, the drug begins acting after 10–15 min;
toward the ear, they only move <1 mm in the case the maximum effect is achieved after around
of the medial canthal tendon and <2 mm in the 30  min; hence, the examination is performed
case of the lateral canthal tendon. In patients with 30–45 min after the injection. This is useful in
severe medial canthal tendon laxity, the lacrimal pediatric patients and other patients who cannot
puncta is moved ≥4  mm laterally; in patients readily receive intravenous infusion. Alleviation
with severe lateral canthal tendon laxity, the lat- of symptoms can also be checked after 1-week
eral canthus reaches the margin of the cornea. use of oral neostigmine bromide 5  mg.
Edrophonium chloride (Tensilon test) was used Eyelid Retraction Test commonly in the past, but discontinuation of
the drug means that this test can no longer be
Method performed.
With the patient in primary gaze, the distance is
measured between the superior corneal margin
Sympathomimetic Test
and the upper eyelid margin or between the infe-
This test is used to examine the function of
rior corneal margin and the lower eyelid margin.
Müller’s muscle and is used in the diagnosis of
Horner syndrome. A positive result can also be
seen in myasthenia gravis patients, so care is
The upper eyelid should be 1–2  mm below the
required in the interpretation. After instilling
superior corneal margin in typical individuals; in
2.5% or 10% phenylephrine hydrochloride into
mild lid retraction, the upper eyelid meets the
the eye with blepharoptosis and waiting for
superior corneal margin; in moderate retraction,
5 min, the extent of blepharoptosis is measured
<4 mm of sclera is visible superior to the cornea;
again. If the extent of ptosis decreases, this
in severe retraction, ≥4 mm of sclera is visible.
reflects the action of the sympathomimetic drug
The lower eyelid should meet the inferior corneal
on Müller’s muscle. Since these drugs can also
margin, and if any sclera is visible inferior to the
cause lower lid retraction by acting on the lower
cornea, this can be diagnosed as lower lid
lid retractors, care must be taken when examin-
ing the extent of blepharoptosis. If the patient’s
medical history shows thoracic or neck surgery, Lid Lag Test
this can help in the diagnosis of Horner
The patient is made to gaze downward, and the
examiner checks whether the upper eyelid fails to
follow the ocular movement and remains in a
higher position than normal. Ice Test
This test is useful for differentiating myasthenia Drug Tests gravis; the change in height of the palpebral fis-
sure is measured after holding ice against the
Anticholinesterase Test patient’s affected eye for 2 min. A difference of
This test is used to diagnose severe myasthenia ≥2 mm is considered a positive result. This test is
gravis. The interpretation can differ slightly reported to have a sensitivity of over 90% and a
depending on the types of drug used. The exam- specificity of up to 100%.
88 J.-Y. Park and H.-Y. Choi Sleep Test

This test can be used to differentiate myasthenia
gravis. The patient enters a dark, quiet room and
keeps their eyes closed for at least 30  min; the
test is positive if this results in complete disap-
pearance of blepharoptosis or an increase of
≥2 mm in the height of the palpebral fissure. Electromyography (Jolly

Test) Fig. 7.6  Measuring proptosis using a Hertel
This test is used to differentiate blepharoptosis of exophthalmometer
muscular or nervous etiology. In myasthenia gra-
vis, the extraocular muscles show reduced activ- the examiner sitting opposite. To measure the
ity in electromyography. patient’s right eye, the examiner uses their left
eye, places it in alignment with the patient’s Radiography visual axis, and measures to vertical distance to
The structure of the orbit and paranasal sinuses is the corneal apex reflected in the mirror of the
inspected using X-ray, CT, or MRI. exophthalmometer. To measure the patient’s left
eye, the same procedure is performed on the
other side. The two measurements are recorded
7.2 Exophthalmometry along with the distance between the lateral mar-
gins of the two orbits (base line) (Fig. 7.6).
These examinations focus on increases in orbital
contents, such as orbital masses, orbital cellulitis, Naugle Exophthalmometer
thyroid eye disease, or leukemia, and on vascular This test measures proptosis based on the supe-
abnormalities in the orbit, such as carotid-­ rior and inferior orbital margins. It is especially
cavernous fistula, or orbital varices. They can useful in patients with an injury to the lateral
also be performed in cases with orbital hypervol- orbital margin, such as lateral orbitotomy
emia, such as craniofacial dysmorphism; cases patients. This method enables pain-free measure-
with increased axial length of the eye, such as ment in patients who may complain of pain dur-
high-degree myopia or congenital glaucoma; and ing measurement with a Hertel exophthalmometer,
cases of proptosis accompanied by extraocular such as children or individuals with thyroid eye
muscle palsy. disease, conjunctivitis, or trauma. It is also pos-
Measuring the extent of proptosis and the dif- sible to measure vertical deviation of the eye.
ference between the two eyes can be used to dif-
ferentiate between diseases causing proptosis. Measurement with a Ruler
Often, unilateral proptosis indicates an intraor- A transparent ruler is placed vertically at the lat-
bital disease, while bilateral proptosis indicates a eral orbital margin, and the height of the patient’s
systemic disease. corneal apex is measured by the examiner look-
ing horizontally at the patient’s eye level
(Fig. 7.7).
7.2.1 Methods Visual Inspection Hertel Exophthalmometer With the patient in a supine position and their
The two arms of the Hertel exophthalmometer eyes closed, proptosis is observed from the
are pressed against the lateral margins of the supero-anterior and supero-posterior positions.
orbits with the same force; the visual axes are The height of the eyelashes was observed relative
aligned by having the patient look into the eyes of to the eyebrows, and this was compared for the
7  Eyelid and Lacrimal System Exam 89

viscous secretions, excessive discharge, pain in

the lacrimal apparatus, and dacryocystitis.
Hypersecretion is caused by overactive tear
production and is usually accompanied by eye
Diseases that can show hypersecretion due to
abnormal irritation of the lacrimal gland include
neurological diseases such as trigeminal nerve
irritation, optic nerve stimulation by strong light,
and facial nerve irritation, as well as systemic
diseases such as thyroid disease and inflamma-
Fig. 7.7  Measuring proptosis using a ruler
tory disease. Local eye diseases that can cause
hypersecretion include corneal disease, intraocu-
right and left sides. Here, taking photographs lar disease, and periocular disease, especially of
helps to compare progression over time. Proptosis the paranasal sinuses or nasal allergies.
is easiest to see when the patient’s head is tilted
back and the examiner looks up from below.
7.3.1 Examination of External Radiography Structures Using a Slit Lamp
Measurements can be made using X-ray or CT
imaging. Punctum
First, the patency of the punctum is checked; the
position of the lacrimal lake should not be visible
7.2.2 Interpretation without everting the lower eyelid. Fluorescein
stain is instilled and its flow into the puncta is
Hertel exophthalmometry results are expressed observed. Swelling and redness around the punc-
as the vertical distance between the corneal apex tum suggest canaliculitis. Punctal stenosis can
and the line connecting the left and right lateral occur in cases of chronic lid ectropion or due to
orbital margins. Normal values are reported to be various acquired causes.
10–14 mm for Asians and 12–20 mm for Western
individuals. The mean values for Koreans are in Eyelid Movement
the range 13.6–14.7 mm. A difference of >2 mm In typical individuals, the blinking force is con-
between the two eyes is considered to be veyed toward the nose, and the eyelid moves in
abnormal. close contact with the eye. Eyelid and Corneal Disease

7.3 Evaluation of Watering Eye In cases of eyelid eversion, epiphora can occur if
tears fail to reach the punctum; in cases of lid
Watery eyes can be divided into epiphora and inversion, trichiasis, or distichiasis, corneal irrita-
hypersecretion, depending on the underlying tion can cause reflex tearing. Lacrimal pump dys-
mechanisms. Epiphora is caused by abnormali- function can be caused by dysfunction or
ties of the lacrimal drainage system. Unilateral deformity of the eyelids due to trauma or scarring,
epiphora is most commonly caused by obstruc- incomplete blinking due to facial nerve palsy, or
tive disease of the lacrimal drainage system or by degenerative lower eyelid laxity. As potential
lower eyelid malposition, and it is usually unac- causes of hypersecretion, it is important to check
companied by other ocular symptoms. During for physical indicators of dry eyes, such as fila-
medical interview, it is important to check the ments, reduced tear meniscus, meniscus floaters,
patient’s history, including intermittent red eye, mucous strands, and papillary conjunctivitis.
90 J.-Y. Park and H.-Y. Choi

7.3.2 L
 acrimal Secretion Function Interpretation
Tests Normal values are in the range 10–30  s, and
results ≤10 s are diagnosed as a lacrimal disorder
The sequence of lacrimal secretion function tests due to mucin deficiency.
is shown in Fig. 7.8. Rose Bengal Stain Tear Film Breakup Time (BUT) Reduced tearing causes degeneration or defects
This is performed before the Schirmer test and in the corneal and conjunctival epithelia. The
before anesthetic instillation. This is an objective rose bengal stain not only stains epithelial defects
method used to diagnose dry eyes that measures but also degenerated epithelial cells and contami-
the instability of the tear film. nated mucin.

Method Method
After touching fluorescein paper to the inferior Soluble 1% rose bengal is applied to a cotton
inside surface of the bulbar conjunctiva or instill- swab, which is then touched to the fornical
ing one drop of 2% fluorescein solution to the conjunctiva.
inferior conjunctival sac, the patient blinks sev- The patient blinks several times and waits 30 s
eral times to spread the stain evenly throughout before washing the eye with normal saline.
the tear film. The corneal surface is observed
under broad illumination by a slit lamp with a Interpretation
blue filter. The patient blinks once before looking Dry eye syndrome is diagnosed if both the cor-
straight ahead without blinking; the examiner nea and conjunctiva are stained under a slit
measures the time after blinking, in seconds, lamp. The extent of staining of the corneal epi-
until dry spots first appear due to breakup of the thelium is assessed by slit lamp or macroscopi-
fluorescein within the tear film. The test is cally (Table 7.2).
repeated five times for each eye, and the mean
time is calculated. Schirmer Test
This test examines lacrimal gland function and
provides a quantitative measurement of tear
Slit lamp examination secretion into the conjunctival sac in patients
with suspected dry eye syndrome.
The Schirmer test I is a standard test of lacri-
mal fluid secretion that examines lacrimal gland
Tear film break-up time function as the sum of basic physiological secre-
tion and reflex tearing. The basic secretion test is
used to examine accessory lacrimal gland func-
Rose Bengal, Fluorescein stain
tion, by administering anesthetic instillation to
eliminate reflex tearing; however, some reflex
tearing is still included in the measurement, and

Schirmer test
Table 7.2  Interpretation of rose bengal stain results
± No staining
+ Spotted staining only in the area of interest
Basic secretion test ++ Staining of the area of interest and the
surrounding area, including the bulbar
Fig. 7.8  The sequence of lacrimal secretion function
tests +++ Staining up to the superior bulbar conjunctiva
7  Eyelid and Lacrimal System Exam 91

conflicting opinions have led to this test being Basic Secretion Test
used less often. In order to prevent reflex tearing, anesthetic
The Schirmer test II examines reflex tearing instillation is applied and both eyes are gently
caused by irritation of the ocular and nasal closed.
mucosa, meaning that it essentially examines the After wiping any lacrimal fluid in the medial
main lacrimal gland. This test sometimes pro- canthus with a cotton swab, the lower eyelid is
duces a normal value in dry eye syndrome. everted and a folded piece of filter paper is
inserted to cover the lower punctum.
Method After 5 min, the length of filter paper that has
Schirmer test I been soaked in lacrimal fluid is measured. A nor-
First, the patient looks straight ahead without mal value is 7–8 mm, while values of ≤4 mm are
anesthetic instillation. After cutting one end of suggestive of tear hyposecretion.
a 5  ×  35  mm piece of standard filter paper
(Watman No. 41 filter paper) into a round Schirmer Test II
shape, this end is folded approximately 5 mm Like the basic secretion test, anesthetic instilla-
and inserted into the conjunctival sac in the lat- tion is applied, and filter paper is inserted into the
eral 1/3 of the lower eyelid by pulling on the conjunctival sac, before inserting a cotton swab
eyelid. The patient is then instructed to gaze into the ipsilateral nostril and rubbing to stimu-
upward and close their eyes. Anesthetic instil- late the nasal mucosa. After 2 min, the length of
lation is not applied. It is convenient to use paper soaked in lacrimal fluid is measured. A nor-
paper specifically designed for this test mal value after 2 min is >15 mm, and values of
(Fig. 7.9a), and it is important to be careful not ≤15  mm are suggestive of reduced reflexive
to let the paper touch the cornea. tearing.
The patient keeps the paper in their con-
junctival sac with their eyes open and moving Interpretation (Table 7.3)
their eyelids freely; after 5  min have passed,
the length of paper soaked in lacrimal fluid is Other Examinations
measured. Here, the patient is instructed to
look slightly above straight ahead and to blink Tear Film Protein Analysis
normally. If the patient wants to close their In dry eye syndrome, a lysozyme assay shows
eyes, they may close them naturally, but they reduced concentration, and this is measured by
should not move their eyes from side to side spectrophotometry or the solution method.
(Fig. 7.9). Lactoferrin is a tear protein with antibacterial

Fig. 7.9  Schirmer test a b

(a) Schirmer test paper
and (b) method
92 J.-Y. Park and H.-Y. Choi

Table 7.3  Interpretation of the Schirmer test results The typical order of examinations in patients
Type of test Normal value Interpretation with epiphora symptoms is listed below:
Schirmer test 10–30 mm Reduced lacrimal
after 5 min secretion suspected
• Medical history
when ≤10 mm • Slit lamp microscopy
Basic secretion 7–8 mm Reduced lacrimal • Palpation and digital compression of the area
test after 5 min secretion suspected around the lacrimal sac
when ≤4 mm • Irrigation and probing of the canaliculus
Schirmer II >15 mm Impaired reflex
test after 2 min tearing suspected
• Fluorescent staining; testing functional
when ≤15 mm obstruction
• Intranasal examination
• Radiography; X-ray, CT
activity that is used as an indicator of lacrimal
• Dacryocystography
gland function, and it shows a reduced concentra-
• Dacryoscintigraphy
tion in dry eyes.

Tear Osmolarity
Osmolarity is known to increase in dry eye syn- 7.4.1 Medical History
drome. Although this test has high sensitivity, it
requires expensive equipment and is rarely used The examiner should ask in detail about whether
outside of research purposes. the patient ever experiences red eye, a large
amount of rheum in the morning, pain or swell-
Conjunctival Impression Cytology ing near the lacrimal sac, or has previous experi-
In dry eye syndrome, this test is used to measure ence of dacryocystitis. These symptoms are
the density of goblet cells, which secrete mucin. suggestive of chronic or intermittent dacryocysti-
A special type of filter paper is pressed to the tis. If there has been any symptomless period
inferior nasal conjunctiva and removed; the paper between severe but intermittent epiphora and
is then observed after staining with a specific dacryocystitis, this is suggestive of a dacryolith
stain. In typical individuals, the maximum goblet causing a “ball valve” effect.
cell density in the inferior nasal conjunctiva is The examiner should ask whether the patient
1500/mm2, and this value is lower in individuals has previously received examinations, surgery,
with dry eye syndrome. or probing of the lacrimal duct; overly invasive
punctoplasty can impair lacrimal drainage. The
Ocular Ferning Test examiner should ask about the patient’s history
In typical individuals the conjunctival mucus of sinusitis, chronic allergy, sinus surgery, cen-
shows ferning when dry, and this response may tral facial fractures, or irradiation, as well as
be limited in cases of reduced mucus. This is a previous facial nerve palsy, and whether tears
very sensitive test. are produced while eating. These are all impor-
tant considerations to help evaluate the possibil-
ity of nasolacrimal duct obstruction. For
7.4 Evaluation of Lacrimal quantification or grading of epiphora, there is
Drainage System the Munk scale and a slightly more simplified
epiphora grading.
When the cause of epiphora cannot be deter-
mined after general ophthalmological examina-
tions, such as slit lamp examination, the following 7.4.2 Visual Inspection
examinations are performed, in order: digital
compression of the lacrimal sac, fluorescein The examiner checks for eyelid ectropion, entro-
retention test, lacrimal duct irrigation, probing, pion, and trichiasis. The examiner also checks
dacryocystography, and dacryoscintigraphy. for eyelid dysfunction or deformity caused by
7  Eyelid and Lacrimal System Exam 93

trauma or scarring, unstable blinking caused by Table 7.4  Punctal patency grading
facial nerve palsy, and degenerative lower lid Grade Clinical finding Way to enter
laxity, since these can also cause lacrimal pump Grade 0 No papilla and Requires
impairment. The patency of the puncta in the punctum (punctal surgical creation
atresia) of papilla
medial canthus is inspected using a slit lamp
Grade 1 Papilla covered by a Requires #25
microscope. membrane(exudative needle, followed
Grading of punctual patency and the corre- or true membrane) or by a punctal
sponding treatments are as follows: fibrosis and is difficult finder and then
to recognize standard
punctum dilator
Grade 2 Less than normal size Requires a
7.4.3 D
 igital Compression, ROPLAS but recognizable punctal finder
Test (Regurgitation and then a
on Pressure over Lacrimal
Grade 3 Normal Requires a
Apparatus System) regular punctum
If the patient has previously suffered from dac- Grade 4 Small slit (<2 mm) No need for
ryocystitis, they should be considered to have intervention
lacrimal duct obstruction. When the patient has Grade 5 Large slit (>2 mm) No need for
experienced dacryocystitis, examinations are per-
formed to rapidly confirm whether there is infec-
tion or obstruction of the lacrimal sac and Table 7.5  Interpretation of irrigation results
nasolacrimal duct. Result Interpretation
Difficulty advancing the Complete obstruction of
irrigation needle the canaliculus Method Irrigation is unsuccessful
The examiner uses their finger to apply upward Difficulty advancing the Complete obstruction
pressure to the lacrimal sac at the medial canthus irrigation needle common canaliculus
and observes whether there is any reflux of muco- Reflux of saline from the
other ipsilateral
purulent fluid from the puncta. If there is reflux of canaliculus
mucus or pus, this indicates dacryocystitis or Irrigation needle cannot Complete obstruction of
obstruction of the lacrimal sac or nasolacrimal be easily inserted the nasolacrimal system
duct. There is rarely reflux in the case of a dac- Mucous reflex from the
canaliculus or expansion
ryolith or tumor.
of the nasolacrimal duct
with no reflux
Irrigation needle enters Partial obstruction of the
7.4.4 Lacrimal Irrigation easily nasolacrimal system
Saline reflux and Functional obstruction in
secretion into the nose a normal state
This test verifies the patency of the canaliculus Irrigation needle enters Only functional
and the nasolacrimal duct. easily obstruction can be
Successful irrigation suspected, and further
examinations are required Method for secondary
An irrigation cannula or a blunt 26-gauge nee- hypersecretion
dle is attached to a 5  cc syringe and inserted
into the canaliculus. As the physiological saline
in the syringe is injected, the examiner checks 7.4.5 Probing
that the saline exits via the nose or throat. The
results of irrigation can help to identify the A Bowman probe is inserted into the canaliculi
location of any anatomical abnormalities and nasolacrimal duct via the puncta to check for
(Tables 7.4 and 7.5). obstruction or stenosis for diagnostic purposes in
94 J.-Y. Park and H.-Y. Choi

adults. In children, this procedure can also be and the common canaliculus are patent and the
used for treatment purposes. probe touches the hard bone of the lacrimal sac,
this is described as a “hard stop”; if the canaliculi Method or common canaliculus are obstructed, the probe
0.5 cc of 0.5% proparacaine is injected into the does not touch the bone, and this is described as
lacrimal sac for anesthesia. a “soft stop.”
A probe is inserted 1–2 mm into the puncta,
vertical to the lid margin (Fig. 7.10a). Considerations
The probe is rotated 90° toward the lateral This procedure is used for treatment in children
canthus such that it is parallel with the lid margin, and is used to diagnose the location of stenosis in
then the eyelid is pulled laterally while pushing adults, as well as for correction in some cases.
the canaliculi nasally, and the probe is advanced The size of the probe is 2-0 or less, and a large
until its tip collides with the wall of the lacrimal probe is used in cases of partial obstruction.
sac (Fig. 7.10b). Before removing the probe, it can be marked at
After rotating the probe another 90°, a gentle the point of insertion in order to measure the dis-
force is applied in the direction of the lateral part tance from the punctum.
of the nose in adults and the medial part of the Usually a Bowman probe is used; the largest
nose in children, as the probe is advanced in the size is 6, and smaller numbers correspond to a
inferior direction until it reaches the inferior smaller size. Beyond size 0, the next smallest
meatus (Fig. 7.10c–f). sizes are 00 and 000, and the smallest size is
0000. During the examination, it is crucial to pull Interpretation the eyelid laterally while inserting the probe into
In areas of obstruction or stenosis, resistance is the canaliculus, in order to prevent misinterpreta-
felt during probe insertion. When the canaliculi tion as soft stop due to canalicular kinking.

a b c

d e f

Fig. 7.10  Order for probing

7  Eyelid and Lacrimal System Exam 95

7.4.6 Fluorescent Staining Jones Primary Dye Test

This test is used to differentiate incomplete mechan- Fluorescein Dye Disappearance ical obstruction and functional obstruction.
Test (FDDT, FDT)
This is a very important test for differential diag- Method
nosis of complete, incomplete, or functional Two percent fluorescein solution is instilled.
obstruction of the nasolacrimal duct or lacrimal Decongestant and local anesthetic is sprayed
sac in epiphora patients. It is also useful for eval- into the inferior meatus.
uating lacrimal drainage after conjunctivodac- A cotton swab is placed in the anterior one-­
ryocystorhinostomy (CDCR). half of the inferior meatus.
The cotton swab is removed after 5 min and
inspected for fluorescein staining.
Two percent fluorescein or wet fluorescein test
paper is applied to the lower conjunctival sac.
A positive result, when the cotton swab has been
The stain is examined after 5 min, during which
stained with fluorescein, indicates that the lacri-
time the patient must not tap or rub their eyes.
mal fluid is being properly drained through the
nasolacrimal duct, meaning that epiphora is
Interpretation caused by hypersecretion. A negative result,
The fluorescein should be distributed symmetri- when no fluorescein is detected on the cotton
cally between both eyelids. Cases with no stain swab, indicates anatomical or functional
remaining are classified as grade 0; cases with a obstruction of the lacrimal duct. These need to
faint band of staining at the lid margin are clas- be differentiated using Jones secondary dye test
sified as grade 1; cases with a broad, bright band (Fig. 7.11).
of stain are classified as grade 3; and intermedi-
ate cases are classified as grade 2. From grade 2, Jones Secondary Dye Test
the result is considered to be FDDT positive. This test is used to differentiate anatomical and
Comparison between the two eyes is more functional obstruction following a negative result
important than the grade for a single eye. An in Jones primary dye test and can be used to
asymmetric response indicates relative obstruc- locate the obstruction.
tion. As temporary causes, it is impossible to
exclude examination abnormalities caused by
allergy, dacryoliths, or nasal polyps.

Fig. 7.11 Jones
primary dye test

Positive Negative
96 J.-Y. Park and H.-Y. Choi

Method If reflux is observed from the other ipsilateral

In the case of a negative result in Jones primary punctum, this is indicative of dacryocystitis or
due test, local anesthesia is induced by instilla- obstruction of the common canaliculus or naso-
tion, and any remaining fluorescein is washed out lacrimal duct. The presence of stain indicates
of the conjunctival sac. complete obstruction of the nasolacrimal duct,
The punctum is anesthetized using 0.5% pro- whereas the absence of stain indicates complete
paracaine on a cotton swab. obstruction of the canaliculus. CDCR is per-
The punctum is enlarged. formed in cases of nasolacrimal duct obstruction,
Physiological saline is used to wash the lower while a Jones tube is placed in cases of common
punctum. canaliculus obstruction.
A cotton swab is placed in the inferior meatus, If reflux is observed near the irrigated cana-
or the irrigation fluid is collected from the nose liculus, this is indicative of canaliculus obstruc-
for inspection (Fig. 7.12). tion and the upper punctum is irrigated. Here,
successful irrigation of the upper punctum indi-
Interpretation cates lower canaliculus obstruction, whereas fail-
The test is positive if fluorescein is detected and ure indicates complete obstruction of the common
negative if fluorescein is not detected. canaliculus requiring Jones tube placement.
If fluorescein is detected and there is no reflux, If the lower canaliculus is obstructed but irri-
this indicates partial or functional obstruction. In gation can be performed via the upper canalicu-
this case, CDCR is performed and lower lid lus, the patient’s complaint of eye watering needs
ectropion is corrected if present. to be re-evaluated. In normal circumstances, even
If fluorescein is not detected, it means that if the lower canaliculus is nonfunctional, the
the fluorescein was unable to reach the lacrimal upper canaliculus is sufficient for lacrimal
sac. In cases of punctal or canalicular stenosis drainage.
or abnormalities in the canalicular opening into
the lacrimal sac, these obstacles can be passed
through by the irrigation syringe needle. For 7.4.7 Dacryocystography
treatment, depending on the extent of stenosis,
a Jones tube can be placed, or the valve of This test is used as a preoperative examination
Rosenmuller can be cut and a silicone tube before CDCR and is also used to identify lacri-
placed. mal duct disorders and to locate obstruction.

Fig. 7.12 Fluorescein
irrigation test

Positive Negative
7  Eyelid and Lacrimal System Exam 97 Method Distension of the lacrimal sac and stagnation

An irrigation needle or polyethylene tube is used of the contrast agent are observed in
to inject a contrast agent into the lower canalicu- dacryocystography.
lus, and images are taken in the Caldwell view
and lateral view to check for obstruction Considerations
(Fig. 7.13). Because the contrast agent is injected forcefully, it
is not possible to diagnose functional obstruction. Interpretation In addition, if the placement of the tube is incor-
It is possible to observe the size of the lacrimal rect or if the contrast agent is injected too slowly
sac, and the presence or absence of diverticula, or too rapidly, the image may be unclear, resulting
fistula, or filling defects such as lacrimal sac in artifacts. For this reason, dacryocystography is
tumor (Fig. 7.14). used as an additional examination to confirm a

Fig. 7.13  Inserting the a

cannula for

98 J.-Y. Park and H.-Y. Choi

a b

Fig. 7.14  Dacryocystography. (a) Obstruction of the right nasolacrimal duct. (b) Obstruction of the left nasolacrimal
duct (digital subtraction DCG)

diagnosis. Computerized digital subtraction dac- • Intraduct delay: Isotope is observed to fill the
ryocystography provides a better image. nasolacrimal duct after 5  min, but is not
drained any further in the subsequent 15 min
(Fig. 7.15).
7.4.8 Dacryoscintigraphy

This test is used to examine the anatomical struc- Considerations

ture of the lacrimal drainage system, as well as to This test enables more accurate diagnosis of
observe its function in a physiological state. functional obstruction, produces more normal
results when compared with the fluorescein Method retention test, and provides a record of images. It
A micropipette is used to instill 10 μL of 99mTc-­ is also easier to compare the results with the other
pertechnetate or 99mTc-sulfur colloid, a volume eye. Compared with dacryocystography, although
corresponding to twice that of the tear film. the radiation exposure is lower, it does not show
Thereafter, a gamma camera is used to observe the detailed anatomical structure. In terms of its
the flow of isotope over time, with a radioactivity downsides, this test requires expensive equip-
of 50–100  μCi, which is approximately 2% the ment and takes a long time, at approximately 1 h
amount of radiation in a cranial X-ray. per test. Interpretation
The flow of isotope is imaged every 10 s during 7.4.9 Other Examinations
the first 160 s (dynamic study) and then at 5, 10,
15, and 20 min (static view). X-ray and CT are used to diagnose nasal sinus
disease, tumors, ethmoid bone disorders, and
• Presac delay: Isotope does not reach the lacri- mucoceles. In patients with lacrimal duct or
mal sac by the end of the dynamic study. nasolacrimal duct obstruction, more detailed
• Preductal delay: The lacrimal sac fills, but the intranasal examination would be needed, such as
isotope remains in the sac after 5  min of nasal endoscopy, in order to differentiate intrana-
imaging. sal tumors.
7  Eyelid and Lacrimal System Exam 99

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and practice of ophthalmology, vol. 4. 2nd ed.
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Chap. 234.
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Slit Lamp Exam
Jong-Soo Lee

The slit lamp examination is a basic ophthalmo- eye including the conjunctiva and cornea, the
logic examination method that allows the eye tis- anterior chamber, the lens, and the anterior vitre-
sue to be examined through an optical section by ous and to accurately track the location of the
cutting each tissue of the eye with a slit light lesion. Using the auxiliary lens, three-­dimensional
beam. By using a light bulb with a vertical fila- observation of the anterior chamber, fundus, vit-
ment as a light source and reducing a circular reous, and retina is also possible.
light beam to a square, the width and length of
the circular light beam can be arbitrarily adjusted,
and the image can be enlarged up to about 40 8.1.1 Principle and Structure
times. (Table 8.1)
We can observe several layers with different
contrasts depending on the path of the ray. Depending on the model, the Zeiss and
Therefore, we can observe various layers of the Rodenstock slit lamps are located at the bottom
eye such as cornea endothelium, anterior chamber of the apparatus for projecting the slit light
and measure corneal thickness, anterior chamber beams. The light rays from the halogen light
depth. source are directed upward and pass through a
focus lens, a slit light aperture, a filter, and an
objective lens and are turned 90 ° from the prism
8.1 Slit Lamp Biomicroscope at the top of the slit light projection to the eye to
be observed. Haag-Streit’s Goldmann 900 type
The basic structure of the slit lamp microscope is has a tungsten light source on top of the
composed of a slit lamp illumination device, a illuminator.
binocular stereoscopic microscope, and an Observed microscopes include Kepler-type
accessory apparatus. Zeiss type, Haag-Streit type refracting telescopes (convex objective and
(Fig.  8.1), and Rodenstock type are available convex eyepieces) and Galileo-type telescopes
now. (convex objective and concave eyepieces). The
It is possible to observe the structures and dis- Zeiss, Rodenstock, and Goldmann slit lamps
ease progression of the anterior segment of the were placed at the first object lens (focal length
100–125 mm) in front of binoculars focused at
infinity to focus at close range and the second
J.-S. Lee, MD., PhD. (*) objective lens (focal length 125–170  mm).
Department of Ophthalmology, Pusan National Goldmann 900BM is a system with one convex
University School of Medicine, Busan, South Korea
e-mail: objective lens designed to focus on the position

© Springer Nature Singapore Pte Ltd. 2019 101

J.-S. Lee (ed.), Primary Eye Examination,
102 J.-S. Lee




6 14



Fig. 8.1  Haag-Streit 900-type slit lamp microscope. (1) plate; (9) handle to control the width of the beam; (10)
Handle to rotate and adjust the length of the beam; (2) locking device to raise or lower the elevation angle; (11) a
lever to change magnification; (3) adjustable handle to fixing device for turning the slit lamp device in the vertical
move the slant lamp forward and backward, up and down, direction to turn the light horizontally; (12) height of
and left and right; (4) fixation light; (5) lever for filter beam; (13) lamp cover; (14) coaxial set screw; (15) cor-
selection; (6) upper and lower control knob; (7) focusing rected the refraction error of the inspector
eyepiece; (8) Goldmann applanation tonometer fixed

of the object being observed. The microscope and color tone, it can be converted by inserting
for left and right eyes is independent, so that the filter into the lever. A heat rejection filter that
the optical axis is not parallel but facing the blocks heat rays without a filter or a light reduc-
object. tion, an ND50 filter that reduces the amount of
You can change the brightness, hue, length, light by 50%, and an invariant color filter that
width, rotation, and axis of the slit light by adjust- facilitates the observation of retinal nerve fibers
ing the light from the light source. It is also pos- (Fig. 8.2). If you adjust the length and width of
sible to change the elevation angle to illuminate the slit light and rotate the lamp house, you can
the slit lights from below. In case of brightness also rotate the slit light.
8  Slit Lamp Exam 103

Table 8.1  Comparison of slit lamp microscopes

Haag-Streit SL (Goldmann
Zeiss SL 900BQ) Rodenstock SL(RO5000SE)
Microscope Galileo binocular Galileo binocular type 6.3–40 Galileo binocular type 6–45
magnification type 5–32 times times times
Light source Halogen 6 V 20 W tungsten 6 V 4.5A(330,000lux) Halogen 6 V
(660,000 lux) Halogen 7.5 V 20 W(660,000lux)
38 W(600,000lux)
Lighting method Erected type Inverted type Erected type
Adjust pupil distance 50–75 mm 52–78 mm 50–75 mm
Slit light width 0–14 mm continuous 0–8 mm continuous change 0–12 mm continuous change
Slit light rotation 0–180° 0–180° 0–360°
Variable adjustment 0.3–9 mm step 6, 1–8 mm continuous change 2.25–12 mm continuous
range slit light length three slit light 30 mm 30 mm manual change 30 mm electric lift
manual type
Front/back left/right Left/right 110 mm Left/right 100 mm Front/back Left/right 100 mm Front/back
adjustment range Front/back 90 mm 80 mm Up/down 29 mm 80 mm
Depth of focus Optional None Exist
Elevation angle 0–20° continuous 0–25°, 5° interval None
scanning change
Filter Blue, green, gray blue, green, gray (10% light Blue, green, gray Correction
(10,20,40% light reduction) glass
Stereo angle 12.5° 13°/4.5° (Convertible) 11°
Stereovariator None Exist None
Features and Beam splitter, depth Stereoscopic view enlargement Fundus exam by Hruby lens
accessories of focus aperture by using stereovariator can achieve clear image
Light brightness Continuous change No adjusting screw No adjusting screw

1 2 3 4 5

1. Open 2. Heat rejection filter

3. 50% light reduction filter 4. Invariant color filter

5. Open (In some slit lamp, cobalt blue)

The Goldman slit lamp can change the illumi- tion and short ones for fundus examination. A long
nation in the vertical direction by tilting the light- reflector uses a short reflector to prevent stereo-
ing device forward, resulting in an elevation scopic vision from disappearing during fundus
angle from below to above the lighting (Fig. 8.3). examination because it blocks one side of the
This is mainly used when observing the cross microscope objective lens when the angle between
section by illuminating the slit light horizontally the illumination device and the microscope is
or obliquely, particularly when observing the about 6°. If the reflector is short, the light quantity
peripheral retina with a three-dimensional mirror. of the vertical three-pole light becomes small.
Goldman slit lamps have two long and short reflec- Therefore, the slit light is inclined forward so that
tors, long reflectors for anterior segment examina- the entire slit light is reflected on the reflector.
104 J.-S. Lee

Fig. 8.2  Adjustment of

brightness and color
tone, type, and function Lamp cover
of filter

Height of beam

Lever for filter selection

Handle to rotate and adjust the

length of the beam

The Zeiss slit lamp can turn the prism mirror

of the lighting device to change the angle of the
reflector continuously from 0 to 20° so that the
light is illuminated from bottom to top. When
illuminating the slit light horizontally, the angle
between the illumination device and the
microscope is 0°, which is coaxially observed.
If a stereovariator is attached to a Goldman slit
lamp, binocular vision is possible, and the obser-
vation range is widened. The Hruby lens has been
used for fundus examination as a concave lens,
but now the +90D lens is often used.
The slit lamp is set so that the alit light of the
illuminating device fits at the position where the
microscope is focused even if the angle of the axis
of the illumination device and the axis of the obser-
vation microscope is changed. When the coaxial set-
screw is released in a counterclockwise direction, the
coaxial axes of the microscope and the illuminating
device are released and can move independently of
each other, so that the illumination can be moved to
the left and right and rear of the observation site.

Fig. 8.3  Change of elevation angle

8  Slit Lamp Exam 105

8.1.2 Illumination Diffuse Illumination

It is a method of observing a wide range of light
Direct illumination that directly observes light by rays at a low magnification by broadening the
observing an object to be observed according to width of the slit light by setting the light beam to
an illumination method, and indirect illumination acute angle, and it is suitable for general observa-
that observes light by irradiating light around the tion of the conjunctiva, eyelid, and cornea, but
object to be observed and reflected or transmitted detailed findings can’t be obtained. Wide-angle
(Fig. 8.4). illumination can be observed easily in the con-

Fig. 8.4 (a) Diffuse illumination shows general observa- dystrophy. (e) Retro-illumination. (e-1) shows corneal
tion of conjunctiva, cornea, iris, and pterygium. (b) Direct endothelial precipitates with retro-illumination from the
focal illumination shows corneal rust ring after removal of iris. (e-2) shows after cataract with red reflex in fundus. (f)
corneal foreign body. (c) Indirect illumination is easy to Specular illumination shows endothelial cell of the cor-
observe mutton fat keratopricipitate on endothelium. (d) nea, a hexagonal corneal endothelial cell
Sclerotic scatter shows stromal deposition of Avellino
106 J.-S. Lee


Fig. 8.4 (continued)
8  Slit Lamp Exam 107


Fig. 8.4 (continued)

junctival sac, conjunctival follicles, conjunctival optical segment and the deeper lesion be
papillae, and corneal scars (Fig. 8.4a). obtained. By controlling the thickness of the
optical section, the position and extent of the Direct Focal Illumination cornea, the anterior chamber, and the lens opac-
The most commonly used illumination method ity can be accurately observed. To create an
is to focus the slit light directly on the part to be effective optical segment, it is important to
observed and to observe the lesion through an maximize the intensity of light and to use the
optical section. The larger the angle between the narrowest possible light to identify the object
illumination and the microscope, the thicker the (Fig. 8.4b).
108 J.-S. Lee Indirect Illumination At this time, the length of the slit light is 2–3 mm,
The coaxial fixation screw is loosened to move and the width is 3–4 mm, and a bright image can
the slit light axis to either the left or the right, and be obtained by adjusting it to the optic nerve head
the lesion is observed in the periphery of the slit (Fig. 8.4e). Figure 8.4e-1 shows retro-­illumination
light without directly irradiating the region to be from the iris. It can detect corneal endothelial
observed. It is easy to observe the surface with precipitates. Figure 8.4e-2 shows after cataract. It
haze because it can reduce the scattering due to is observed by red reflex in the fundus.
direct illumination, and it is helpful to observe
the change under the object surface to be observed Specular Reflection
or the buried foreign object by using the This is a type of direct local illumination method
retroreflected light from the tissue. Focusing the in which the microscope axis is aligned with the
light on the iris allows you to observe bleeding or optical axis where the slit light is reflected and
abnormal findings in the vicinity (Fig. 8.4c). the mirror surface of the reflection surface is
observed using Snell’s law. In other words, the Sclerotic Scatter incident angle and the reflection angle of the light
It is also referred to as indirect lateral illumina- beam become the same, and the total reflection
tion. It is a method of unrolling the coaxial fixing occurs at the boundary of the medium. Typically,
screw, irradiating the sclera near the edge of the the cornea is used to observe the corneal
cornea, and observing the cornea center with a endothelial cell morphology and size by focusing
slit lamp. When the light is reflected in the corneal on the posterior surface of the cornea. Adjust the
tissue, it passes through the opposite edge, so that angle of the slit light to 2–3 mm and the width to
the inside of the cornea is observed using light 1–2  mm so that the angle of the axis of the
transmitted as an optical fiber. There is an illumination device and the axis of the microscope
advantage of being able to easily observe is about 60° and the magnification of the
microscopic corneal opacity, corneal edema, and microscope is 20–40 times the maximum. When
posterior corneal deposition (Fig. 8.4d). the corneal surface is observed, the reflection
from the tear layer is strong, and light reflected Retro-illumination from the corneal endothelium is faintly visible on
It is a type of indirect illumination method in the side. At this time, when the observation
which three polarized light are irradiated behind microscope is pushed forward about 0.5 mm and
the observation part and the lesion is observed the focus is adjusted to the endothelial cell of the
using the reflected light. The slit light has the cornea, a hexagonal corneal endothelial cell can
maximum brightness, but the width of the pole is be observed (Fig. 8.4f).
reduced to a minimum, and the angle between the
illumination axis and the microscope axis is
positioned near the center where the backlight is 8.1.3 H
 ow to Proceed with Slit
maximized. If necessary, the coaxial fixing screw Lamp Examination
can be loosened to move the illumination light
transversely by changing only the angle of the Always observe the anterior segment and the
illumination while the position of the microscope entire face with a flashlight or penlight before
axis and the illumination axis is fixed. The cornea the slit lamp examination. Adjust the eyepiece of
is a reflected light from the iris and the front of the slit lamp to match the refractive error of the
the lens. It can detect fine lesions such as corneal examiner (Fig. 8.5).
edema, blisters, deposits, blood vessels, and iris Fit the calibration bar (or use the fingers of
pigmentation, and the anterior surface of the lens the examiner), and make the slit light the small-
can be observed as reflected light from the back est in the center of the field of view. Next,
of the lens. The lens opacity, such as after observe each eye on the left and right eyes, and
cataract, is observed by red reflex in the fundus. adjust the eyepiece by rotating the eyepiece
8  Slit Lamp Exam 109

Calibration bar


Central pivot
Calibration bar

Fig. 8.5  Adjusting the eyepiece

lever so that the rim of the slit light is most

clearly focused. Adjust the eyepiece pupil dis-
tance to match the eyes of the examinee so that
the slit light on the calibration bar looks like one
with two eyes. Rotate the adjustment knob to
adjust the front, back, left, and right directions of
the slit lamp microscope, and set the height of
the microscope to the middle.
The examiner and the patient face each other
with a slit lamp microscope in between. The
height of the patient’s chair should be adjusted so
that the patient’s chin is placed on the chin rest
and the forehead is fixed firmly on the forehead
support to fix the face. It is very important to
adjust the height of the chair so that the patient is
in a comfortable position.
Fluorescent test paper, 1% Rose Bengal solu-
tion, eye anesthetic, methyl cellulose, eye drops
of antibiotics, and saline solution are prepared.
Main power is 5.5 V or 6.0 V. The current 7.5 V
is overloaded and should be used only for a short
Fig. 8.6  The portable slit lamp
time. Adjust the adjustment knob to the left or
right by adjusting it to the left or right eye to be
inspected. The illuminator is located on the the presence (depth), extent, and extent of the
patient’s ear, the microscope is on the front, and lesion by illuminating slit light of various widths
the angle between the illuminator and the micro- and lengths from various directions and angles.
scope is 20–30°. The narrower the width of the slit light, the better
First, the lesion is observed as a whole at a the depth of the lesion. The wider the width of the
wide magnification with a low magnification of slit light, the easier it is to observe the planar
about ten times. If necessary, increase the view. In children, it is best to sit on the guardian’s
observation magnification, increase the knees, hold the head lightly, and observe the eye
illumination, reduce the patient’s glare, and of the children. However, if the children are not
narrow the width of the slit light beam for detailed cooperative, the portable slit lamp can be used to
observation of the cross section. Observation of examine the eye (Fig. 8.6).
110 J.-S. Lee

Table 8.2  Main observation points of the anterior seg-

ment of the eye
Lid Shape, color, injection, shape of
punctum, Meibomian gland opening,
scar, thickening, discharge, mass
Eyelashes Number, arrangement, direction, scale,
Fixation light attachment
Palpebral Color, pigmentation, injection, vessel,
conjunctiva chemosis, pustule, scar, stone,
infarction, mass, wound
Bulbar Position of blood vessel, caliber,
conjunctiva meandering, hemocyte
Tears Tear meniscus height, reservoir, tear
breakup time
Cornea Transparency, shape, surface curvature,
blister, epithelium, detachment, ulcer,
Fig. 8.7  The fixation light foreign body, neovascularization nerve,
parenchymal deposits, endothelium
The examination starts from the outer part of Anterior Floater, haziness, hyphema, exudates,
the eyelid, conjunctiva, and sclera and progresses chamber hypopyon
to the inside of the eye gradually, such as the cor- Iris Color, pigmentation, congestion,
opacity, edema, bleeding,
nea, the anterior chamber, and the lens. In general neovascularization, mass, defective
low-magnification observation, eye movements area, degenerated atrophy, synechiae,
of the patient’s eye are minimized by watching pupillary membrane
the ears, shoulders, and fingers of the examinee. Lens Transparency, opacity, pigment,
vesicle, cortex, nucleus
For high-magnification examinations, fixation
light should be fixed in front of eyes that are not
examined. Focus on the target and allow the brane, and the dark part between the two lines is
patient to watch accurately (Fig. 8.7). the corneal epithelium. These findings are clearly
appeared from the edge of the cornea, to observe
whether the epithelial advised to start a scan from
8.1.4 Site-Specific Observation the edge of the cornea.
(Table 8.2) Corneal epithelial edema can be seen with
small droplet-shaped epithelial edema with
We can observe the general eyelid position, retro-­illumination, specular reflection, and
shape, change of skin, and eyelid clearance with scleral scatter. The corneal epithelium defect
the diffuse illumination. Observe the number of appears to be pale turbidity when observed by
eyebrows, arrangement, direction, and scales. direct or indirect illumination, and yellow fluo-
We also observe the color and pigmentation, rescence can be observed by observing through
congestion, blood vessels, edema, and scarring of the cobalt blue filter with a fluorescent dye.
the palpebral and bulbar conjunctiva with the dif- Droplet-shaped epithelial edema is observed by
fuse illumination or direct focal illumination. narrowing the slit light, and the surface line ris-
Then, we can observe the thickness, retention ing is seen, and the space of the blur appears
time of tear, and tear film breakup time. dark under it.
In the slit light, the cornea is observed as a In case of corneal neovascularization, superfi-
parallel hexahedron. When narrowing the slit cial neovascularization under the epithelium is
light and intensifying the illumination, two dis- easy to observe directly, and erythrocytes flowing
tinct lines appear on the surface of the cornea. in the corneal stromal neovascularization are
The outer line is reflected from the surface of the observed by retro-­illumination using the reflected
tear film, the inner line is the Bowman’s mem- light from the iris and the lens.
8  Slit Lamp Exam 111

Corneal edema, cell infiltration, and scarring, illumination, so if you examine them again with
which are lesions of the corneal stroma, are direct focal illumination, you will not miss cata-
observed by retro-illumination by reflected light racts. In the specular reflection method, the front
from the fundus. The corneal edema is cloudy and back shagreen of the lens can be observed
and the thickness of stroma is increased. well. We also can observe the vitreous and retina
The corneal scar has sharp margin and the scar through the fundus examination. See at the chap-
area is turbidity deeply observed. Observe the ter fundus examination (chapter 15).
range, depth, and thickness of the corneal lesion The vital staining is a method of observing
by narrowing the slit light. The apparent line on fluorescence by staining with an eye drop or a
the back of the cornea reflects from the test strip. Fluorescence can easily detect the
Descemet’s membrane, and the nerve appears to state of migration in the corneal epithelium and
be thin like a thread in the corneal stroma, which the retention of the tissue defect. We can easily
is long, thick, and clear in the pathological state. observe the lesion with the use of a cobalt blue
The keratic precipitate (KP) can be observed filter to prevent patient glare even if the light
in size, number, and color by direct or indirect amount is maximized. The vital staining is used
illumination, and the morphology and size of the to measure the papillary proliferation of the pal-
corneal endothelial cells can be observed using pebral conjunctiva of upper eyelid, cone in the
specular reflection. keratoconus, the seidel test, intraocular pressure
We also can observe the depth and shape of measurement.
the anterior chamber while moving the left and
right by narrowing and shortening the slit light by
direct focal illumination. The pupil is a dark Suggested Reading
background, and microscopic inflammatory cells
float; cloudiness, hemorrhage, and hypopyon are Arffa RC.  Grayson’s diseases of the cornea. 3rd ed. St
examined. When the aqueous humor is cloudy, Louis: Mosby; 1991.
the convective phenomenon of aqueous humor is Bennett TJ, Miller GE. Lissamine green dye-An alterna-
tive to Rose Bengal in photo slit-lamp biomicrogra-
easily seen. The angle of the anterior chamber, phy. J Ophthal Photo. 2002;24(2):74–7.
trabecular pigmentation, and iris synechiae is Berliner ML. Biomicroscopy of the eye, vol. 1. New York:
observed using gonio lens. Direct focal illumina- Paul B. Hoeber; 1949.
tion is used to observe iris color, posterior syn- Fuchs E.  Textbook of ophthalmology. New  York:
D. Appleton & Co; 1892.
echiae, and neovascularization. Iris atrophy Justice J Jr, Soper JW.  An improved method of view-
should be observed with retro-illumination. ing topical fluorescein. Trans Am Acad Ophthalmol
We also can observe the crystal lens. First, Otolaryngol. 1976;81:927–8.
widen the slit light and observe overall, and Mártonyi CL, Bahn CF, Meyer RF. Slit lamp: examination
and photography. Sedona: Time One Ink, Ltd; 2007.
observe the state of transparency, opacity, pig- Romanchuck KG.  Seidel’s test using 10% fluorescein.
ment, vacuole, and nucleus. By direct focal illu- Can J Ophthalmol. 1979;14:253–6.
mination, the entire image is observed while Shahinian L. Corneal valance: a tear film pattern in map-­
sequentially focusing each layer of the lens from dot-­fingerprint corneal dystrophy. Ann Ophthalmol.
the anterior capsule to the posterior capsule. In Van Herick W, Schaffer RN, Schwartz A.  Estimation
mydriasis state, relatively weakly localized cata- of width of angle of the anterior chamber. Am J
racts are observed on the whole plane by retro- Ophthalmol. 1969;68:626–9.
Conjunctiva and Cornea Exam
Jong-Soo Lee

9.1 Lymph Node Exam

The purpose of this examination is to evaluate the

presence or absence of lymph node metastasis in
various conjunctivitis and eyelid malignancies.
The preauricular lymph node and the subman-
dibular lymph node are visualized and promoted
to determine whether they are painful.
A grossly visible lymph node is seen in
Parinaud syndrome and epidemic keratoconjunc-
tivitis. If you have pain, you may suspect herpes
simplex conjunctivitis, epidemic conjunctivitis,
inclusion conjunctivitis, and trachoma. Small,
painless lymph nodes are seen in pharyngocon-
junctival fever and acute hemorrhagic conjuncti- 1
vitis. The temporal conjunctiva, 2/3 of the upper
eyelid, and 1/3 of the lower eyelid are excreted
into the preauricular lymph node, and the rest of
the eye are excreted into the submandibular lymph
nodes (Fig.  9.1). These lymph nodes are impor-
tant to metastasis of eyelid malignant tumor.

9.2 Eyelid Eversion Method

Since gross finding is important in examining the 2

conjunctiva, the conjunctiva is exposed by invert-
ing the upper and lower eyelids, and the overall Fig. 9.1  Emission of lymphatic fluid from the eye. 1.
Preauricular lymph nodes. 2. Submandibular lymph nodes
condition of the conjunctiva is observed.

J.-S. Lee, MD., PhD. (*)

Department of Ophthalmology, Pusan National
University School of Medicine, Busan, South Korea

© Springer Nature Singapore Pte Ltd. 2019 113

J.-S. Lee (ed.), Primary Eye Examination,
114 J.-S. Lee

9.2.1 L
 ower Eyelid Eversion finger pushes the eyeball and twists the eyelid
Methods frame with the thumb. Remove the index fin-
ger, and fix the thumbed skin to the orbit
You can see the entire conjunctiva of the lower (Fig. 9.3).
eyelid by allowing the patient to sit upright or Place the thumb of the opposite hand against
lying down and pulling down with the thumb of the lower eyelid and push the eyeball into the
the left hand slightly pressed down on the lower orbit, lifting the upper eyelid to expose the con-
eyelid (Fig. 9.2). junctival fornix. When inverting the eyelids
using ancillary equipment, grasp the eyelash
with the thumb and index finger, place the
9.2.2 U
 pper Eyelid Eversion choker or swab horizontally on top of the eyelid
Methods plate with one hand, lift the eyelash up while
pushing it toward the eyeball, and remove the
Point the patient’s gaze downward, and then choker (Fig. 9.4).
wrinkle the upper eyelid skin of the upper eye-
lid with the thumb and index finger. The index
9.3 Vital Staining

Small erosions or defects in the cornea and con-

junctiva are difficult to detect. When the surface
of each conjunctiva and cornea is stained, it can
be easily used for the diagnosis of epithelial ero-
sion or defect. Characteristic staining pattern is
helpful for diagnosis of cornea and external eye
disease. When describing the staining, the depth
and scope should be set to micropunctate, macro-
punctate, coalescent (patch), and whether the
depth is limited to the corneal epithelium or the
corneal stroma. Fluorescein is stained green on
Bowman’s membrane, a defective part of the cor-
nea in the intercellular lesions, and rose bengal is
reddish in dead cells or cells with no function. In
Fig. 9.2  Lower eyelid eversion methods addition, lissamine green is less irritating than

Fig. 9.3  Upper eyelid eversion methods

9  Conjunctiva and Cornea Exam 115

rose bengal and can be used for the diagnosis of eyelid about 3–4 times (after about 15 min) and
dry eye syndrome because it is stained with check for lesion under cobalt blue filter. When
abnormal mucin (Table 9.1). using the test strip, drop saline solution without
preservative onto the test strip and shake off the
test strip. After the upper sight, contact the lower
9.3.1 Fluorescein Staining temporal conjunctival sac and perform the exam-
ination. The lower eyelid should be pulled to
Fluorescein staining can be used to diagnose eye avoid conjunctival or eyelid border damage.
diseases that are suspected of corneal epithelium
defect, corneal erosion, or corneal ulcer.
Fluorescent materials are useful for applanation 9.3.2 Rose Bengal Staining
tonometer, contact lens fitting, nasolacrimal duct
penetration and obstruction testing, tear film It is useful for diagnosis of ocular epithelium
break-up time measurement, and seidel testing defect, staining of mucin, and dry eye syndrome.
(Fig. 9.5). After 1% solution is instilled into the conjunc-
The stained state of the cornea or conjunctiva tival sac, the eyelid is blinked about 3–5 times,
is observed by injecting sterile 2% fluorescein or and the conjunctival lesion is observed. The cor-
test strip into the conjunctival sac. After placing a nea and conjunctival lesions were severely dam-
drop of water into the conjunctival sac, flush the aged as the score increased from 0 to +9 according
to the intensity of staining, divided into three
areas: the nasal conjunctiva, the temporal con-
junctiva, and the cornea (Fig. 9.6).

9.3.3 Lissamine Green Staining

It is useful to diagnosis in dead or denatured

cells, abnormal mucin, and dry eye syndrome.
Use a 0.5% lissamine green test strip, and use
it in the same way as using fluorescence or rose
bengal test strips. Normal corneal epithelium is
not stained in the pigmented point, but there are
various types of staining when there is a corneal
Fig. 9.4  Upper eyelid eversion methods using ancillary epithelium defect. For example, dendritic defects
equipment are suspected to be herpes simplex keratitis and

Table 9.1  Types and differentiation of vital staining

Differentiation Flourescein Rose bengal Lissamine green B
Normal cell staining No stain Stain No stain
Dying or degenerated cell staining No stain Stain Stain
Staining inhibition by mucin None Exist None
Comparative spread through Fastest Slowest Fast
collagen parenchyma
Mechanism of staining promotion Intercellular Inadequate defense Intercellular cleavage and cell
cleavage of tears death/degeneration
116 J.-S. Lee

Fig. 9.5  Leakage of aqueous identified in the bleb fistula during fluorescein staining

9.4 Bacteriological Exam

Diagnosis of bacterial keratitis is not sufficient

with clinical findings and should be accompa-
nied by bacteriological examination.
Bacteriological tests are not only helpful for
diagnosis, but also for selecting appropriate ther-
apy, and should be performed before administra-
tion of antibiotics.

Fig. 9.6  Rose bengal staining in dry eye 9.4.1 Notes on Sampling

Table 9.2  Superficial punctate epitheliopathy As a pre-treatment, use 0.5% proparacaine, an

Location Cause eye-topical anesthetic. The eyelids are opened by
Upper Foreign body in the eyelid using a sterilized speculum, and then the corneal
Vernal keratoconjunctivitis materials for microbial culture are collected.
Superior limbic keratoconjunctivitis Since the live bacteria may not exist in the
Lower Staphylococcal blepharitis
mucous or mucous secretions, the specimens
Lagophthalmos should be obtained after mucous or mucous
Drug toxicity secretion removal. Corneal material is obtained
Interpalpebral Seborrheic blepharitis by scraping corneal tissues from the advancing
Dry eye syndrome borders of the infected area using a sterilized sur-
UV exposure
Neurological disease
gical knife or a bent needle.
When culture and smear samples are prepared,
smear samples are prepared after culturing. The
herpes zoster keratitis, and spot defects are basic mediums are blood, chocolate, and fungus
caused by herpes simplex, epidemic keratocon- medium. If anaerobic bacteria are suspected,
junctivitis, and trichiasis. Irregular erosion may anaerobic medium is used. If acanthamoeba
be caused by improper use of contact lenses, infection is suspected, non-nutrient medium
trauma, and ultraviolet radiation. The causes of coated with E. coli is used. Gram stain, acridine
superficial punctate epitheliopathy are shown in orange stain, and Giemsa stain are basically used
Table 9.2. in smear samples. The hypopyon that occurs in
9  Conjunctiva and Cornea Exam 117

eyes with bacterial keratitis is usually sterile, and removed tissue may be directly cultured in a cul-
aqueous or vitreous taps should not be performed ture medium or inoculated into a liquid culture
in order to avoid intraocular inoculation of the medium.
microorganisms, unless there is a high suspicion
of microbial endophthalmitis.
9.4.4 Stains

9.4.2 Culture and Scratch Microbial pathogens may be categorized by

examining stained smears of corneal scrapings.
Laboratory investigation includes corneal scrap- The material for smear is applied to a clean glass
ing to identify organisms and determine sensitiv- microscope slide in an even, thin layer for micro-
ity to antibiotics. Samples are taken from the bial staining. After drying, it is advisable to
eyelid, conjunctival sac, and corneal ulcer sur- immobilize the slides in a 95% alcohol fixative
face with cotton swabs and planted in the medium for about 5 min.
(Fig. 9.7).
Scratch the corneal ulcer base and border with Acridine Orange Stain
a sterile surgical knife or Kimura spatula to col- This is useful as a primary staining method to
lect the specimens and examine them for smear quickly detect the presence or absence of bacte-
and culture (Fig. 9.8). ria. The acridine orange dyes used are diphenyl-
methane dyes, which bind to double-­ stranded
nucleic acids and display bright fluorescence
9.4.3 Biopsy under a fluorescence microscope. Bacteria have
bright orange fluorescence, and human cells and
Indications for corneal biopsy include corneal other background substances have green or yel-
biopsy of the deep cornea in which lesions are low fluorescence (Fig. 9.9). Therefore, when the
difficult to obtain by corneal scarring or if inflam- number of bacteria is small, the method is more
mation progresses without previous detection of sensitive than Gram stain. However, since it is
bacteria. The corneal biopsy method uses a small not known whether bacteria are Gram-positive
2–4 mm round trephine. Care should be taken not bacteria or Gram-negative bacteria, Gram stain is
to puncture the cornea. As a test method, the additionally required.

a b

Fig. 9.7  Sampling with a cotton swab. (a) Eyelid margin. (b) Conjunctival Sac
118 J.-S. Lee

a b

Fig. 9.8  Sampling of corneal ulcer. (a) Ulcer base. (b) Ulcer borderline Giemsa Stain

It is used for the discovery of fungi and the
structural observation of cells. If infection with
a fungus or acanthamoeba is suspected,
calcofluor-­white, methenamine silver, trichrome
stain is helpful. If a mycobacterial infection is
suspected, antacid staining is preferred. Recently,
a fluorescent antibody test has been attempted to
diagnose bacterial keratitis. It has the advantage
of being able to test even if it is being treated by
detecting the antigen of bacteria.

9.5 Pachymetry
Fig. 9.9  Acridine orange stain in Streptococcus pneu-
moniae keratitis Because corneal edema occurs mainly on the
posterior surface of the cornea, and cornea stro- Gram Stain mal edema is controlled by the corneal endothe-
This is the most basic dye for smears testing. Due lium, the measurement of corneal thickness is an
to differences in cell wall structure and chemical indicator of endothelial function.
composition of bacteria, Gram-positive bacteria A device for measuring the thickness of a cor-
appear blue, and Gram-negative bacteria appear nea is called a pachymeter. There are optical
pink (Fig. 9.10). methods using a slit lamp, using an ultrasonic
9  Conjunctiva and Cornea Exam 119

a b

Fig. 9.10  Gram stain. (a) Gram-positive bacteria retain the color of the crystal violet stain in the Gram stain. (b) Gram-­
negative bacteria lose the crystal violet stain and take the color of the red of pink counterstain

Table 9.3  Diseases requiring examination of corneal 9.5.1 Classification of Pachymetry

Application for refractive surgery Corneal thickness measurements can be made
Thinning of the cornea with contact and noncontact methods. The differ-
 Keratoconus ences are shown in Table 9.4.
 Pellucid marginal degeneration
 Terrien marginal degeneration Ultrasonography is a contact type, so it is
Corneal endothelial decompensation possible to measure the corneal opacity even
 Corneal endothelial degeneration though it has a risk of infection. In particular, it
A state in which corneal endothelial function is can be measured regardless of the position of
predicted to decrease the patient and can be measured during surgery.
 After laser iridotomy The noncontact type is an Orbscan measure-
 Contact lens user
 Those who use antipsychotic drugs (butyrophenone)
ment method using an optical method, which
Corneal thickness affects clinical evaluation can interpret the shape of the front and back of
 Glaucoma (intraocular pressure) the cornea by projecting the slit light, obtaining
the image, and analyzing it with a triangular
measurement method. In addition, when using
probe, using a specular microscope, using a con- a specular microscope, it is possible to measure
focal microscope, and using Orbscan. Recently, it not only the thickness of the cornea but also the
is an indispensable test for preoperative evalua- morphological abnormality of the corneal
tion of corneal surgery including corneal refrac- endothelial cell and the functional abnormality
tive surgery. Corneal thickness is also important of the corneal tissue. Corneal thickness mea-
in the diagnosis of glaucoma and is also used to sured with Pentacam using a Scheimpflug cam-
evaluate corneal status after corneal transplanta- era is clinically useful because of its small
tion, keratoconus evaluation, and corneal edema error.
(Table 9.3). In general, in order to alleviate the burden on
It is a clinically useful technique for evaluat- the patient, noncontact measurement method
ing corneal edema that can occur after intraocular which can perform various examinations includ-
surgery, eye disease, or corneal guttata. The mea- ing corneal endothelial cell and anterior angle
surement error is usually about 0.2%. shape analysis is widely used. The ultrasonic
120 J.-S. Lee

Table 9.4  Comparison of two corneal thickness measurement methods

Contact Noncontact
Ultrasound method Slit scanning Specular method Scheimpflug method
Instrument SP-3000 Instrument ORB Instrument FA-3509 Instrument Pentacam
Noninvasive Noninvasive Noninvasive Noninvasive
Measured during surgery Corneal shape Corneal endothelium Anterior segment
analysis analysis analysis
Error between inspectors by probe Noncontact and less Noncontact and less Noncontact and less
manipulation error error error

Fig. 9.11  Z-scan curve. Image Intensity [%]

(a) Corneal endothelial
layer. (b) Corneal
100 A B C
stromal cell. (c) Corneal
epithelial layer




0 depth [mm]
0 100 200 300 400 500 600

measurement method, which can measure the to 0.65–0.75 mm. Even in the presence of normal
surgical region without depending on the position corneal thickness, corneal endothelial dysfunc-
of the patient, is useful. tion is associated with increased corneal thick-
ness, especially in the morning. If the thickness
of the cornea is 0.7 mm, it can be diagnosed as
9.5.2 Types of Pachymetry corneal endothelial cell decompensation or cor-
neal epithelial cell edema. Using an Ultrasonic Probe
The most widely used method is to place the Using a Confocal Microscope
observer perpendicular to the corneal surface to This method is performed using Z-scan (confocal
measure the exact thickness. However, it is diffi- microscopy through focusing, CMTF). Based on
cult to measure the corneal thickness if posterior the principle that each layer of the cornea emits a
corneal folding or corneal opacity is severe. At different reflective intensity, the thickness of the
the same time, the corneal center and peripheral corneal epithelium layer, the stromal layer, and
thickness cannot be measured at the same time. the entire layer can be accurately measured.
The measurement position is not known pre- When the corneal layer is measured by Z-scan,
cisely, and the cornea is depressed by contact three wavelengths are observed in the endothelial
with the cornea at a right angle within 10°, which layer (a), the area where the corneal epithelium
has a disadvantage that it affects the cornea mea- and the stromal layer meet, or the subepithelial
surement value. neural network or the corneal stromal cell (b),
The normal finding is that the cornea is trans- and the corneal epithelial layer (c). This can be
parent and has a thickness of 0.5 mm. If edema of used to measure the thickness of the cornea
the corneal epithelium occurs, it becomes thicker (Fig. 9.11).
9  Conjunctiva and Cornea Exam 121 Using an Orbscan information about the anterior segment. In other

Orbscan divides the cornea into several sections words, in addition to corneal thickness, various
along each border, with 20 tilted right and 20 information such as anterior chamber depth, ante-
tilted left, totaling 40. By using the corneal cross rior chamber angle, anterior chamber volume, and
section, the shape of the front and back faces is corneal topography are shown at once. Recently,
changed to the three-dimensional point and ana- the Galilei G6 has been introduced and used in
lyzed, and accurate information on the shape of combination with the placido method used in the
the anterior and posterior cornea is obtained, and Orbscan while using the double Scheimpflug.
the corneal thickness can be measured at the Pentacam can measure 25,000 points, while G2
same time. The thickness of the central cornea can measure 122,000 points, resulting in more
and the thickness of the peripheral cornea can be accurate images.
measured simultaneously without direct stimula-
tion of the cornea. The corneal thickness and the Using an Anterior OCT
change of state according to each part of the cor- The image of the anterior segment was imaged
nea can be measured because the state of the tear by changing the light source of OCT used in the
film can be reflected without pressing the cornea. conventional retinal disease or optic nerve dis-
The disadvantages are the focus depth error of ease using the interference pattern from 820 nm
slit-scanning method. It is important to note that to 1310  nm. A representative 1310  nm anterior
the corneal thickness may be too thin when cor- OCT system displays the anterior segment struc-
neal opacity is present or may be misdiagnosed ture as a high-resolution direct cross-sectional
as keratoconus due to abnormal protrusion of the image, which allows for in  vivo imaging and
posterior cornea. measurement of the cornea, anterior chamber,
and anterior angle including the central part of Using a Specular Microscope the lens. Furthermore, as the measurement speed
A part of the slit light reflected from the aqueous is increased and the resolution is gradually
humor is reflected from the endothelial layer of increased, the clinical application value is also
the cornea to measure the distance between the increasing.
anterior and posterior corneas, that is, the thick-
ness of the cornea. In case of contact, eye contact
should be made at the center of the cornea, and 9.6 Specular Microscope
eye anesthesia is necessary. It is difficult to mea-
sure if corneal edema or opacity is severe. The Since corneal endothelial cells play an important
morphology of corneal endothelial cells, such as role in maintaining the transparency of the cor-
cell density, mean cell area, hexagonal cell struc- nea, corneal endothelium test is one of the most
ture, and coefficient of variation, can be verified important exams in corneal transplantation.
with less deviation and reproducibility than with Currently, specular microscopy is the most com-
ultrasonography. monly used instrument for examining corneal
endothelial cells.
The specular microscope is a machine that Using a Pentacam
allows direct observation of corneal endothelial
Pentacam is based on the principle of a
cells, which can measure the density and mor-
Scheimpflug camera that rotates 360°. It has the
phology of corneal endothelial cells.
advantage of getting a clear image that is not dis-
In case of contact microscope, endothelial
torted because the depth of focus is deeper than
cells of central cornea and upper, lower, inner,
the Orbscan method. An image obtained by three-
and outer sides were observed by direct contact
dimensionally scanning the cornea from the front
with the cornea after local anesthesia. It is diffi-
of the lens to the back of the lens provides various
cult to measure the number of cells enlarged on a
122 J.-S. Lee

grid of 2 mm intervals and to calculate the aver- 9.6.2 Judgment

age value.
The use of noncontact specular microscopy When the specimen is observed under a specular
does not require anesthetic agents, and the microscope, the following values are obtained as
acquired corneal endothelial cell image is auto- the test results, and the average values are shown
matically interpreted. Therefore, the frequency of in Table 9.5.
use is gradually increasing recently. However, if
corneal stromal or epithelial edema is severe, it is Endothelial Cell Density
difficult to observe endothelial cells. The contact The density of corneal endothelial cells decreases
type is not often used because of the proficiency with age. In addition, long-term use of contact
of the examiner and the necessity of anesthesia in lenses, anterior segment diseases such as acute
the eye, but contact type is more useful in mea- glaucomatous attack, trauma, and surgery are
suring the corneal endothelial cell density in the also factors contributing to corneal endothelial
peripheral cornea. Most of the light is transmitted cell loss. In the keratoanalyzer for donor corneas,
through the corneal epithelium, while 0.02% of the endothelial cells in the central cornea are
the light is reflected between the anterior aqueous measured in principle, but in the case when the
fluid and the corneal endothelial cells, which is central portion is difficult to measure, the mea-
collected on the lens to obtain the image of the surement is performed in the periphery of the
endothelium. cornea. Measuring and averaging at multiple
Specular microscope is useful in assessing the sites can more accurately measure the condition
extent of endothelial damage after cataract sur- of the donor cornea. The lower limit of endothe-
gery and intraocular lens implantation and may lial cell density for corneal grafts may vary
be useful in assessing the status of the donor cor- depending on the medical standard or the sur-
nea in corneal transplantation. It is helpful to geon, but in general, the lower limit is 2000 cells/
observe the disappearance or change of endothe- mm2, and if it is less than 2000  cells/mm2, it is
lial cells even after corneal refractive surgery, or used only for superficial kieratoplasty. When the
ocular trauma, before or after intraocular surgery number of cells is less than 500 cells/mm2, cor-
or corneal endothelial degeneration. neal decompensation increases the incidence of
bullous keratopathy.

9.6.1 Method Average Volume of Endothelium

Basically, when the density of the corneal
Place the center of the cornea in the center of endothelial cells is high, the cell area becomes
the instrument and adjust the patient’s jaw small. When the density is low, the cell area
height. becomes large. The standard deviation shown
After focusing on the corneal endothelial on the data screen is the limit of the variation
cells using an autofocusing device, images are of the corneal endothelial cell area, MAX is the
taken. maximum cell area and MIN is the minimum
In the corneal endothelial cell image displayed cell area. The normal cell area is about 300 μm2
on the video screen, about 50–100 endothelial in adults.
cells in the central cornea are selected and ana-
lyzed through an image analysis program. The
analysis included the mean corneal endothelial Table 9.5  Mean value of normal corneal endothelial
cell density, endothelial cell area, cell surface cells
area coefficient of variation, and endothelial cell Cell density 2777–3410 cells/mm2
polymorphism (ratio of hexagonal cells). Average cell area 296–367 μm2
After analyzing the image displayed on the Hexagonality Over 55–67%
video screen, the analysis result is output. Coefficient of variation Under 0.26–0.40
9  Conjunctiva and Cornea Exam 123

Fig. 9.12 Corneal
endothelial cell findings
by specular microscopy Coefficient of Variation (CV) subject, if it is less than 60%, it is regarded as an

It is the value of the standard deviation of cell abnormal finding (Fig. 9.12).
areas/mean cell area (SD/AVE), indicating the The results of the examination of the left eye by
degree of cell polymegathism. That is, as the CV specular microscope showed that a total of 73 cells
of the corneal endothelial cell increases, the poly- were counted (NUM) and the results were inter-
megathism of endothelial cell increases, and this preted. The average cell area (AVE) is 408 μm2,
can be interpreted as a recovery process by stim- the maximum cell area (MAX) is 1017 μm2, the
ulation. In the normal subjects, CV is about minimum cell area (MIN) is 152  μm2, and the
0.25  in the 20  s and about 0.3  in the 60  s and standard deviation (SD) is 175 μm2. The corneal
when the coefficient of variation is 0.35 or more endothelial cell density (CD) was 2450 cells/mm2,
are considered abnormal values. the coefficient of variation (CV) was 0.42, and the
incidence of hexagonal cells (6A) was 49%. Hexagonality
Hexagonality is the ratio of the number of hex-
agonal cells in the number of corneal endothelial 9.7 Corneal Sensitivity Test
cells, and healthy corneal endothelial cells are
usually hexagonal in shape and almost uniform in The cornea is rich in nasociliary nerve in the first
size. However, when the corneal endothelial cell branch of the trigeminal nerve, and it plays an
disorder occurs, the corneal endothelial cell death important role in maintenance of corneal epithe-
or dislocation causes peripheral corneal endothe- lial and endothelial cell. Corneal is sensitive to
lial cells to migrate or enlarge. Consequently the corneal center 5  mm, horizontal, vertical, and
size and shape of the cells become uneven, and peripheral area. Therefore, if corneal sensitivity
the occurrence rate of hexagonal cells is of these areas is decreased, it should be consid-
decreased. ered pathological change except for changes due
Hexagonality is used as an indicator of pleo- to aging process.
morphism, which indicates the presence or The cornea distribution of the nasociliary
absence of stress on corneal endothelial cells, as nerve of the trigeminal nerve is examined for
well as the coefficient of variation. In the normal the aging process, herpes simplex, herpes zos-
124 J.-S. Lee

ter, corneal disease caused by adenovirus, cor-

neal degeneration, soft contact lens user,
cerebellar plexus tumor, and diabetic keratitis. It
is possible to confirm the degree of corneal per-
ception when there is corneal ulcer and corneal Fig. 9.13  Corneal perception meter
degeneration and to know how hard the cornea
is attached after transplantation. When the long- the patient starts to feel the end of the nylon
term contact lens is used, the sensitivity can thread, measure the length of the nylon thread.
Corneal perception is reduced in normal
aging, herpes simplex, herpes zoster, corneal dis- 9.8 Keratometry
ease caused by adenovirus, corneal degeneration,
soft contact lens user, and cerebellar plexus In addition to measuring the curvature of the cor-
tumor. nea, we can measure the quality of the surface of
the cornea.
The corneal reflex of the keratometry can be
9.7.1 Method determined by measuring the curvature radius of
the corneal surface that corresponds to the 3.0– Using a Cotton Swab 3.5  mm diameter corneal center rather than the
Let the patient look at the front and gently touch entire cornea. The principle of the test is to mea-
the cornea to instantly blink. At this time, be sure the corneal reflex images on two optical time
careful not to touch the eyelashes, and it should tables attached to the telescope while using a
be approached from the side of patient to avoid short focus lens with a low depth of focus. This
seeing the cotton swab. test is indicated by the radius of curvature (mm)
Spread the cotton at the end of the swab thinly of the cornea and the refractive index (D) of the
and long. cornea.
Let the patient’s eye see the opposite of the It is used for measurement radius curvature of
eye being examined. the cornea, astigmatism, basic curvature when
The patient’s eyelids are spread apart by the prescribing contact lenses, and lens dioptric
tester’s fingers. power when inserting an intraocular lens during
Place the end of the swab horizontally from cataract surgery.
the outside of the eye to be examined. There are two types of curvature measure-
Check the eyelid closure reflex, epiphora, and ments currently in use, manual and automatic
foreign body sensation. (see Chap. 2). Using a Corneal Perception

Meter 9.9 Corneal Topography
It is used to evaluate the sensation of the cornea
by adjusting the length of the nylon thread This is to observe and record the surface mor-
(5–60 mm). phology of the cornea in astigmatism and kerato-
The longer the length, the more sensitive the conus. The light is reflected on the cornea, and
sensation (Fig. 9.13). the degree of deformation of the cornea is photo-
Hold the instrument like a pencil. Rotate the graphed with a video camera, analyzed by com-
knob attached to the instrument, and pull the puter software, and the curvature of each part of
nylon thread long. Press the cornea vertically the cornea is displayed in various colors. This is
until the patient is able to feel the nylon thread called the topography of the cornea. The basic
touching the cornea and shorten the thread. When quad map of the corneal topography consists of
9  Conjunctiva and Cornea Exam 125

Table 9.6  Point of judgment and indication of measuring device of corneal disease
keratoscope Slit type Point of judgment
Corneal Good Good Is there any reduction in corrected visual acuity due to
transplantation irregular astigmatism?
Excimer laser Good Good Is there any asymmetry in corneal thickness or
keratectomy curvature?
Pterygium Good Considerable What is the range and degree of corneal shape change?
Corneal suture stitch Good Considerable What is the degree of mire distortion?
out What is the interpretation of asymmetric and regular
astigmatism components?

an anterior elevation map, a posterior elevation thesizing a three-dimensional slit-scanning image

map, a pachymetry map, and an axial map. The and to measure the thickness of the cornea effec-
steep face is a red color with a warm color, and tively and with high reproducibility. However,
the flat face is a blue or in green color. In order to since scanning is performed continuously for
measure the corneal topography accurately, the several seconds, it is necessary to pay special
condition of the ocular surface, tear film status, attention to decrease of reproducibility due to
the patient’s ability to watch, and the proficiency movement of the subject during the measure-
of the examiner are important. ment. Therefore, it is recommended to use the
It is measured in eyes with keratoconus, pen- slit-scanning method when information on the
etrating keratoplasty, corneal trauma, Terrien corneal thickness or the shape of the corneal pos-
marginal degeneration, pellucid marginal degen- terior surface is required. Otherwise, computer-
eration, irregular astigmatism, and before and ized video keratoscopy should be used (Table 9.6).
after corneal refractive surgery. It is performed to
evaluate the changes of corneal morphology
according to the time course. 9.9.2 Method

Place the center of the cornea in the center of the

9.9.1 Types of Corneal Topography instrument and adjust the patient’s jaw height.
To measure the patient’s right eye first, a con-
Currently, the measurement principle of the cor- centric plate is placed on the cornea of the patient,
neal topography analyzer is divided into two and the monitor shows the entire cornea of the
types. patient.
One is computerized video keratoscopy, which The examiner identifies the concentric circles
is interpreted by digitizing the reflection image reflected on the cornea through the hole in the
based on placido disc, and the other is slit-­ center of the plate.
scanning device (slit type). The corneal topogra- The focus of the corneal reflex is photo-
phy with a placido-based device has a cone or graphed, and the computer displays the curvature
hemispherical illumination device that produces of each part in multiple colors.
a ring-shaped light. The camera attached to the
computer manually or automatically obtains an
annular image that is reflected at about 10  mm 9.9.3 Judgment
from the center of the cornea.
The plaque-based method is easy to measure Corneal topography is helpful in the case of kera-
because of the short inspection time and high toconus, which is difficult to diagnose clinically
reproducibility of results. The height measure- and refractive status due to astigmatism can be
ment by the slit-scanning method can be used to seen in normal eye. Diagnosis of keratoconus
analyze the front and back of the cornea by syn- using corneal topography may vary depending on
126 J.-S. Lee

the type of measuring machine; the following posterior surface of the cornea using a slit method
sections are useful for clinical use. The video cor- and then determine the lens power after measur-
neal topography can be diagnosed as keratoconus ing the anterior chamber depth.
if the average simulated keratometry (SimK) is
45.7D, the central corneal curvature is 47.2D, Evaluation of Smoothness
and the inferior corneal I-S value is 1.4D or of Corneal Surface
higher. It can be diagnosed as keratoconus if the Corneal epithelial defect or corneal dystrophy is
central corneal curvature is greater than 47D, the inaccurate in corneal surface reflections.
central corneal curvature differs more than 1D Therefore, it is impossible to properly evaluate
from the opposite eye, and the inferior corneal the smoothness of the corneal surface due to the
steepness is more than 3D. Pentacam shows that mires distortion. If the mires distortion is
the central corneal curvature is more than 47.2D, detected, it is necessary to identify the cause and
the steepness of the inferior cornea is more than treat it accordingly.
1.2D, SimK astigmatism is more than 1.5D, and
skewed radial axes (SRAX) is greater than 21,
and it can be diagnosed as keratoconus (Fig. 9.14). 9.10 Wavefront Aberrometry Quantification of Regular The wavefront aberrometer is an automated,

and Irregular Astigmatism objective instrument that measures the imperfec-
It is necessary to evaluate the optical performance tion of an ocular optical system more precisely
of the cornea by corneal topography before sur- than the wavelength of light. We expected good
gery in keratoconus. When the corneal abnormal- visual outcome after correcting refractive error.
ity is so severe that the distortion of the mire is But, although refractive errors are minor after
too large or the evaluation in the color code map refractive surgery or cataract surgery, patients
is difficult, it is preferable to refer to the image present with complaints of glare, halo, light
data of the mire or to evaluate the corneal status stretching, and poor visual quality due to mon-
using a photokeratoscope. After surgery, it is ocular diplopia. The concept that can explain this
advisable to partially stitch out by reevaluating is wavefront aberration. When the rays from one
the shape of the cornea due to the suture effect. point do not gather at one point, the image is
blurred and distorted, and the top surface is not Corneal Thickness flat, which means aberration. The aberration is
A slit-type examination is required to measure divided into chromatic aberration and monochro-
corneal thickness. In order to prevent keratoecta- matic aberration. Currently commercially avail-
sia by excimer laser surgery, it is recommended able wavefront aberration was developed to
to check whether there is any asymmetry in the measure monochromatic aberrations. Wavefront
shape of the posterior surface of cornea or the aberrations consist of lower-order aberrations
corneal thickness distribution by automatic diag- corrected with spherical or cylindrical lenses,
nostic program with built-in video keratoscope. such as myopia, hyperopia, and astigmatism, and
higher-order aberrations that are not corrected. Corneal Refractive Power Depending on the method of measuring the
When excimer laser surgery is performed, the wavefront aberration, there are several types
curvature of the anteroposterior surface of the (Table 9.7).
cornea changes, and corneal irregular astigma- The Hartmann-Shack method is an analyzing
tism occurs. Therefore, it is not possible to accu- light reflected from the center of the retina.
rately evaluate the corneal refractive power only Tscherning, ray tracing, and OPD scan methods
by measuring the automatic corneal refractome- are analyzing the image pattern on the retina
ter. In this case, it is better to measure the antero- itself.
9  Conjunctiva and Cornea Exam 127

Fig. 9.14 Corneal
topographic quadrant
maps. Sagittal curvature,
elevation (front and
back), corneal thickness
map. a is normal cornea,
b shows keratoconus
with posterior elevation

128 J.-S. Lee

Table 9.7  Wavefront aberrometry according to measure- ously known order aberrations with special func-
ment principle tions. There are three ways to refer to each
Type Product name Manufacture company Zernike polynomial, denoted by order, name, and
Hartmann-­ KR-1 W® Topcon number (Fig. 9.15).
Shack WaveScan™ Abbott The wavefront aberration is classified into pis-
Tscherning WaveLight® Alcon ton, tilt, defocus, astigmatism, coma, and spheri-
Ray tracing i-trace® Tracey Technology
cal aberration. The piston is a zero-order
Galilei™G6 Zeimer
OPD scan OPD scan Nidek
aberration with a constant phase shift, and tilt is
III® tilted with respect to the x- and y-axes as the first-­
order aberration. Defocus and astigmatism cor-
respond to the second-order aberration with the
9.10.1 Method
least aberration of the actual aberrations and can
be corrected with spherical and cylindrical lenses.
Place the center of the cornea in the center of the
Higher-order aberrations are called higher orders,
instrument, and adjust the patient’s jaw height.
coma and trefoil corresponding to the third-order
Let the patient look at the red light in the cen-
aberrations, and spherical aberration, quatrefoil,
ter of the laser. Scan the eye by projecting 256
and secondary astigmatism corresponding to the
fourth-order aberrations.
We analyze wavefront aberration considering
color code, Zernike polynomial aberration, root Zernike Coefficients
mean square, retinal image quality, and pupil
and RMS (Root Mean Square)
We use the Zernike coefficient and the root mean
square (RMS) as a measure of order intensity. In
9.10.2 Judgment the case of defocus and astigmatism as second-­
order aberrations, the intensity is expressed using
The third and fifth orders in the high-order aber- diopter. The unit for the third-order higher-order
ration are asymmetric aberrations, and the fourth aberration is the root mean square (RMS) associ-
order and sixth order are symmetric aberrations. ated with the Zernike coefficient.
The third-order coma aberration and the fourth-
order spherical aberration can be checked first,
and the remaining aberrations can be referred to. 9.11 Confocal Microscopy I nterpretation of Color Code It has a high resolution of about 1.4 times higher
Map than that of conventional optical microscopes,
It is useful to know the meaning of color in the has a deep focal depth, and is capable of various
wavefront aberration map such as the various col- images processing using a computer. Usually, the
ors provide information to one eye in corneal reason why the image is blurred in the optical
topography. The main aberration of the eye, that microscope is that the light other than the focal
is, the refractive power, can be known through the plane is not processed by the illumination pro-
total wavefront aberration map. The blue color is cess. However, the confocal microscope is capa-
myopia, the color of the red is hyperopia, and the ble of three-dimensional observations of
color of green is close to the emmetropia. relatively thick materials and living cells that
were difficult to observe with conventional Zernike Polynomials microscopes until now.
and Naming of Aberrations Light from the light source is emitted and
It is a polynomial introduced to efficiently compressed by the objective lens and then irradi-
express the wavefront aberration and a standard ated onto the sample. At this time, the laser light
form of wavefront aberration using a function. It is compressed to a small point through the objec-
is designed to correspond well with the previ- tive lens again by the reflected light coming from
9  Conjunctiva and Cornea Exam 129

Piston: Z(0,0)

Tilt: Z(1,–1) Tilt: Z(1,1)

Astigmatism: Z(2,–2) Defocus: Z(2,0) Astigmatism: Z(2,2)

Trefoil: Z(3,–3) Coma: Z(3,–1) Coma: Z(3,1) Trefoil: Z(3,3)

Tetrafoil: Z(4,–4) Astigmatism: Z(4,–2) Spherical: Z(4,0) Astigmatism: Z(4,2) Tetrafoil: Z(4,4)

Pentafoil: Z(5,–5) Trefoil: Z(5,–3) Coma: Z(5,–1) Coma: Z(5,1) Trefoil: Z(5,3) Pentafoil: Z(5,5)

Hexafoil: Z(6,–6) Tetrafoil: Z(6,–4) Astigmatism: Z(6,–2) Spherical: Z(6,0) Astigmatism: Z(6,2) Tetrafoil: Z(6,4) Hexafoil: Z(6,6)

Fig. 9.15  Zernike Pyramid Periodic Table. Each Zernike polynomial is denoted by order, name, and number

the sample in the compression focus, only the epithelium and endothelial layer of the cornea
light of the face that is exactly in focus is passed and imaging the tissue 3–4 times. The shape of
through the position. Since the image is electri- the cell can be known through the necessary
cally signalized, image processing such as image images or information. Using a Z-scan, the thick-
quantification by a computer, stereoscopic recon- ness of the cornea can be measured by focusing
struction such as contrast, and overlapping of on the whole cornea.
images can be facilitated. It mainly consists of a
light source, a microscope, a computer for con-
trol analysis, and a monitor. 9.11.2 Judgment
It is useful to diagnose normal corneal struc-
ture, wound healing process after corneal refrac- In the corneal epithelium of normal subjects, epi-
tive surgery, effect of contact lens, abnormality of thelial surface cells with bright nuclei (Fig. 9.16)
tear film, keratoconus, corneal dystrophy, acan- (a), wing cells with constant cell boundaries (b),
thamoeba keratitis, herpes keratitis, corneal and nerve plexus under the epithelial layer (c)
trauma, and drug toxicity to the cornea. were observed. In Bowman’s membrane, there is
a wrinkle-like shade.
The anterior part of the corneal stromal cell
9.11.1 Method layer shows a nuclear morphology of the poly-
gon. In the middle region, the distribution of
Place the center of the cornea in the center of the nerves appears (d). The closer to the endothelial
instrument, and adjust the patient’s jaw height. cell layer, the more prominent a nucleus in the
First, 2% proparacaine is applied to the eyes, parenchymal layer of the posterior cornea. The
and immersion gel is applied to the end of the tip endothelial cell layer has a hexagonal monolayer
to contact the cornea. Automatically moving the of endothelial cells (e).
130 J.-S. Lee

a b

c d

Fig. 9.16  Confocal microscopy of normal cornea. (a) Corneal epithelium surface layer. (b) Wing cell layer. (c)
Subepithelial nerve plexus. (d) Corneal stroma. (e) Corneal endothelial layer

In the case of posterior polymorphous corneal behind the stromal layer (Fig. 9.17b) can be seen.
dystrophy, abnormalities of the Descemet’s The nerve plexus distributed in the corneal tissue
membrane and corneal endothelial layer of the is thickened. In the case of corneal endothelial
cornea are the main lesions. A band- or blister-­ cells, pleomorphism is not a typical form, but
like hyporeflective image with a diameter of polymegathism is a common confocal micro-
6–159 μm is observed in the posterior part of the scopic finding.
corneal tissue. Band-like lesions on adjacent cor- In Fuchs’ corneal dystrophy, the lesion is the
neal endothelial cells (Fig. 9.17a) and the lesion corneal endothelial cell layer, and abnormal
9  Conjunctiva and Cornea Exam 131

a b

Fig. 9.17  Confocal microscopy of posterior polymorphic corneal dystrophy. (a) Corneal endothelial layer. (b) Posterior
corneal stroma

a b

c d

Fig. 9.18  Confocal microscopy in Fuchs’ corneal dystrophy. (a) Subepithelial nerve plexus. (b) Anterior corneal
stroma. (c) Posterior corneal stroma. (d) Guttata of corneal endothelium

findings are observed mainly in the corneal pos- thicker than normal (Fig. 9.18a), dense granular
terior pole and endothelial cell layer. Corneal form was observed sporadically, and a wrinkled
epithelium is normal finding, but nerve plexus form on the vertical line was observed in some
of anterior portion of the corneal stroma is cases (b). The corrugation shape becomes
132 J.-S. Lee

a c

Fig. 9.19  Confocal microscopy of keratoconus. (a) Subepithelial nerve plexus. (b) Bowman membrane. (c) Corneal
stroma near the Descemet’s membrane

clearer toward the posterior pole of the corneal 9.12 Fluorophotometry

stroma (c), and corneal endothelium shows gut-
tata (d). In the case of using a fluorophotometry, it is pos-
Confocal microscopic findings of the keratoco- sible to measure the degree of damage to the func-
nus show that the surface of the corneal epithelium tional barrier function of corneal endothelial cells
is somewhat obscure and elongated shape, and the which cannot be observed by clinical examination
nerves subepithelial layer of the wing cell layer are or a specular microscope. That is, the endothelial
somewhat thicker than normal (Fig.  9.19a). cell damage and recovery process, which is not
Bowman’s membrane shows a dark shadow of correlation to morphological or functional dam-
larger shape than a normal wrinkled structure. age, may be determined by measuring the perme-
That is, the ruptured form of the Bowman’s mem- ability of the corneal endothelial cells. The
brane (b). In the corneal parenchymal cells, near method of evaluating corneal permeability with a
the epithelial layer, the shade of the nucleus fluorophotometry using a fluorescent material is
increases, the cell boundary becomes unclear, and highly reliable and can provide quantitative mea-
the reflectivity increases in the parenchyma area. surement of the function of the tight junction
The shape of the nucleus becomes clearer toward between the corneal endothelial cells, thus pro-
the deep part, while as the number of cells viding valuable information related to the corneal
decreases, vertical line of Vogt’s striae are observed layer. However, the spatial resolution for distin-
around the Descemet membrane (c). However, the guishing the fluorescence of the cornea and the
endothelial cell layer maintains a normal hexago- tear layer is insufficient and takes a long time for
nal mosaic shape without any significant change, measurement. There is also a disadvantage that
and no unusual changes are seen. the change in barrier function of the periphery of
9  Conjunctiva and Cornea Exam 133

the cornea cannot be measured. In addition, ract surgery increased by 61.88% in normal
depending on the amount of tear film or concen- subjects but increased by 118.13% in patients
tration of fluorescent material, which varies from with diabetes, and the corneal permeability was
person to person, the measured value according to significantly increased in diabetic patients.
the corneal permeability increases, resulting in a
large standard deviation. For those with low per-
meability, it is advisable to increase the concen- 9.12.1 Meibomian Gland
tration of the fluorescent eye drops to increase the Dysfunction (MGD)
fluorescence of the cornea to a measurable extent. Assessment
This is useful for confirming changes in barrier
function of corneal epithelium and endothelium Meibomian glands secrete oily components called
following wound healing process after corneal meibum that form the lipid layer of the tear film.
refractive surgery, changes in blood aqueous bar- The lipid layer of the tear film prevents evapora-
rier after cataract surgery, follow-up of intraocular tion of the tear fluid, and thus meibomian gland
surgery, and response of blood aqueous barrier to dysfunction (MGD) mainly causes evaporative dry
drugs for inflammation treatment. eye. So It is important to adequate evaluate the
To measure the endothelial permeability of the morphology and function of meibomian glands.
cornea, 50  μl of 10% fluorescent material was
applied to the lower conjunctival sac four times at Lid Margin Telangiectasia
intervals of 5 min, and the fluorescence intensity (LMT) Score
of the corneal stroma and the anterior chamber There are about 30–40 glands in upper lid margin
was measured using a fluorophotometry. To mea- and fewer (20–40) in the lower lid margin, and the
sure the permeability of the epithelium layer, vascular zone, which can be observed with telan-
20 μl of 2% fluorescence was applied to the lower giectasia, is the zone from the mucocutaneous
conjunctival sac, and the corneal fluorescence junction near the meibomian gland orifice to the
was measured 45 minutes later. eyelash root. It is easier to observe the telangiecta-
This is a method of examining the permeabil- sia in the upper because the vascular zone in the
ity of corneal endothelial cells by measuring the upper eyelid is wider than in the lower eyelid. The
exchange of fluorescent materials between the LMT was scored based on the degree of telangiec-
cornea and the aqueous humor; the mean corneal tasia at the upper eyelid margin, with 0 point in the
endothelium permeability was measured as absence of capillary dilatation, 1 point in the case
3.48 × 10−3/min in normal and 3.75 × 10−3/min in of mild capillary dilatation, 2 points in the case of
the presence of diabetes. The corneal endothe- moderate capillary dilatation, and severe capillary
lium permeability measured at 4 days post-cata- dilatation defined as 3 points (Fig. 9.20).

a b

c d

Fig. 9.20  Upper lid margin telangiectasia score. a shows no mild capillary dilatation. c shows moderate capillary dilata-
capillary dilatation as 0 point. b shows 1 point in the case of tion as 2 points. d shows severe capillary dilatation as 3 points
134 J.-S. Lee M  eibomian Gland Secretion whether it is partial or complete loss of meibo-

(MGS) Score mian glands for each eyelid. In patients with
For measurement of MGS, we pressed softly skin MGD, the meiboscore was useful for diagnosing
and palpable conjunctiva near the center of upper MGD.
lid margin using a sterilized cotton swab. MGS is
defined as 0 point for secretion of clear secretion, Interferometry
1 point for turbid secretion, 2 points for granular Interferometry of the tear film lipid layer is useful
secretion, and 3 points for solid form secretion in screening and evaluating dry eye. It allows
from meibomian orifice (Fig. 9.21). noninvasive grading of the tear film lipid layer
and estimation of its thickness on the basis of the Meibography observed interference colors.
Meibography is a technique that uses transillumi- The LipiView Interferometer compensates for
nation biomicroscopy of the everted eyelid with lid thickness variations providing a normalized
infrared imaging. This noninvasive meibography and uniform brightness across the surface. It is a
system enabled us to observe the entire meibo- highly accurate instrument initially developed to
mian gland, from the nasal part to the temporal precisely measure tear lipid layer thickness. Then
part of the upper and lower eyelids within 1 min. it calculated on a frame-by-frame basis and plot-
A slit-lamp microscope equipped with a charge- ted for ~1 billion data points per eye. The results
coupled device camera and infrared-pass filter are then displayed and are available for printout
visualized the meibomian gland as a bright area. (Fig. 9.24).
The normal appearance of the meibomian glands It also enables practitioners to evaluate blink
using this technique is shown in Fig. 9.22. characteristics such as blink rate and the presence
This system clearly evaluates various morpho- of incomplete blink. The most recent version of
logical changes in meibomian glands such as the system has added a high-resolution infrared
dropout, truncation, dilation, or distortion related meibography component. Although most often
to ocular surface diseases (Fig.  9.23). It can be used in combination with the therapeutic
classified, so-called meiboscore, according to LipiFlow system, LipiView is now available as a

a b

c d

Fig. 9.21  a is clear meibum secretion which is defined as 0 point. b shows turbid meibum secretion as 1 point. c is 2
points for granular secretion. d shows 3 points for solid, tooth paste-type meibum secretion
9  Conjunctiva and Cornea Exam 135

Fig. 9.22  The meibography system and normal appearance of the meibomian glands of lower lid using noninvasive
meibography (white arrows)

a b

Fig. 9.23  a shows meibomian glands dropout (white arrows) and b shows gland truncation (black arrows) with duct
dilatation (white arrows head)

Fig. 9.24  LipiView results are displayed in a frame-by-frame graphical representation that shows fluctuations in lipid
thickness measurements between each blink

standalone diagnostic instrument. The system dilation plus gland atrophy and dropout, which
utilizes interferometry to measure lipid layer are common to MGD.
thickness down to the submicron level of accu- Dynamic changes in the interference pattern
racy. It further incorporates what the manufac- have also been studied. Figure  9.25 illustrates
turer terms dynamic meibomian imaging (DMI) the interferometric patterns recorded using the
to produce detailed images of the meibomian tear interferometer. These techniques have been
glands in order to demonstrate ductal gland used to measure tear lipid film thickness in nor-
136 J.-S. Lee

a b

Average LLT: 100+ nm Partial Blinks: 1 / 9 Average LLT: 3-9 nm Partial Blinks: 12 / 13
Maximum LLT: 100+ nm @ frame 362 CFactor: 0.99 Maximum LLT: 6-8 nm @ frame 553 CFactor: 1.00
Minimum LLT: 99 nm @ frame 539 Standard Dev: 10 Minimum LLT: 3-3 nm @ frame Standard Dev: 6
Lipid Thickness (nm)

Lipid Thickness (nm)

100 100
75 75
50 50
25 25
0 0
0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20
Time (sec) Time (sec)

Fig. 9.25  Tear lipid layer thickness patterns as seen with interferometry. a is normal tear film lipid thickness that is
over 100 nm. b shows lack of lipid layer, its lipid thickness under 40 nm

mal subjects and in disease, with fairly good Foulks GN, Bron AJ.  Meibomian gland dysfunction: a
agreement between investigators. The simplic- clinical scheme for description, diagnosis, classifica-
tion, and grading. Ocul Surf. 2003;1(3):107–26.
ity and noninvasiveness of interferometry and Kim J, Foulks GN. Evaluation of the effect of lissamine
its direct relationship to the amount of lipid on green and rose Bengal on human corneal epithelial
the tear film make it an attractive technique that cells. Cornea. 1999;18(3):328–32.
may offer opportunities to relate lipid thickness Kitzmann AS, Winter EJ, Nau CB, et al. Comparison of
corneal endothelial cell images from a noncontact
to evaporation. The tear interferometer patterns specular microscope and a scanning confocal micro-
are characterized by lack of the aqueous layer, scope. Cornea. 2005;24(8):980–4.
lack of both the aqueous and lipid layers, and a Klais CM, Buhren J, Kohnen T.  Comparison of endo-
lack of the lipid layers. Therefore, the evalua- thelial cell count using confocal and contact specular
microscopy. Ophthalmologica. 2003;217:99–103.
tion of the function using them is considered to Langston DP, Foulk GN.  Cornea and external disease.
be more reliable than the simple lipid layer Boston: Little Brown; 1991.
thickness. Maeda N, Klyce SD, Smolek MK, et al. Automated kera-
toconus screening with corneal topography analysis.
Invest Ophthalmol Vis Sci. 1994;35:2749–57.
Mannis MJ, Holland EJ.  Cornea. 4th ed. Philadelphia:
Suggested Reading Elsevier; 2005.
Mathers WD, Daley T, Verdick R.  Video imaging of
Arita R, Suehiro J, Haraguchi T, et al. Topical diquafosol the meibomian gland [letter]. Arch Ophthalmol.
for patients with obstructive meibomian gland dys- 1994;112(4):448–9.
function. Br J Ophthalmol. 2013;97(6):725–9. Mishima S.  Corneal thickness. Surv Ophthalmol.
Benson WH, Lanier JD.  Comparison of techniques 1968;13:57–96.
for culturing corneal ulcers. Ophthalmology. Nemoto Y, Arita R, Mizota A, et  al. Differentiation
1992;99:800–4. between chalazion and sebaceous carcinoma
Bourne WM, Kaufman HE.  Specular microscopy of by noninvasive meibography. Clin Ophthalmol.
human corneal endothelium in vivo. Am J Ophthalmol. 2014;8:1869–75.
1976;81(3):319–23. Spencer W, Zimmerman L.  Conjunctiva. Philadelphia:
Cavanagh HD, Shields W, Jester JV, et  al. Confocal WB Saunders; 1985.
microscopy of the living eye. CLAO J. 1990;16:65–73. Swartz T, Marten L, Wang M. Measuring the cornea: the
Dingeldein SA, Klyce SD. The topography of normal cor- latest developments in corneal topography. Curr Opin
neas. Arch Ophthalmol. 1989;107:512. Ophthalmol. 2007;18:325–33.
Feenstr RPG, Tseng SCG.  Comparison of fluores- Wise RJ, Sobel RK, Allen RC.  Meibography: a review
cein and rose Bengal staining. Ophthalmology. of techniques and technologies. Saudi J Ophthalmol.
1992;99:605–17. 2012;26(4):349–56.
Pupil Exam
Jae Ho Jung

Pupil light  reflex is a reflex that controls the goes up again to the superior cervical ganglion
diameter of the pupil, in response to light stimu- and travels along the internal carotid artery;
lus. A  higher  intensity of light makes mio- finally, it reaches into the cavernosu sinus. It
sis (pupil constriction), whereas a lower intensity travels along the abducens nerve in the cavern-
makes mydriasis (pupil dilatation). Neural path- ous sinus and next travels along the nasociliary
wau of pupil reflex is composed of afferent fibers nerve which is the first branch of the trigeminal
from the retina to the Edinger-Westphal (EW) nerve. Then, it becomes the long ciliary nerve
nucleus of the oculomotor nucleus and efferent and distributes to the pupil dilator muscle and
fibers from the EW nucleus to the pupillary induces pupil dilation (Fig. 10.1).
sphincter. The afferent fibers travel through the   Before testing pupils, the patient should be
retina, optic nerve, optic chiasm, and optic radia- instructed to remove patient's glasses. Examiner
tion and are separated before lateral geniculate has to make a relexed and comportable enviro-
nucleus and connected to EW nucleus in the dor- ment. A distant, non-accommodative target two to
somedial side of the oculomotor nucleus three lines larger than the patient's uncorrected
complex. visual acuity should be used as target. If a target is
Efferent fibers are divided into parasympa- too small for the patient might use accommoda-
thetic pathways and sympathetic pathways. The tion, with assocaited with pupillary constriction.
parasympathetic pathway starts from the EW This accommodation may contaminate test
nucleus and travels along with the oculomotor results.
nerve fibers, and after making a synapse at cili-
ary ganglion, it becomes a short posterior cili-
ary nerve and distributes to the pupil sphincter 10.1 E
 xamination of Pupil Shape,
and ciliary muscle which are responsible for Size, and Location
inducing pupil contraction. The sympathetic
pathway started from the hypothalamus and 10.1.1 Methods
goes down to the level of the eighth cervical
vertebrae and the second thoracic vertebrae • First, the red reflex provided by from the
along the spinal cord through the midbrain, direct ophthlamopscope can be useful when
pons, medulla, and lateral tegmentum. And it comparing the two eyes, also helpful evaluate
general shape, size and location of pupil.
• Although pupil testing using direct ophthal-
J. H. Jung, MD., PhD. (*)
Department of Ophthalmology, Seoul National moscope or pupillometer provides gross
University College of Medicine, Seoul, South Korea

© Springer Nature Singapore Pte Ltd. 2019 137

J.-S. Lee (ed.), Primary Eye Examination,
138 J. H. Jung

observations, the slit lamp cab ne hlepful to ­pupillometer (Fig. 10.2). To avoid stimulating

exmine the pupil and iris in more detail. accommodative pupil constriction, the pupil-
• Measurment of pupil size should be under ometer should be held away from the visual
normal room light conditions to the nearest axis of the patient.
0.5  mm using a millimeter ruler or Haab

Optic nerve

Ciliary body ganglion

Oculomotor nerve
Optic tract
Red nucleus

Lateral geniculate

EW nucleus EW nucleus

Pretectal nucleus
EW nucleus
Optic nerve

Oculomotor nerve Ciliary body ganglion Pupil sphincter

Trigeminal ganglion

Fig. 10.1  Pupil light reflex pathway. (a) Pupil light reflex. (b) Parasympathetic pathway of the pupil sphincter. (c)
Sympathetic pathway of the pupil dilator
10  Pupil Exam 139

c Ophthalmic a.
Lacrimal gland

Midbrain Nasociliarv n.
Pupillary dilator m.
oblongata Subclavian a. ECA

Ciliosoinal Superior cervical

center ganglia

sympathetic roots

Fig. 10.1 (continued)

Fig. 10.2  Haab pupillometer

10.1.2 Results substance with iron is in the iris, the color turns
into brown.
The normal pupil diameter is 2–4 mm, and it is
defined as anisocoria when the pupil diameter is
4 mm or more and the pupil contraction is 2 mm 10.2 Pupillary Reaction Test
or less. The difference between both pupils is
within 1.0 mm. The iris (iris crypt) or iris collar- 10.2.1 Anisocoria test
ette should be clearly visible and should be sus-
pected of corneal opacity, anterior inflammation, Observing the difference in  pupil size between
and iris atrophy if not visible. If the color of the the two eyes under dim light and bright light.
bilateral iris is different, the congenital anomalies
of the dilated muscles such as heterochromia of Methods
iris, uveitis, tumor, or congenital Horner’s syn- • Let the patient see the distant target under
drome should be suspected. When the foreign normal room light. 
140 J. H. Jung

• Change room light intensity, and observe any Methods

puil  size difference occur  under dim light or Direct pupillary  reaction to light.  Observing a
bright light. pupil’s direct and consensual responses to light,
the test should be performed under normal to dim Results illumination with fixing the distance non-
20 percent of normal had physiologic pupil size accommodative target.
difference, the difference less than 1.0  mm. Indirect pupillary reaction to lgiht.
However, the different pupil size should be Evaluate  consensual response of  pupil constric-
addressed pathologic in nature or pharmacologic tion in the oppsitie eye. Direct and indirect pupil-
etiology. If the amount of anisocoria is the same lary light reaction (Fig. 10.4).
in both the bright light and the dim light, then the
anisocoria os physiologic. If there is greater • Each  procedures should be repeated several
anisocoria in the bright light, the larger pupil is times and in the other eye, while observing
not constrict, examiner should consider parasym- and grading the magnitude of changes and
pathetic pupil proble. However, there is a greater rapidity of change. The responses are recorded
amount of anisocoria in the dim light, possible as  grade 4 (prompt response) to 1 (delayed
causes should be address syspathetic nerve issue, response sluggish) and observing whether the
such as Horner’s syndrome. Each disease has degree of pupil contraction is complete or
characteristic pupil changes according to illumi- incomplete.
nation (Fig. 10.3, Table 10.1). Results
By the pupil’s reaction, we can see whether the
10.2.2 Pupillary reaction to light test disorder of visual pathway is afferent or effer-
ent. The normal response is when the light is
The pupillary light reflex consists of both an shined, the pupil is contracted, and then the
afferent and efferent pathway. Under normal con- pupil dilates slowly. In the presence of an affer-
ditions, when light is placed into one eye, pupil ent pupillary movement disorder, if the light is
will constrict and a consensual pupil constriction reflected in the eye with disorder, the pupil con-
in the oppsite eye. traction does not occur due to the disappear-

Fig. 10.3 Pupil a Dim Light Bright Light

anisocoria in dim and
bright light condition.
(a) Physiologic. (b)
Horner’s syndrome on
the right eye. (c) Third
nerve palsy on the right

10  Pupil Exam 141

Table 10.1  Common causes of anisocoria and its differential diagnosis

Pupillary dilator Tonic pupil (early) Third nerve palsy Horner’s syndrome
In normal light

Dim light

Bright light


Pilocarpine Delay response

2% pilocarpine 2% pilocarpine
0.125% pilocarpine
Other features Pupillary spasm Exotropia ptosis Partial ptosis
Loss of tendon reflex pain (sometimes)

a b 10.2.3 Swinging Flashlight Test

The purpose of the swinging flashlight test is to

compare the strength of the direct pupillary
response with that of the consensual response in
the same eye. Methods
• In a half-dark room, let the patient watch over
a distance non-accommodative target. 
• The light beam is directed in the right eye and
held for two ~ three seconds, then qucikly
moved to the left eye and held for two ~ three
seconds. This procedure should be repetaed
for at least three to four cycles. When moving
the light beam between the eyes, use a slight
u-shaped motion, making sure to avoid the
transilluminator crossing the patient’s visual
Fig. 10.4  Test Method of pupillary reaction to light. (a) axis, which may stimulate accommodation. It
Direct light reflex. (b) Indirect light reflex is critical that the magnitude, angle and dura-
tion of the light be kept the equal for each eye
ance of the direct and indirect reflex. But direct (Fig. 10.6).
and indirect reflexes of the pupil occur when
the light reflects in the normal eye. In these Results
cases, one eye suspects extensive retinal dis- It is an objective and sensitive test that can detect
ease or optic nerve disease. In the presence of the difference  of afferent visual  transduc-
an efferent pupil movement disorder, both tion between the left eye and the right eye. A rela-
direct and indirect reflexes within the eye with tive afferent pupillary movement disorder is
disorder are lost or reduced (Fig. 10.5). defined as a pupillary escape in which abnormal
142 J. H. Jung

a b c

Fig. 10.5  Interpretation of the light reflex test. (a) Normal. (b) Abnormal efferent pupil movement (left eye). (c)
Abnormal afferent pupil movement (left eye)

pupil dilation occurs when an abnormal pupil is pare the progress in patients who are not able to
alternately illuminated within the normal pupil. It perform visual field tests or in patients who are
is important to observe pupillary reaction time being treated. In addition, amblyopia patients
and compare the difference in pupillary reaction with RAPD with 0.6 log units or more are more
between the two eyes. At this time, the abnormal likely to have underlying disease and are useful
eye is denoted by RAPD (+). In this case, visual in distinguishing ischemic or nonischemic cen-
pathway disturbance before the lateral geniculate tral retinal vein occlusion. Another way is to use
nucleus is strongly suspected, and sometimes it ten neutral density filters arranged in a circle on a
can be observed even in a variety of retinal disor- plastic sheet. A patient’s visual acuity is not nec-
ders or amblyopia. essarily correlate with the degree of RAPD, how-
Among the quantitative evaluation methods ever it has correlation with visual field. RAPD do
of relative afferent pupillary movement disor- not cause anisocoria.
der, there is a method using neutral density fil-
ters. After the diagnosis of relative afferent
pupillary movement disorder by alternate light 10.3 Near Reflex
test, the neutral filter was sequentially added to and Accommodation
the normal eye by 0.3 log unit neutral density
(ND filter), and alternate light test is performed Convergence, accommodation, and pupil con-
until the relative afferent pupillary movement striction occur together when we look at the near
disorder disappeared. Observe whether there is object. So we can observe the pupil shape with
a defect. this principle. The test method is to observe
A neutral filter between 0.1 log unit and 2.0 whether pupil contraction occurs or not when the
log unit is most useful. The use of a neutral filter patient first looks at distant object and then looks
allows quantification of afferent pupillary dys- at the near 20  cm object (Table  10.2). This  is
function and is consistent with the results of rarely added to routine pupil test becuase the near
visual field tests. Therefore, it is possible to com- reflex is always present when the direct light
10  Pupil Exam 143

Fig. 10.6 Swinging affected eye normal eye

flashlight test

5 mm 5 mm

constriction 4 mm

constriction 2 mm

dilation 4 mm

Table 10.2  Causes of light near dissociation

Cause Location Mechanism
Loss of afferent light reflex Anterior optic tract (the Damage of the retina or optic tract
retina, optic nerve, optic
Loss of light reflex to the Midbrain tectum Infection (Argyll-Robertson pupil)
pretectal area of EW
Tonic pupil Ciliary ganglion Aberrant regeneration of pupillary sphincter by
control neuron
PRP, cryotherapy, orbital Short ciliary nerve, Aberrant regeneration after damage of the short
surgery post-ciliary ganglion ciliary nerve or post-ciliary nerve
Third nerve aberrant Third nerve tract Aberrant regeneration of pupillary sphincter by
regeneration control neuron or EOM neuron
Peripheral neuropathy Short ciliary nerve, Axonal loss
post-ciliary nerve, ciliary
144 J. H. Jung

reflex is intact. In other words, if a normal direct 10.4.2 10% Cocaine

reaction to light is observed, then there is no need
to checl the near response.  Light-near dissocia- It is used for the diagnosis of Horner’s syndrome.
tion is a phenomenon in which pupil contraction It enlarges the pupil in the normal state but does
occurs more strongly in the near reflex than in the not enlarge the pupil in Horner’s syndrome. The
light reflex, because the reflex nerve is located mechanism is that 90% of norepinephrine (NE) is
more ventral than the reflex nerve. reabsorbed in neuronal synapses, and cocaine
increases this reabsorption and induces pupil
10.3.1 Methods

Have the patient look at distant places at normal 10.4.3 1% Hydroxyamphetamine
Have the patient watch closely the target (pen- It is used to differentiate between preganglionic
cil or examiner’s fingers), slightly below the and postganglionic cause of Horner’s syndrome.
examiner’s eye level, toward the patient. Or pull Pupil enlargement occurs in Horner’s syndrome
the patient’s fingers forward from a distance to with preganglionic cause. There is no pupillary
observe the rate and degree of pupil contraction. response in Horner’s syndrome with postgangli-
Do not use lights at this time. onic cause. The norepinephrine in the pregangli-
It is inspected and recorded several times. If it onic nerve secretion induced by 1%
is difficult to judge the contraction of the pupil, hydroxyamphetamine leads to pupil dilation. The
observe the process of returning to the pupil pupil enlarges in Horner’s syndrome with pre-
enlargement by moving the gaze to the distant ganglionic because neurotransmission is
target after watching the near distance. possible.

10.3.2 Results 10.4.4 0.5% Apraclonidine (Iopidine)

Light-near dissociation can be observed in the The alpha 2 antagonist apraclonidine can be
tonic pupil, Parinaud’s syndrome, pineal gland used for the diagnosis of Horner’s syndrome. It
tumors, and Argyll-Robertson pupil, and all the helps to diagnose by using alpha 1 receptor
light and near reflex will disappear in diabetes, antagonistic effect rather than alpha 2 antagonis-
Miller Fisher syndrome, Botox, paraneoplastic tic effect.
syndrome, etc. It has a similar positive rate to that of cocaine
test, and reaction occurs in the patients with
Horner’s syndrome. When 0.5% apraclonidine is
10.4 Drug Test administered, the pupil contracted by Horner’s
syndrome becomes larger than the pupil size of
10.4.1 0.1% Pilocarpine the normal contralateral eye. In addition, the pto-
sis disappears, and the inversion phenomenon
It is used to diagnose Adie’s tonic pupil and occurs which the abnormal eyelid height becomes
pupil contraction. When examined 30 min after higher than that of the normal eye. It has become
administration, the pupil contraction does not a standard test for the diagnosis of Horner’s syn-
occur in the normal eye, but the pupil contraction drome and is also used as a medication for
occurs in the tonic pupil. This is due to an over- Horner’s syndrome. However, do not use into
sensitivity of the eye by the parasympathetic newborns or patients allergic to clonidine drugs
stimulant. (Table 10.3).
Table 10.3  Anisocoria diagnosis
Response to the Response to
light and near the pupil Response to the pupil Response to other
Clinical diagnosis General characteristics Neuroanatomy reflex Anisocoria dilator constrictor drugs
Pysiologic Round and regular Positive, normal Both No change Dilation Constriction Normal
10  Pupil Exam

Traumatic iris Irregular pupil margin, iris atrophy Pupil Vary depending Dilated by Dilation Various degree of NA
sphincter muscle on the degree of the light constriction may
damage occure
RAPD Round and regular, + on swinging Anterior visula More consensual No Dilation Constriction Normal
flashlight test pathway disease  to the light and response
near reflex
Dorsal midbrain Intermediate dilation on both eye Dorsal midbrain Less on light, No Dilation Constriction NA
syndrome more on near response
Tonic pupil Insidious pupil dilation and finally Ciliary ganglion No light reflex, Increased in Dilation Constriction Constriction on
(Adie’s pupil) constriction (sector pupil palsy, tonic to near, bright light 0.125%
vermiform movement) tonic redilation pilocarpine
Dilated by the Unilateral, very large, and round Pupil sphincter Fixated to Increased in Already No constriction No constriction
drugs 8–9 mm bright light fully on 0.5~2%
dilated pilocarpine
Oculomotor nerve Unilateral intermediate dilation Parasympathetic Fixated Increased in Dilation Constriction Constriction on
palsy (5–7 mm), various ptosis nerve in Third birght light 0.5~2%
cranial nerve pilocarpine
Horner’s Unilateral small and round pupil, Sympathetic tract Response all Increased in Dilation Constriction Cocaine
syndrome mild ptosis dark light 4–10% or
apraclonidine test
is usefull for
Argyll-Robertson Both small and irregular Midbrain Response to near No Poor reflex Constriction NA
pupil reflex response in
dark light
146 J. H. Jung

a b

Fig. 10.7  Change of ptosis after apraclonidine instillation in Horner’s syndrome. (a) Horner’s syndrome. (b) Benign
mass at the lung apex. (c) Loss of ptosis after applying of apraclonidine eye drops

10.5 Slit Lamp Examination 10.6 Differential Diagnosis

of Pupillary Abnormalities
It is necessary to observe the iris structure pre-
cisely through slit lamp examination. If iris atro- By examining the pupil size and response, we can
phy or sphincter abnormality is observed, it is know the function of the optic nerve. We can
necessary to confirm the past history of ocular examine the functions of pupil constrictor and
trauma. If pupil is dilated, it is helpful to diag- dilator to differentiate the central nervous system
nose the tonic pupil when the partial iris shrink- and peripheral nervous system lesions (Fig. 10.8).
age or wormlike movement is observed under
light stimulus (Fig. 10.7).
10  Pupil Exam 147


Same size in both

More prominent in More prominent in
dark and bright
dark place bright place

Normal iris
Abnormal Partial shape
dilator m. Dilation disability iridoplegia
from functional or
NO anatomical cause


Physiologic 10% cocaine Synechiae, uveitis, Miosis with Consider Traumatic iridoplegia,
old tonic pupil, instill 0.1% dilation by ischemic iris,
miotic eye drop pilocarpine drugs side rosis

NO Tonic pupil Iris damage
Miosis with 1% pilocarpine

Horner`s syndrome

3rd nerve palsy Dilated by drugs

1% Hydroxyamphetamine



Preganglionic Postganglionic
problem problem

Fig. 10.8  Decision-making in anisocoria

Bremner FD, Smith SE.  Bilateral tonic pupils: Holmes

Suggested Reading Adie syndrome or generalized neuropathy? Br J
Ophthalmol. 2007;91:1620–3.
Bell RA, Thompson HS. Optic tract lesions and relative Bremner FD, Booth A, Smith SE.  Benign alternating
afferent pupillary defect. In: Thompson HS, editor. anisocoria. Neuro-Ophthalmology. 2004;28:129–35.
Topics in neuro-ophthalmology. Baltimore: Williams Bruno MK, Winterkorn JMS, Edgar MA, et al. Unilateral
and Wilkins; 1979. p. 164–5. Adie pupil as sole ophthalmic sign of anti-Hu paraneo-
Bremver FD, Smith SE.  Pupil abnormalities in selected plastic syndrome. J Neuroophthalmol. 2000;20:248–9.
autonomic neuropathies. J Neuroophthalmol. Burde RM, Loewy AD.  Central origin of oculomotor
2006;26:209–19. parasympathetic neurons in the monkey. Brain Res.
148 J. H. Jung

Chen PL, Chen JT, Lu DW, et  al. Comparing efficacies Koc F, Kavuncu S, Kansu T, et  al. The sensitivity and
of 0.5% apraclonidine with 4% cocaine in the diag- specificity of 0.5% apraclonidine in the diagno-
nosis of Horner syndrome in pediatric patients. J Ocul sis of oculosympathetic paresis. Br J Ophthalmol.
Pharmacol Ther. 2006;22:182–7. 2005;89:1442–4.
Dacey DM, Liao HW, Peterson BB, et  al. Melanopsin- Papageorgiou E, Ticini LF, Hardiess G, et al. The pupil-
expressing ganglion cells in primate retina signal lary light reflex pathway. Neurology. 2008;70:956–63.
colour and irradiance and project to the LGN. Nature. Sadun AA, Bassi CJ, Lessell S.  Why cataracts do not
2005;433:749–54. produce afferent pupillary defects. Am J Ophthalmol.
Fotiou DF, Brozou CG, Tsiptsios DJ, et al. Effect of age 1990;110:712–4.
on pupillary light reflex: evaluation of pupil mobility Thompson HS, Mensher JH.  Hydroxyamphetamine test
for clinical practice and research. Electromyogr Clin in Horner’s syndrome. Reply. Am J Ophthalmol.
Neurophysiol. 2007;47:11–22. 1975;79:525–6.
Jacobson DM, Vierkant RA.  Comparison of cholinergic Wilhelm H, Wilhelm B, Mildenberger I. Primary aberrant
supersensitivity in third nerve palsy and Adie’s syn- regeneration of abducens nerve fibers into the pupil-
drome. J Neuroophthalmol. 1998;18:171–5. lary pathway. Neuroophthalmology. 1994;14:85–9.
Karden RH, Haupert CL, Thompson HS.  The relation- Young RS, Kimura E.  Pupillary correlates of light-
ship between static perimetry and the relative afferent evoked melanopsin activity in humans. Vis Res.
pupillary defect. Am J Ophthalmol. 1993;115:351–6. 2008;48:862–71.
Jong-Hoon Shin

Tonometry is a routine procedure in ophthalmo- 2.9 mmHg. Normal IOP is defined arbitrarily, and
logical examination; it is performed for diagnos- glaucoma cannot be diagnosed through tonometry
ing not only ocular hypertension and glaucoma alone.
but also ocular hypotension caused by eye
trauma, retinal detachment, or intraocular
inflammation following intraocular surgery for 11.1 Goldmann Applanation
corneal, lenticular, and vitreoretinal diseases. Tonometer
Tonometry is a basic procedure performed on
nearly all outpatients in ophthalmology, except The Goldmann applanation tonometer, attached
those who visit with an eye infection. Normal to a slit lamp, is used to measure IOP in the sitting
intraocular pressure (IOP) is 10–21 mmHg, with position and is widely applied in clinical settings.
a mean value of approximately 15.5 mmHg and The method is based on the principle of measur-
standard deviation of approximately 2.6 mmHg. ing the force required to flatten a round corneal
The statistical distribution of IOP values is surface with a diameter of 3.06  mm. Briefly, it
similar to a Gaussian curve, but it tends to be uses the Imbert–Fick law, explained by the eq.
asymmetric toward the side with higher IOPs. W = Pt × A, where W is the applanation force, Pt
Statistically, adding twice the value of the stan- is the internal pressure, and A is the area of the
dard deviation to the mean yields an IOP of surface being flattened. If A is constant, Pt can be
20.7 mmHg, which is described as the upper limit derived by measuring W (Fig.  11.1). This law
of normal IOP.  However, considering the asym- assumes that the cornea is completely round, its
metry in the IOP distribution and the fact that thickness is infinitesimal, and it is dry and com-
optic nerve impairment occurs at IOPs less than pletely flexible. Therefore, it does not apply to
21 mmHg, the upper limit of normal IOP cannot actual situations. The presented equation has been
actually be 21  mmHg. In Korea, IOP measure- modified according to the characteristics of the
ments on all residents (age, 40 years) of Namil- cornea, and it is actually applied to the eyeball.
myeon, Geumsan-gun, yielded a mean IOP of The force that resists corneal applanation does
13.5  mmHg, with a standard deviation of have an effect, but if the diameter of the surface
being applanated is set to 3.06 mm, tear surface
tension and corneal resistance offset each other,
allowing the law to be applied. Unlike the Schiotz
tonometer, this tonometer does not need to
J.-H. Shin, MD. (*) account for scleral rigidity, which makes it the
Department of Ophthalmology, Pusan National
University Yangsan Hospital, Yangsan, South Korea most clinically accurate IOP measurement device.

© Springer Nature Singapore Pte Ltd. 2019 149

J.-S. Lee (ed.), Primary Eye Examination,
150 J.-H. Shin

Prism holder


Area of the corneal A

surface contact
(3.06 mm)
Semicircular area Pt

Dial W = Pt x A

Fig. 11.1  Principle behind measurement using Goldmann applanation tonometer (Imbert–Fick law). (a) Goldmann
applanation tonometer, (b) Imbert–Fick law

11.1.1 Structure impregnated paper strip is used to stain the lac-

rimal layer. Just as in an anterior segment
• Biprism: The part that directly contacts the examination, a slit-lamp microscope is fixed in
cornea. Internally, two prisms, one on top and front of the face, and the patient is instructed to
one on the bottom, facing in opposite look straight while making sure the patient is
directions, form two divided semicircles. It is calm. The room is darkened, and the patient is
designed such that the inner margins of the instructed to keep the eyes open, making sure
semicircles align when the diameter of the the eyelashes or eyelids do not touch each other.
applanation surface is 3.06 mm. The line on the adjustment knob is set to 1  g,
• Connecting rod: It attaches the biprism to the and the slit-lamp beam is directed toward the tip
body. of the biprism through a cobalt blue filter. The
• Adjustment knob: The knob that adjusts the angle between the biprism and light beam
applanation force. Turning the knob clockwise should be ≥60°. While looking at the biprism
increases the applanation force. By multiplying from the side, it is adjusted in the up-and-down
the value displayed on the scale (in units of g) and left-and-­ right directions to approach the
by 10, after the inner margins of the semicircles center of the cornea. When it gets sufficiently
are aligned, the value is converted to units of close to the cornea, it is viewed through the eye-
mmHg. piece of the slit-lamp microscope at a low mag-
nification of ≤10×. As soon as the tip of the
biprism touches the cornea, green semicircles
11.1.2 Method form on the top and bottom. The position of the
biprism is adjusted to bring the equal-sized
The 0 mark on the biprism knob is first lined up semicircles to the upper left- and lower right-
with the white line on the sleeve. For cases hand sides of the horizontal plane. The adjust-
involving corneal regular astigmatism of ±3 ment knob is turned to align the inner margins
diopters or more, the line with the weakest cor- of the top and bottom semicircles (Fig. 11.2). If
neal curvature of astigmatism is aligned with the semicircles pulsate, the inner margins are
the red line on the sleeve. For sterilization aligned to the center of the pulsation range. The
before measurement, the tip of the biprism scale of the adjustment knob is multiplied by 10
should be cleaned with 70% alcohol and allowed to obtain the IOP in units of mmHg, which is
to dry. After topical anesthesia, a fluorescein-­ recorded, in addition to the measurement time.
11 Tonometry 151

a b c

Fig. 11.2  Formation of semicircles by Goldmann applanation tonometer. (a) Appropriate, (b) low IOP, (c) high IOP

If the measurement was difficult or other inac-

curate factors were present, the results are 11.1.4 Calibration
recorded with a side note to repeat at a later
time. If IOP measurement is performed on a If possible, the device should be calibrated before
patient with adenovirus or herpes virus infec- each examination, but if not, it is necessary to
tion, hepatitis B, or acquired immunodeficiency, have it calibrated at least once every 1–2 months.
the biprism is washed in running water immedi- A balance rod, an accessory part, and a support
ately afterward and soaked in 10% sodium for it are used. The line in the center of the
hypochlorite solution, 3% hydrogen peroxide, balance rod represents 0 g, the next line represents
or 70% isopropyl alcohol for 5  min to prevent 2 g, and the line farthest from the center represents
the transmission of infection. 6 g. If problems are detected during calibration,
the device should be sent for repair.

11.1.3 Precautions Operational Check

on the 0-g Position
Sometimes, IOP measurement may result in dam- After setting the tonometer to its operational
age to the corneal epithelium; therefore, it should position, the balance rod, with the support fixed
be performed in the last stage before the pupils are at the 0-g line, is inserted into the tonometer. The
dilated. The tip of the biprism coming in contact adjustment knob is turned to align with the 0-g
with an eyelash or eyelid or pressure applied to position, and the balance rod is checked to see if
the eyeball when the eyelid is opened may cause a it moves with light force. Check to ensure that
measurement error. Therefore, greater attention when the adjustment knob is turned to −0.1 g, it
should be paid when the gap between the eyelids tilts toward the examiner and when it is turned to
is narrow, and the examination should be per- +0.1 g, it tilts toward the patient.
formed using the fingers to press down and fix the
eyelids against the upper and lower orbital edges. Operational Check
Moreover, the width of a semicircle may be mea- for the 2-g Position
sured as larger than its actual size due to tearing. The balance rod, with the support fixed at the 2-g
In such cases, the measurement should be per- line, is inserted into the tonometer. The 900
formed again after cleaning the tip of the biprism. model has the longer end of the balance rod
The appropriate width of the semicircle is 0.25– toward the examiner, whereas the 870 model is
0.3 mm (approximately 1/10th of the applanation longer at the patient end. The adjustment knob is
diameter). turned to align with 2  g, and just as with the
152 J.-H. Shin

method used for 0 g, ensure that when the adjust-

ment knob is turned to +1.9 g, it tilts toward the
examiner and when it is turned to +2.1 g, it tilts
toward the patient. Operational Check

for the 6-g Position
The balance rod, with the support fixed at the 6-g
line, is inserted into the tonometer. After turning
the adjustment knob to align with 6 g, ensure that
turning to +5.9 g results in the balance rod tilting
toward the examiner and turning to +6.1 g results in
the balance rod tilting toward the patient (Fig. 11.3).

Fig. 11.4  Perkins tonometer

11.2 Perkins Tonometer
higher than 0  mmHg, the internal light source
This is a portable tonometer that uses a prism in a sends out a light beam through a cobalt blue fil-
manner similar to the Goldmann applanation ter. With the eyelids of the patient are open suf-
tonometer, but it is used on patients who cannot ficiently wide, the biprism is placed adjacent to
walk, such as infants, and those who cannot sit up the cornea, without touching the eyelid margin
for a slit-lamp examination as well as during or eyelashes. As soon as a contact is made with
surgery and inpatient examination. the cornea, the top and bottom semicircles are
observed through the eyepiece. The adjustment
knob is turned until the inner margins of the top
11.2.1 Methods and bottom semicircles line up, thereby adjust-
ing to the applanation force. When aligned
After topical anesthesia in a dark room, a fluo- semicircles are seen, the value at that point is
rescein paper strip is used to stain the lacrimal read, and this measurement is repeated approxi-
layer. When the adjustment knob is turned mately three times (Fig. 11.4).

Biprism 11.2.2 Precautions

This device can be used to examine a patient in

the sitting or lying position, and the measured
IOP has high precision. Moreover, because the
duration of contact of the device with the cornea
is short, it can easily be used to measure children
Check weight who are asleep. However, the measurement posi-
tion is unstable, and a certain level of expertise is
required to appropriately use the device. Repeated
measurements can reduce the IOP because of a
massage effect, and attention should be paid to
this possibility.
Notably, measurements in the lying position
Fig. 11.3 Calibration of Goldmann applanation tend to yield results that are 2–3  mmHg higher
tonometer than those obtained in the sitting position.
11 Tonometry 153

11.3 Tono-Pen Tonometer 11.3.2 Methods

This is a portable electric applanation tonometer With the batteries loaded, a rubber cover is fitted
based on the Mackay–Marg principle. It has an on the plunger, ensuring it is not very loose for air
outer shell (diameter, 3  mm) at the tip of the to enter. The activation button on the body is
probe, which contains a 1 mm plunger. As the tip pressed, after which two horizontal lines appear
of the probe lightly contacts the cornea, every on the display, at the top and bottom, indicating
small movement of the plunger is detected as an that the device is ready for measurement. After
electrical impulse. The results are provided as topical anesthesia, the patient is instructed to
mean IOP and percentage variability, based on look straight. The tonometer is lined up at a right
4–10 repeated measurements. It is a battery-­ angle to the cornea and brought in contact with it,
operated device and can measure IOP in the quickly and softly, without pressing down on the
sitting or lying position in a relatively easy cornea. The measurement is completed when a
manner. short “beep” is heard. Once 4–10 measurements
Because the area of corneal surface needed for are recorded, the mean value is calculated
the measurement is small, this device can be used automatically and displayed, accompanied by a
eve n if there is an anomaly in the cornea. It is continuous beeping sound. Variability is
particularly useful for cases involving heavy displayed as a short horizontal line on the bottom
tearing or a narrow gap between the eyelids of the screen, indicating 5%, 10%, 20%, or >20%.
(Fig. 11.5). If the value is ≥10%, the measurement must be
repeated until a value of 5% is obtained. To
accomplish this, when the plunger comes in
11.3.1 Structure contact with the cornea, it must not press down
on the cornea. Calibration should be performed
• Probe tip: This is the part that comes into daily before use, when unexpected measurement
direct contact with the cornea. It has a plunger values are observed, when the batteries are
(diameter, 1 mm), located in the center of an replaced, and when calibration was not performed
outer shell (diameter, 3 mm). properly the previous time. With the plunger
• Activation button: This is a button used facing vertically downward, the activation button
to switch the tonometer on and for is pressed twice in rapid succession. The word
calibration. “CAL” will appear on the screen, and after
• Liquid crystal display: This displays various maintaining this state for approximately 15 s, the
information during calibration. It also indi- word “UP” will appear. At this time, the plunger
cates the measurement status of the tonometer is turned to face upward, and when the word
and ultimately displays the measured IOP and “Good” appears shortly thereafter, the calibration
its variation. is successfully completed. If the word “Bad”
appears, the calibration must be performed again.

11.3.3 Precautions

The center of the cornea should be measured

whenever possible, but if the corneal surface is
uneven because of corneal erosion or
degeneration, a smooth surface as close as
possible to the center should be measured. The
measured values are approximately the same as
Fig. 11.5 Tono-Pen those from a Goldmann applanation tonometer,
154 J.-H. Shin

but the results may appear slightly higher when 11.4.1 Structure
the IOP is low and slightly lower when the IOP is
high. At IOP  ≥20  mmHg, the accuracy drops • Air-jet sprayer: This component sprays the air
slightly. needed for corneal applanation, with the
applanation force increasing over time.
• Optical applanation detector: This component
11.4 Noncontact Tonometer detects the condition in which the maximum
amount of light is reflected from the corneal
The noncontact tonometer (NCT), developed by surface that has been flattened by the air-jet.
Grolman in 1972, can measure IOP without • Positioner: This component is used to position
directly contacting the eyeball of the patient. the air-jet such that the air is directed toward
Corneal applanation is performed instantaneously the center of the cornea.
by an air puff. The device comprises three major
components: an air-jet sprayer, an optical
applanation detector, and a positioner to 11.4.2 Methods
accurately aim the air-jet toward the corneal
surface. In the instant that the air-jet is sprayed When the power switch is turned on, a recharging
toward the cornea, the optical applanation mark should appear on the upper portion of the
detector on the left and right sides measure the monitor. The height of the device is adjusted such
corneal distortion, and the time required to flatten that the patient can rest his or her chin on the chin
a certain amount of area or the air pressure support without any problem. The patients are
needed for flattening is converted to an IOP given advance notice that a short burst of air will
value. The latest model is equipped with an be sprayed into the eye during the measurement
automatic air sprayer, which allows the air to be but that the procedure will be painless. The
sprayed automatically when the corneal apex and position is adjusted until the monitor shows
spray nozzle are accurately aligned (Fig. 11.6). accurate air-jet aiming at the cornea. After correct
Because this device does not require topical positioning, an indication is provided that the
anesthesia and poses no concerns about possible device is ready for measurement. Once the air-­
infection due to contact, it is often used for spray button is pressed, part of the cornea is
general IOP screening. flattened by the air, which causes changes in the
specular reflection on the monitor. The change in
light intensity caused by this specular reflection
is converted to an IOP value and displayed on the

11.4.3 Precautions

A single measurement of IOP by using an NCT is

very brief (1–3 ms). Consequently, the measured
values may fluctuate significantly depending on
whether the measured value represents the
maximum or minimum value of IOP fluctuations
caused by the heartbeat. In particular,
glaucomatous eyes, for which IOP has greater
significance, tend to show greater fluctuations.
Therefore, the values measured by NCT would
Fig. 11.6  Noncontact tonometer, NCT also show large fluctuations. Therefore, at least
11 Tonometry 155

three IOP measurements should be taken with

NCT, and the average of those measurements
should be used. The standard range of fluctuation
is <3 mmHg.
NCT is known to have a tendency to produce
low results when the actual IOP is lower than
normal and high results when it is higher than
normal. Therefore, it is necessary to use the
Goldmann applanation tonometer for
IOP ≥18 mmHg. If there is dust buildup in the
device, especially the air sprayer, dust can enter
the eyes of the patient as the air is sprayed.
Moreover, when measurements are recorded on
a patient with a contagious eye disease, such as
epidemic keratoconjunctivitis, tears from the
patient can be blown onto the device by the air
spray, which can cause infection in the next Fig. 11.7  Pulsair tonometer
patient who is measured. Therefore, precautions
should be taken against these possibilities. 11.5.1 Methods
When the device is installed for the first time,
an eye model is used for calibration, but if While the examiner looks through the eyepiece,
measured IOP values are suspicious, the device the measuring unit is placed very close to the
should be recalibrated. cornea of the patient, but not actually touching it.
Once the measuring unit gets close enough to the
patient’s eye, a green light appears, and when the
11.5 Pulsair Tonometer unit is moved even closer, a cross-shaped light
appears for focusing. After the distance is
This device is based on the same principle as the adjusted by focusing, the air is sprayed
NCT, in that the air pressure required to flatten a automatically, and the IOP is measured.
certain amount of corneal area by air spray is
measured and converted to IOP. Because it uses a
noncontact method, it does not require topical 11.6 Ocular Response Analyzer
anesthesia, and the risk of infection transmitted
by tears is also low (Fig.  11.7). Because the The recently introduced Ocular Response
measuring unit is handheld, the device can be Analyzer (ORA; Reichert Corporation,
used without any restrictions based on the New  York, USA) is a type of noncontact
position or posture of the patient. However, tonometer that uses air to analyze the dynamic
because the working unit of the power pump is aspects of corneal deformation. When a time-­
connected to a large tube, the movement is not varying airstream strikes the cornea, the time
completely free. The device does not come of applanation is determined not only by the
directly in contact with the eye. Therefore, it air pressure but also by the rate at which it is
presents less of a fear factor, which makes it increasing or decreasing. The relationship
convenient for use on children. In cases involving between pressure and its rate of change is
the patient not being able to open the eyelids, determined by the stiffness of the cornea. In
poor corneal exposure, or an uneven corneal the ORA, the air pressure increases, reaches
surface because of corneal erosion or its peak, and then decreases. The function of
transplantation, measurement may be difficult, or the ORA is to measure the corneal applanation
the reliability of the results may be compromised. force when the air pressure is increasing
156 J.-H. Shin

(“force-in” applanation, P1) and the applana- stare at a green light surrounded by red light
tion force when the air pressure is decreasing and to place the forehead vertically against the
(“force-out” applanation, P2). The difference forehead support. After the patient is instructed
between these forces is called corneal hyster- to blink, the measurement button is pressed.
esis (CH) (Fig. 11.8). The variables shown as The resulting data are displayed on a computer
measurement results include the corneal-com- screen (Fig. 11.9).
pensated IOP, CH, corneal resistance factor,
and Goldmann-correlated IOP.  It is believed
that CH, in addition to central corneal thick- 11.7 Rebound Tonometer (Icare)
ness, influences IOP.  IOP measured by this
tonometer is less affected by corneal thick- Recently, the Icare tonometer, a rebound tonom-
ness. Although the results are highly corre- eter, was developed. An advantage of this device
lated with IOP measured with a Goldmann is that it does not require corneal anesthesia. IOP
applanation tonometer, the ORA tends to yield measurement with this device is based on the
results that are a few mmHg higher. High CH principle of a small plastic probe of the tonome-
is associated with the progression of glau- ter, grounded on the forehead of the patient, com-
coma, but additional studies on this topic must ing in contact with the corneal surface and
be monitored. rebounding. Because the probe is very small,
topical anesthesia of the cornea is not required,
just as with pneumatic tonometers. The Icare
11.6.1 Methods tonometer can be used on adults and children
because it is readily portable and convenient to
The patient should be seated comfortably in use. Its accuracy is known to be similar to that of
front of the device. Soft contact lenses should the Tono-Pen and Goldmann applanation tonom-
be removed, and the necktie should be loos- eters. The fact that it does not require topical
ened, if one is worn. The patient is instructed to anesthesia of the cornea enables the potential
keep the eyes open and is explained that a slight application of this device at home to measure
air puff will be felt. The patient is instructed to IOP.

Fig. 11.8 Applanation
signal and air pressure. Applanation Signal Pressure (air pulse)
Corneal “Out” Signal Peak
hysteresis = applanation
pressure 1 − applanation “In” Signal Peak
pressure 2. (Copyright
2004 Reichert Inc.)

Pressure 1
Hysteresis Applanation
Pressure 2

0 10 15 20 25
Time - msec
11 Tonometry 157

11.7.1 Methods 11.8 Dynamic Contour Tonometry

The patient is instructed to relax and look straight. As with the Goldmann tonometer, this type of
The tonometer is placed in front of the patient’s device is designed to be fixed on a slit lamp for
eye; at this time, the central groove must be in the measurements. The tonometer has a concave
horizontal position. The Icare tonometer probe detecting unit with a contact surface at the end
must be positioned at 90° to the corneal surface, that fits the corneal surface, with a diameter of
with the probe tip and corneal surface at a 10.5  mm. In the center, there is a piezoelectric
distance of 4–8 mm. The measurement button is pressure sensor (size, 1.2 mm) that converts the
pressed gently, such that the tonometer does not IOP to an electrical signal. The pressure signal is
shake. After six measurements, the resulting IOP altered by pulsatile intraocular blood flow and is
is displayed on the screen (Fig. 11.10). measured for approximately 5 s, after which the
diastolic IOP is displayed on the LCD screen of
the tonometer. The difference in IOP between the
systolic and diastolic phases of the heartbeat is
expressed as the ocular pulse amplitude (OPA),
which is approximately 1.5–3 mmHg in healthy
people (Fig. 11.11).
IOP measured through dynamic contour
tonometry is less affected by central corneal

Fig. 11.9  IOP and CH being measured with ORA

Fig. 11.10  IOP being measured with Icare tonometer Fig. 11.11  Pascal tonometer
158 J.-H. Shin

thickness than is that measured by a Goldmann

tonometer. Therefore, it is believed to be useful Scale
for measuring IOP after refractive surgery.
Because the measurement requires at least 5 s of Needle
contact with the corneal surface, the measured
values may not be accurate when used on
patients with nystagmus or those who are

11.8.1 Methods

After topical anesthesia, a silicone tip is attached

to the tonometer, and contact is made with the
cornea. Contact must be maintained for at least
five cardiac cycles. The tonometer makes a sound Weight Clamps
when the contact period has been sufficiently
long. When the measurement is performed appro-
priately, IOP, OPA, and a quality score appear on
the display. The results are considered reliable if
the quality score is 1 or 2. Base

Fig. 11.12  Schiotz tonometer

11.9 Schiotz Tonometer
(Indentation Tonometer)
the radius of corneal curvature is lower than
When the tonometer is placed on the center of average; these results are lower than the actual
the cornea, the plunger causes the cornea to IOP when the coefficient of OR is lower than
become indented to a certain degree. The degree average. Abnormally high coefficients of OR
of corneal indentation is expressed on the scale may be found in cases involving hyperopia,
by the movement of the needle. Each line on the chronic glaucoma, or vasoconstriction therapy,
scale represents an indentation of 0.05  mm whereas abnormally low coefficients of OR may
caused by the plunger, and the result is con- be seen in cases involving myopia, miotic ther-
verted to IOP on the basis of the weight used apy, vasodilation therapy, or retinal detachment
and the scale. Because the cornea and sclera are (Fig. 11.12).
elastic, placing the tonometer increases the IOP
and stretches the eyeball. This elasticity is
referred to as the coefficient of ocular rigidity 11.9.1 Structure
(OR). Eyes with weak elasticity are said to have
a high coefficient of OR. The Schiotz tonometer • Scale: This contains lines numbered from 0 to
is affected by the radius of corneal curvature 20, in 1  mm increments. A movement of
and coefficient of OR. 0.05  mm by the plunger is represented by a
The conversion table is based on the average change of one line on the scale.
radius of corneal curvature (7.8 mm) and coeffi- • Needle: This magnifies the movement of the
cient of OR (0.0215). Because of this factor, plunger by a factor of 20 and indicates the
measurement by the Schiotz tonometer produces result on the scale.
results that are higher than the actual IOP when • Clamps: These hold the tonometer during IOP
the coefficient of OR is higher than average or measurement.
11 Tonometry 159

• Weight: Weights of 5.5, 7.5, and 10 g can be 11.9.3 Precautions

used. If the measured value with a 5.5 g weight
is <4, a 7.5 or 10 g weight is used for the The weight placed on the tonometer (5.5, 7.5, or
measurement. 10 g) and the scale reading are used as the numer-
• Base: This is the area that comes in direct con- ator and denominator to express the results as
tact with the cornea and has the plunger fractions (i.e., 6/5.5 and 7/7.5), or such fractions
located in the center. can be converted to mmHg based on the conver-
• Plunger: This protrudes from the center of the sion table. Although this device was once widely
base and has a rod shape (diameter, 3  mm). used because of its convenience, it is not used as
When the cornea causes it to move by much currently due to errors associated with the
0.05 mm, the result is shown on the scale as a coefficient of OR.
movement by one line.

11.10 Other Tonometers

11.9.2 Methods
For the diagnosis and treatment of glaucoma, it is
After loading a 5.5 g weight, the tonometer is
necessary to continuously measure IOP over a set
placed vertically on the test block, ensuring that
period of time or number of days. A continuous
the needle is pointing exactly at 0. After topical
IOP monitoring device has been developed for
anesthesia, the patient is placed in the supine posi-
this purpose, while efforts are ongoing to develop
tion and instructed to look straight at a specific
other types of tonometers. In addition, there is a
point on the ceiling, light source, or the tip of a
phosphene tonometer that can be used for
finger, while a pillow is used to adjust the head
such that the face is horizontal. It would be ideal
to have the patient open the eyes voluntarily, but if
it is difficult to do so, the examiner should use the
thumb and forefinger or the forefinger and middle 11.11 Glaucoma Provocative Test
finger to gently pull back the upper or lower eye-
lid in the horizontal direction. The fingers must be A provocative test is performed in cases where
fixed on the edges of the upper and lower eye glaucoma is suspected, but not confirmed, based
sockets to ensure no pressure is applied to the eye- on IOP, optic disk, and visual field findings at a
ball. While holding the handle of the tonometer stage before the onset of clear visual impair-
with two fingers, the tonometer base is brought to ment. Briefly, a provocative test is aimed to
the center of the cornea and placed vertically assist in early determination of glaucoma. If a
erect. The position of the tonometer needle on the significant increase in IOP is found in a provoc-
scale is read. If the pressure pulsates strongly, the ative test, such cases may be diagnosed as open-
middle of the pulse is used as the value. If angle glaucoma or chronic closed-angle
the tonometer needle points to a value of <4, a 7.5 glaucoma, not normal tension glaucoma.
or 10 g weight is placed on the tonometer, and Because provocative tests do not yield false-
measurement is recorded using the same method. positive and false-negative results, a positive
If the values measured using a 5.5 and 10 g weight provocative test result should be viewed as
show a difference of ≥3 mmHg, the coefficient of merely suggesting glaucoma and indicating the
OR would be considered to be abnormal, requir- need for stricter care. Because of its high false-
ing IOP correction. The procedure is repeated positive and false-negative rates, this type of test
until three consecutive measurements show dif- is not commonly used today.
ferences on the scale that are no more than 0.5. Provocative tests can be divided into tests per-
The device should be sterilized thoroughly before formed when open-angle or closed-angle glau-
and after use. coma is suspected.
160 J.-H. Shin

11.11.1  Open-Angle Glaucoma measuring IOP after continued use of 0.1%

betamethasone eyedrops, four times a day for W  ater Provocative or 4–6 weeks. According to the classification used
Hemodilution Test by Becker et al., after the administration of 0.1%
The water provocative test is the most commonly betamethasone for four times a day for 6 weeks,
used provocative test for glaucoma. The patient is those who show an IOP of <20, 20–31,
instructed in advance to discontinue the use of and  ≥32  mmHg are classified as poor,
any drugs that may affect IOP and to fast for at intermediate, and high responders, respectively.
least 8 h before the test. It is best to perform the However, there are cases in which the IOP
test in the morning on an empty stomach. increases rapidly over a short period of time, as
The patient is instructed to drink water that is well as those in which the elevated IOP does not
slightly colder than room temperature: 1  L for decrease. Therefore, it is safer to avoid using the
adults and 14  mL per kilogram for children, steroid eyedrop method, if possible. If it is
within 5  min. The IOP is measured before necessary, sufficient explanation should be given
drinking the water, at 5-min intervals for the first to the patient.
15  min after drinking the water and at 15-min
intervals thereafter for up to 1  h. If there is a
tendency for elevated IOP even 1 h after drinking 11.11.2  Angle Closure Glaucoma
the water, measurements are continued at 15-min
intervals until elevated IOP is no longer observed. Dark-Room Test
The peak IOP typically appears between 10 and The dark-room test is a relatively physiological
30  min after drinking the water. Cases wherein examination, as well as a safe examination. First,
the IOP is elevated by at least 8 mmHg, compared after measuring the baseline IOP, the patient is
with that before drinking the water, are defined to placed in a dark room. Being placed in a dark
show a positive provocative test result. room may cause the patient to feel drowsy.
The degree of increase in IOP is influenced by However, because sleep can cause miosis, it is
the IOP level at the time of drinking the water. If necessary for the examiner to periodically ensure
the level is high at that time, the subsequent that the patient is awake. After 60–90  min, the
increase in IOP will be much greater. Therefore, IOP should be measured immediately in a dark
determination by a water provocative test does place, while the anterior chamber angle is also
not look at the absolute value of how much IOP observed. Compared with the baseline IOP, if
has been elevated but is based on whether the there is an increase of ≥8 mmHg in the IOP or the
elevation in level after drinking the water anterior chamber angle is completely closed,
represents an increase of at least 30%. The results such cases are determined as positive cases,
of water provocative tests are of a limited which would require immediate initiation of
diagnostic value because of their high false-­ treatment for closed-angle glaucoma. Even if the
positive rate. result is negative, closed-angle glaucoma cannot
be ruled out. Bulbar Compression Test
After applying 50 g of force on the insertion area Mydriatic Test
of the external rectus muscle for 4 min, a decline The mydriatic test is used for measuring the IOP
of ≤30% in IOP is considered a positive result. and anterior change angle after dilating the pupil
with a mydriatic. This method has a higher Steroid Eyedrop Test probability of yielding a positive result than does
If clear results could not be obtained through a the dark-room test, but it should be performed on
water provocative test, a steroid eyedrop test may only one eye due to the risks involved. The test
be used. This method involves obtaining a uses mydriatics with short efficacy, such as 3%
baseline IOP based on several measurements and eucatropine hydrochloride or 0.5% tropicamide.
11 Tonometry 161

The IOP and anterior chamber angle are examined

when the pupil has dilated by approximately
5–7 mm, 5–10 min after the eyedrop application.
Subsequently, the test is repeated every 15 min,
up to a total of 1 h.
The result is considered positive if the IOP has
increased by ≥8 mmHg or the anterior chamber
angle is completely closed. Upon completion of 1
the test, a mild mydriatic, 0.5–1% pilocarpine, is
administered topically. This test may be 2
performed when the results from a prone-position
test in a dark room are inconclusive. Prone-Position Test

Fig. 11.13  Aqueous outflow pathways. (1) Trabecular
The IOP is measured after the patient stays in the meshwork in the Schlemm’s canal pathway. (2) Uveal–
prone position for 1 h. If the IOP has increased by scleral pathway. (3) Iris pathway
≥8 mmHg, the result is considered positive. This
test is often performed together with the dark-­
room test. dicting the onset of primary open-angle glau-
coma, assessing the validity of antiglaucoma
therapy, discovering extensive diurnal variation
11.12 A
 queous Outflow Rate Test in IOP, diagnosing closed-angle glaucoma, and
(Tonography) discovering myasthenia gravis.

The IOP is usually determined by the balance

between aqueous production in the ciliary epi- 11.12.1  Methods
thelium and aqueous outflow from the anterior
chamber angle. Therefore, the IOP may increase After topical anesthesia, the Goldmann applana-
because of overproduction of aqueous humor or tion tonometer is used to measure the baseline
obstruction or impairment of aqueous outflow IOP.  Subsequently, the patient is placed in the
pathways. Clinically, however, most cases of supine position, and a Schiotz tonometer is
elevated IOP involve impairment of aqueous placed on the surface of the cornea for 4  min.
outflow. In rare cases, glaucoma may be caused The weight of the tonometer causes the IOP to
by elevated upper scleral venous pressure. The increase and the rate of aqueous outflow to
aqueous humor plays a role in maintaining the increase above the normal rate. The IOP gradu-
IOP and supplying nutrients to and removing ally decreases, whereas the production and out-
metabolites from the cornea and lens flow of aqueous humor reach an equilibrium
(Fig. 11.13). after a certain amount of time. The tonometer is
This is a useful method for investigating the connected to a recording device that continu-
aqueous humor circulation in glaucoma and ously measures the gradual decrease in IOP. The
identifying the mechanism of antiglaucoma observed changes in IOP are used to measure the
drugs. This test can determine aqueous outflow amount of aqueous humor that has moved from
impairment, the primary cause of elevated IOP, the eyeball by using the Friedenwald table. The
from the amount of aqueous outflow. If equation for the coefficient of aqueous outflow is
obstruction of the aqueous outflow pathways is as follows: C = ∆V/T∆P (C average coefficient
present, the rate of decrease in IOP becomes of aqueous outflow, ∆V change in the amount of
slower, and the overall level of decrease becomes aqueous humor, T  set time, ∆P  difference in
lower as well. Clinically, this test is used for pre- IOP).
162 J.-H. Shin

11.12.2  Determination Lowe RF.  Primary angle-closure glaucoma. A

review of provocative tests. Br J Ophthalmol.
The average coefficient of the aqueous outflow in Schacknow PN, Samples JR.  The glaucoma book: a
normal eyes is 0.28  μL/min/mmHg (normal, practical, evidence-based approach to patient care.
0.20 μL/min/mmHg). New York: Springer; 2010.
Shaarawy TM, Sherwood MB, Hitchings RA, Crowston
JG. Glaucoma. 2nd ed: Elsevier; 2014.
Shin J, Lee JW, Kim EA, Caprioli J.  The effect of cor-
Suggested Reading neal biomechanical properties on rebound tonom-
eter in patients with normal-tension glaucoma. Am J
Allingham RR, Damji KF, Freedman SF, Moroi SE, Ophthalmol. 2015;159(1):144–54.
Rhee DJ.  Shields textbook of glaucoma. 6th ed. Stamper RL, Lieberman MF, Drake MV. Becker-Shaffer’s
Philadelphia: Lippincott Williams & Wilkins; 2010. diagnosis and therapy of the glaucomas. 8th ed.
Gabelt BT, Kaufman PL.  Changes in aqueous humor Edinburgh (Scotland): Mosby; 2009.
dynamics with age and glaucoma. Prog Retin Eye Res. Tonnu PA, Ho T, Sharma K, White E, Bunce C, Garway-­
2005;24(5):612–37. Heath D. A comparison of four methods of tonometry:
Gedde SJ. Curbside consultation in glaucoma: 49 clinical method agreement and interobserver variability. Br J
questions. 2nd ed. Thorofare: Slack; 2015. Ophthalmol. 2005;89(7):847–50.
Kaufmann C, Bachmann LM, Thiel MA.  Comparison
of dynamic contour tonometry with Goldmann
applanation tonometry. Invest Ophthalmol Vis Sci.
Anterior Chamber Angle Exam
Keun-Heung Park

12.1 Gonioscopy chamber cannot be visualized directly because

the light is reflected from the corneal surface and
It is used to diagnose and differentiate various returned to the anterior chamber. Therefore,
lesions such as glaucoma, inflammation of the goniolens, a suitable contact lens, is attached to
anterior segment, congenital anomaly, eye the surface of the cornea to change the path of the
trauma, ischemic ocular disease, laser treatment, light so that a frontal angle can be observed
before and after eye surgery, anterior chamber (Fig. 12.1).
angle tumor, or foreign body. It is performed for The anterior angle examination is important in
the exact diagnosis and classification of glau- confirming the normal anatomical structure of
coma, the degree of occlusion of the anterior the angle, the degree to which the angle is open,
chamber angle due to peripheral anterior syne- the pigmentation of angle, and the presence of
hiae (PAS), the prediction of IOP control, and the abnormality of the angle. However, functional
selection of treatment modalities. It is also help- evaluation cannot be performed in the gonio-
ful in diagnosing and determining the degree of scopic examination. Therefore, it cannot be said
inflammation in uveitis. It is also performed to that aqueous humor is normally flowing out even
evaluate the adequacy of eye solution before and if it is normal gonioscopy test.
after surgery, such as goniotomy and laser tra-
beculoplasty. It can be used to diagnose various
diseases at the periphery of the iris such as tumor,
cysts, perforation, foreign body at the periphery
of the iris, traumatic iridodialysis, laceration of
Descemet’s membrane, or ocular disease near the
base of the vitreous. n’=1.50

12.1.1 Principle i

Total reflection
Because of the curvature of the cornea and the
difference in refractive index between the cornea Fig. 12.1  Optical principle of gonioscopy (n, refractive
and air, the light from the angle of the anterior index; i, incident angle)

K.-H. Park, MD. (*)

Department of Ophthalmology, Pusan National
University Hospital, Busan, South Korea

© Springer Nature Singapore Pte Ltd. 2019 163

J.-S. Lee (ed.), Primary Eye Examination,
164 K.-H. Park

a b c

Koeppe type Goldmann type Zeiss type

Fig. 12.2  Various gonioscopy lenses. (a) Koeppe type. (b) Goldmann type. (c) Zeiss type

12.1.2 Types and Methods skill, but this lens does not make angle of the
anterior chamber deformed and has a wide
There are two types of gonioscopy, a direct goni- range of view.
oscopy and an indirect gonioscopy, according to
the characteristics of the lens (Fig.  12.2). Method
Observation can be started from any direction, The patient is laid down and topical anesthesia is
but the lower anterior chamber angle is the larg- performed, and the corneal surface of the lens is
est, so it is easy to understand the structure of the filled with methylcellulose. Then, the lens is first
anterior chamber. Pigment and inflammation inserted into the lower conjunctival sac and then
substances are likely to accumulate here. In gen- inserted into the upper conjunctival sac. After the
eral, the lower anterior chamber angle is observed nasal side of the lens is slightly raised, saline is
first (Table 12.1). filled between the lens and the cornea. Take a
portable slit lamp and observe the entire anterior Direct Gonioscopy chamber angle while changing the observation
The gonioscopy is applied to the cornea with direction.
the patient lying down, and the anterior cham-
ber is observed directly with a loupe or portable Indirect Gonioscopy
slit lamp, which is used for goniotomy or pre- The patient is placed in front of a slit lamp micro-
operative diagnosis (Fig. 12.3). The most com- scope, and using a contact lens with a built-in
monly used direct gonioscopy lens is the reflector, anterior chamber angle is observed
Koeppe type, a 50D semicircular gonioscopy. indirectly. When the reflector is above, the lower
Compared with indirect gonioscopy, the equip- anterior chamber angle is observed, and when the
ment is somewhat complicated and requires reflector is low, the upper anterior chamber angle
12  Anterior Chamber Angle Exam 165

Table 12.1  Comparison of gonioscopy types Goldmann Gonioscopy Lens

Direct gonioscopy Indirect gonioscopy There are one or two mirrors, so the lens should
Requires surgical Slit lamp microscope be rotated to the opposite side of the anterior
microscope or portable required chamber angle to see. Since the curvature of the
slit lamp microscope Observe in sitting position
Observe in a lying Observation with mirror
lens is smaller than the curvature of the cornea,
position requires skills the lens will not be detached from the eye with-
Since it is an actual Accurate anterior chamber out pressing the lens. Excessive pressure can
image, the positional angle observation is cause wrinkles in the cornea, resulting in poor
relationship is clear possible
Easy to observe the The location of the
visibility. Depending on the gonioscopy, the
whole anterior chamber Schwalbe line is easy to position, height, and angle of the mirror are dif-
angle see, so it is useful to ferent, and the angle of anterior chamber can be
Both eyes can be determine the height of seen differently. For example, Goldmann’s one-
examined at the same PAS
time, so the two eyes Cannot use for surgery of
sided view shows angle of anterior chamber
can be compared anterior chamber angle but higher than that of Goldman’s three-sided view.
Useful for anterior laser treatment is possible Therefore, it is easy to observe the eye with
chamber angle surgery Even if the corneal opacity narrow angle of anterior chamber, which is dif-
Difficult to see when is present, the angle is
corneal opacity is observable to some degree
ficult to see all the way to the bottom of the
present or angle is It is necessary to rotate the angle due to iris root. In addition, Goldman’s
closed lens to observe the entire three-sided view shows an anterior chamber
A bed and a large anterior chamber angle angle in a more horizontal direction than
examination room are
Goldmann’s one-sided view, so that the width
of the trabecular meshwork is shown widely
and the anterior chamber angle is easy to
observe when it is the opening angle.
Understand the characteristics of this gonios-
copy and use appropriate gonioscopy.

After topical anesthesia, fill the concave portion
of the lens with methylcellulose. Have the patient
look up, then place the lens on the lower eyelid,
lift the upper eyelid with the other hand, place the
lens on the upper eyelid, and lightly press. Let the
mirror go to the 12 o’clock position, observe the
widest 6 o’clock angle, then rotate the lens, and
observe the anterior chamber angle in each direc-
tion. Trabecular meshwork looks slightly nar-
Fig. 12.3  Direct gonioscopy
rower than it actually is because it is slightly
tilted with respect to the mirror. When the ante-
is observed. Although it is difficult to observe the rior chamber angle is narrow, tilt the lens toward
anterior chamber angle in the ear and nose direc- the anterior chamber angle you want to look at
tions compared to the up and down directions, (dive bomber view), or let the patient see the mir-
observation can be easier when the slit lamp light ror (Fig.  12.4). If the anterior chamber angle is
is turned horizontally and the angle between the wide and deep, let the patient’s eye slightly
microscope and the slit lamp light is minimized. pointed to the opposite side of the mirror (cruise
If corneal edema is severe, apply 75–100% glyc- missile view), and then the trabecular meshwork
erine solution to the cornea or remove the corneal will become parallel to the mirror and can be
epithelium and then observe. observed without deformation. With this tech-
166 K.-H. Park

a b c

Cannot see Make patient to Not to press

angle at 12’ Look downward angle at 12’
due to narrow

Fig. 12.4  Dive bomber view. (a) Cannot see angle at 12′
Fig. 12.5  Indentation gonioscopy
due to narrow width. (b) Make patient to look downward.
(c) Not to press angle at 12′

nique, laser trabeculoplasty can be performed

without changing the size of the laser beam.

Zeiss Gonioscopy
There are four mirrors, so you can observe 360°
anterior chamber angle without rotating the lens.
Because the curvature of the lens is similar to the
curvature of the cornea, methylcellulose is not
necessary. However, care should be taken not to
push the eyeball at the time of examination, and
it may be advantageous to perform indentation Fig. 12.6  Sussman 4 mirror lens
to the movement of the aqueous humor. In this
Method way, it is possible to distinguish whether the
After topical anesthesia, place the lens on the anterior chamber angle closure is a simple con-
patient’s eye in the same manner as the Goldmann tact state or closure due to adhesion. If the
gonioscopy. Gently place the lens on the cornea angle is simply contacting, it can be reopened
without pressing. The lens is better placed in a with this technique. The lenses that can be used
square shape rather than a diamond shape. for the indentation gonioscopy are Zeiss-type
Observe first from the angle of 6 o’clock and goniolens, Iwata-­ Ricky lens, and Ocular
observe the other angle. If necessary, indentation Sussman mirror lens (Fig. 12.6).
gonioscopy is performed.
Indentation Gonioscopy Let the patient see the opposite direction of the
If the anterior chamber angle is narrow or anterior chamber angle to be seen and press the
closed and the anterior chamber angle structure lens toward the direction of the anterior chamber
cannot be seen, the indentation gonioscopy angle to be seen. Be careful not to slip the lens,
(Fig. 12.5) is necessary. If the central cornea is press carefully, and observe; because if
pressed, the surrounding iris moves backward, Descemet’s membrane wrinkles are formed, the
and the anterior chamber angle is widened due visualization of the angle is worsened (Fig. 12.7).
12  Anterior Chamber Angle Exam 167

curvature of the sclera and the rough trabecular

meshwork starts at this point, the pigment is piled
up like dust on the shelf (Sampaolesi’s line).
Axenfeld-Rieger syndrome has an anteriorly dis-
placed Schwalbe line (posterior embryotoxon).

12.1.4 Angle Grading Becker-Shaffer Classification

Fig. 12.7  A 55-year-old woman with primary angle-­
closure glaucoma. When the Sussman 4 mirror lens is 1 . Fourth degree: The anterior chamber angle is
pressed against the cornea, the trabecular meshwork 45° wide, the front of the ciliary body is visi-
hidden by the iris (small arrow) becomes observed. If ble, and the anterior chamber angle is in a nor-
trabecular meshwork is still not visible, the peripheral iris
mal state without occlusion.
has adhesion (large arrow) to the trabecular meshwork.
The point at which the open angle changes to the closed 2
. Third degree: The anterior chamber angle is
angle is clearly observable 20°−45° in normal condition.
3. Second degree: The anterior chamber angle is
12.1.3 Normal Anterior Chamber moderately narrowed to 20°, and there is a
Angle and Normal Gonioscopy possibility of occlusion.
(Figs. 12.8 and 12.9) 4. First degree: The anterior chamber angle is
10°, the anterior chamber is narrowed, and the Ciliary Body possibility of occlusion is high.
A part of the anterior surface of the ciliary body 5. Slit: The width of the anterior chamber angle
is visible. In the case of colored people, it looks is less than 10°, and the possibility of closure
darker than the iris. At the angle recession glau- is very high.
coma after trauma, the width of the ciliary body 6. Zero degree: The anterior chamber angle is
band is irregularly widened. fully closed (Fig. 12.11). Scleral Spur Spaeth Classification

It is a grayish white line, the point of attachment In addition to the Shaffer classification, the
of the fibers of the trabecular meshwork and cili- approximated area and shape of the iris were also
ary muscle. classified to include the width of the anterior
chamber angle as well as the shape of the anterior Trabecular Meshwork chamber angle (Fig. 12.12). Record the approxi-
This is a light gray band between the scleral spur mated area of the iris as A to E. Perform indenta-
and the Schwalbe line, with brown deposits as the tion gonioscopy and, if the approximated site is
age increases. different after indentation, record it in parenthe-
ses. The shape of the anterior chamber angle can Schwalbe Line be determined by the area between trabecular
Anatomically, it is the thickened end of the meshwork surface and a hypothetical line drawn
Descemet’s membrane of the cornea. An indirect at the 1/3 peripheral portion of the iris, and record
gonioscopy examination reveals that the parallel- the shape as steep (s), regular (r), and queer (q)
epiped lines of the cornea produced by the slit (Table 12.2, Fig. 12.13).
lamp light meet at this point (Fig. 12.10). Because (C) D20s: 12 o’clock direction anterior cham-
the curvature of the cornea is steeper than the ber recordings are bulging of the peripheral iris.
168 K.-H. Park

Fig. 12.8  Structure of

anterior chamber angle

Schwalbe’s line
Trabecular meshwork
Schwalbe’s line Scleral spur
Trabecular meshwork Ciliary body
Scleral spur
Ciliary body


Fig. 12.11 Measurement of anterior chamber angle

width by Becker-Shaffer classification
Fig. 12.9  Actual gonioscopy findings Scheie’s Classification:

Pigmentation of Trabecular
As age increases, the degree of pigmentation of
the trabecular meshwork also increases. After
surgery or by disease, pigmentation can be

Fig. 12.10  Examination of corneal parallelepiped test. 12.2 A

 nterior Chamber Depth
You can check the location of the Schwalbe line Test

If the iris is not pressed, the iris attaches to the 12.2.1 Anterior Chamber Depth Test
scleral spur. When it is compressed, trabecular Using Slit Lamp Microscope
meshwork is seen and there is no pigmentation.
D20r +: 3 o’clock and 6 o’clock direction Van Herick Technique
anterior chamber recordings have flat peripheral The center and peripheral anterior chamber depth
iris, trabecular meshwork, and pigmentation. can be measured using a slit lamp microscope.
A10s: At 9 o’clock direction, the anterior
chamber record shows that the peripheral iris is Method
bulging, and the iris is attached to the anterior Make the slit beam thin and illuminate it at the
part of the trabecular meshwork, and the trabecu- angle of 45–60° from the temporal side and
lar meshwork is not visible. observe the eye from the front. Evaluate the
In addition, recession of the anterior chamber anterior chamber depth of the center. How
angle is observed at 2 to 4 o’clock position, and many times the distance from the back of the
peripheral anterior synehiae (PAS) is observed cornea to the front of the lens to the corneal
from 7 to 10 o’clock. thickness is compared and evaluated roughly.
12  Anterior Chamber Angle Exam 169

30° A
s B
40° r C
q D

Fig. 12.12  Spaeth’s anterior chamber angle classification

Table 12.2  Spaeth grading system

Angle width The curvature of the peripheral iris The iris insertion
10 q – queer, concave A – anterior to meshwork
20 r – regularly flat B – behind Schwalbe line
30 s – steeply convex C – centered at scleral spur
40 s – very steep and convex D – deep angle width visible face of the ciliary
E – extremely deep angle

a b (C) D20s

Schwalbe’s line Angle recession

Scleral spur
A10s D20r–
Iris root
Trabecular meshwork

Fig. 12.13  Anterior chamber angle examination ((a) picture, (b) record)

Generally, if it is 6 times or more, it is deeper, 12.2.2 Haag-Streit Anterior Chamber

4–5 times is moderate, and 3 times or less is Depth Measuring Instrument
shallower. Assess the peripheral chamber depth.
Project the slit beam at 60° from the front (per- Anterior chamber depth can be accurately
pendicular to the cornea) to the temporal lim- observed by the Haag-Streit slit lamp microscope
bus of the cornea and evaluate in the same attaching an accessory device using a prism.
manner as in the central anterior chamber. If the
anterior chamber depth of the periphery is less Method
than 1/4 of the corneal thickness, the possibility Place an anterior chamber depth-measuring
of the anterior chamber angle occlusion is high instrument on the upper rod of a Haag-Streit slit
(Fig. 12.14). lamp microscope and make the slit beam as thin
170 K.-H. Park

Fig. 12.14 Anterior
chamber depth
measurement using a slit Slit beam illuminated at 45~60°
lamp microscope, Van
Herick technique
Corneal thickness

Chamber depth

as possible through the gap in the plate attached

to the anterior chamber depth-measuring instru-
ment. Replace the right eyepiece of the slit lamp Anterior
microscope with the eyepiece provided with the Chamber depth
instrument. Turn the eyepiece so that the gap in
the eyepiece is facing horizontally. The light
source is illuminated from the front of the cornea,
and observe the eye from the left side of the
patient. When the examinee observes with his or
Fig. 12.15  Scheimpflug camera image shows anterior
her right eye, an optical slice of slit beam is chamber depth
divided into two segments (upper and lower).
Move the upper scale of the anterior chamber
computer after taking an image of anterior seg-
depth-measuring instrument to align the two
ment. It is good in accuracy and reproducibility.
divided beams of the back of the cornea with the
front of the lens and then read the scale to obtain
the anterior chamber depth (mm).
Use a Scheimpflug camera (Pentacam®, Oculus)
to photograph the anterior segment, with caution
not to press the eyeball. Use the computer to
12.2.3 Ultrasound Biomicroscopy
measure the depth of the anterior chamber. Draw
a vertical line between the back of the cornea and
(See Chap. 17)
the front of the lens and then measure the dis-
It is a noninvasive method to observe the ante-
tance between the back of the cornea and the
rior segment structures using high-frequency
front of the lens (Fig. 12.15).

Place the ultrasonic probe vertically on the sur- 12.2.5 Anterior Segment Optical
face of the cornea on the axis. Measure the ante- Coherence Tomography
rior chamber depth several times while taking
care not to press the cornea. The Zeiss Visante OCT, the Cirrus HD-OCT
5000, and the Heidelberg Spectralis OCT with
anterior segment module can be used to obtain
12.2.4 Scheimpflug Camera Test anterior chamber angle image and to determine
whether anterior chamber angle is open or closed.
It is possible to perform objective evaluation by The anterior chamber angle and the anterior
measuring anterior segment in the photo using opening distance can be quantitatively measured
12  Anterior Chamber Angle Exam 171

closure and synechial closure. Arch Ophthalmol.

Foster PJ, Devereux JG, Alsbirk PH, et  al. Detection of
gonioscopically occludable angles and primary angle
closure glaucoma by estimation of limbal cham-
ber depth in Asians: modified grading scheme. Br J
Ophthalmol. 2000;84(2):186–92.
Gazzard G, Friedman DS, Devereux JG, Chew P, Seah
SKL. A prospective ultrasound biomicroscopy evalu-
ation of changes in anterior segment morphology
after laser iridotomy in Asian eyes. Ophthalmology.
Fig. 12.16 Anterior chamber angle image of Cirrus 2003;110(3):630–8.
HD-OCT 5000 shows angle opening distance (AOD S0161-6420(02)01893-6.
500/750), trabecular iris space area (TISA 500/750), and Jensen PK, Nissen O, Kessing SV.  Exercise and
scleral spur angle reversed pupillary block in pigmentary Glaucoma.
Am J Ophthalmol. 1995;120(1):110–2. https://doi.
by drawing the lines between the scleral spur, the Sakata LM, Lavanya R, Friedman DS, et al. Comparison
inner side of the cornea, the iris surface, and the of gonioscopy and anterior segment ocular coher-
angle recess (Fig. 12.16). ence tomography in detecting angle closure in dif-
ferent quadrants of the anterior chamber angle.
Ophthalmology. 2008;115(5):769–74. https://doi.
Suggested Reading Scheie HG.  Width and pigmentation of the angle of the
anterior chamber: a system of grading by gonioscopy.
Balidis MO, Bunce C, Sandy CJ, Wormald RPL, Miller AMA Arch Ophthalmol. 1957;58(4):510–2. https://
MH. Iris configuration in accommodation in pigment
dispersion syndrome. Eye (Lond). 2002;16(6):694– Singh P, Tyagi M, Kumar Y, Kuldeep K, Sharma
700. PD.  Gonioscopy: a review. Open J Ophthalmol.
Bruno CA, Alward WLM. Gonioscopy in primary angle 2013;3(04):118–21.
closure glaucoma. Semin Ophthalmol. 2002;17(2):59– 2013.34025.
68. Thomas R, Thomas S, Chandrashekar G.  Gonioscopy.
Fellman R.  Gonioscopy. Atlas of Glaucoma. https://doi. Indian J Ophthalmol. 1998;46(4):255.
org/10.3109/9780203007204-11. Troncoso MU.  Gonioscopy and its clinical applica-
Forbes M.  Gonioscopy with corneal indentation: a tions. Am J Ophthalmol. 1925;8(6):432b. https://doi.
method for distinguishing between appositional org/10.1016/S0002-9394(25)90063-3.
Optic Nerve Head and Retinal
Nerve Fiber Exam 13
Keun-Heung Park

13.1 O
 ptic Nerve Head Goldmann three-mirror lens, Hruby lens, or Volk
Examination lens. Use a green light to examine the retinal
nerve fiber layer.
13.1.1 Funduscopy

Ophthalmoscopy to observe lesions of the optic 13.1.2 Result

nerve head is important in diagnosing glaucoma
and assessing progression of the disease. Observe Normal Finding
and record the shape, size, and depth of the optic The size of the optic nerve head cupping is
nerve head cupping, the color of optic nerve expressed as the ratio of the horizontal diameter
head, the running of the blood vessels, and the of the cupping to the horizontal diameter of the
presence of small bleeding around the optic nerve disc (C/D ratio), but sometimes it is also evalu-
head. Also, if you record the optic nerve head ated in the vertical direction. The C/D ratio of a
with your fundus camera longitudinally, it will normal person is 0.4 or less, the difference of the
help you to know whether the glaucoma is pro- binocular C/D ratio is 0.2 or less, and the C/D
gressing or not. ratio is rarely more than 0.6. Direct Ophthalmoscopy Optic Nerve Head Change

The width of the slit beam is 1/3–1/2 of the width
Initially, optic nerve head cupping may not be
of the optic nerve head. Determine the neural rim
evident, but if high intraocular pressure persists,
using the shadow that is produced by moving the
optic nerve head cupping will proceed from the
direct ophthalmoscope up, down, left, and right.
top to bottom and then to the temporal side. At
Identify the edge of the neural rim in one place.
the same time, the blood vessels on the optic
Observe the circle and width of the neural rim
nerve head are deflected and bent toward the
along the circumference of the optic nerve head.
nasal side. The base of the optic nerve head cup-
ping is free from blood vessels and pale, and the Binocular Ophthalmoscopy cribriform plate is visible. In ophthalmoscopy,
You can inspect the optic nerve head three-­ when the difference between the two eyes in the
dimensionally by slit lamp microscopy with C/D ratio is greater than 0.2; the C/D ratio is
greater than 0.5; the vertical oval cup is present,
or local or peripapillary atrophy, or neural rim
K.-H. Park, MD. (*) notch; or bleeding from the optic nerve head is
Department of Ophthalmology, Pusan National
visible, glaucoma is suspected (Fig. 13.1).
University Hospital, Busan, South Korea

© Springer Nature Singapore Pte Ltd. 2019 173

J.-S. Lee (ed.), Primary Eye Examination,
174 K.-H. Park

Optic Nerve Head Cupping advantage is that you can record the state of the
The boundaries of the optic nerve head cupping neural rim. The disadvantage is that the accuracy
should be measured not at the pale hue in the of optic nerve head cupping boundary is lower
optic nerve head but at the bending point of the than that of stereoscopic photography.
blood vessel going from the cupping to the edge
of the optic nerve head. In the early period of
chronic glaucoma, the vertical diameter is 13.1.4 Optic Nerve Stereoscopic
enlarged before the horizontal diameter, so pay Photography
attention to the vertical C/D ratio.
In two-dimensional images, it is sometimes dif-
Neural Rim ficult to accurately determine the boundaries of
If the IOP is consistently high, the boundary optic nerve head cupping. A fundus camera is
between the neural rim and the cupping becomes used to photograph two consecutive photographs
clearer, and a notch develops in the neural rim. at different angles in a horizontal direction. This
The blood vessels on the optic nerve head are dis- method requires a lot of training to obtain a good
placed to the nasal side. image and has a disadvantage of poor reproduc-
ibility. Therefore, it is difficult to follow up the
Retinal Nerve Fiber Layer depth change of the optic nerve head cupping.
If the fundus is examined with green light, a Presently, a prism is adopted in the camera, and a
defect of the retinal nerve fiber layer may be method of taking two three-­dimensional photo-
found locally. Reflexes in the retina with loss of graphs at the same time is widely used because it
nerve fibers are less than those seen in normal is possible to obtain a highly reproducible stereo-
retinal tissues. scopic image and digital analysis of the retina
around the optic nerve head and the optic nerve
13.1.3 Photograph of the Optic
Nerve Head Method
A method of obtaining a stereoscopic image
The most convenient and inexpensive method for using a fundus camera is as follows. Enlarge the
objectively monitoring the optic nerve head sta- pupil as much as possible. Turn the lever for ste-
tus of a patient is to photograph and compare the reoscopic photography to make the camera in the
optic nerve head. The optic nerve head pallor and semifixed status. This will limit the range in
optic nerve head cupping ratio can be calculated which the camera moves when you move the
directly from the photograph. The most important camera handle to the left or right, to the range

Peripapillary atrophy
a b c

Neuroretinal rim loss

Fig. 13.1  Glaucomatous optic nerve head change. (a) atrophy, or neural rim notch. (c) Bleeding from the optic
The difference between the two eyes in the C/D ratio is nerve head is visible; glaucoma is suspected. (b
greater than 0.2. (b) The C/D ratio is greater than 0.5, or Peripapillary atrophy (upper), neuroretinal rim loss
the vertical oval cup is present, or local or peripapillary (lower))
13  Optic Nerve Head and Retinal Nerve Fiber Exam 175

used for stereoscopic photography. Take a picture dle to distinguish between neural rims and optic
of the optic nerve head with the camera knob to nerve head cupping. You can obtain various
the left and shoot it again to the right. The larger parameters including optic nerve head, optic
this range, the better the stereoscopic effect can nerve head cupping, and neural rim area and
be obtained. Move within the appropriate range volume. You can also divide the optic nerve
in order not to be covered by pupil, which may head into multiple zones and obtain index val-
affect the image quality. ues in each zone. The thickness of the retinal
nerve fiber layer is also obtained, and it helps to
evaluate the minute changes over time
13.1.5 Optic Nerve Head Analysis (Fig. 13.3).
The index for the cup is represented by the lin-
This is for quantitative analysis of information on ear cup/disc ratio and the cup shape measure.
neural rims, optic nerve head cupping, and other Indices for the neural rim appear as rim area and
optic nerve heads. rim volume. Indices for RNFL are height varia-
tion contour and mean RNFL thickness. Each Stereophotogrammetry indicator is categorized as normal (green), border
In addition to the first developed PAR IS 2000 (yellow exclamation mark), abnormal (red mark),
(Topcon ImageNet®), there are Rodenstock and displayed asymmetry of both eyes.
Optic Nerve Head Analyzer®, Humphrey Retinal Moorfields regression analysis (MRA) compares
Analyzer®, and Glaucoma-Scope®. These ana- the rim area and volume values with normal val-
lytical instruments analyze the information using ues, taking the area and age of the optic nerve
a digitally recorded stereoscopic fundus photo- into consideration.
graph or a 35 mm photograph taken with a digi-
tizer. The boundary of optic nerve head cupping Optical Coherence
is set by the examiner, or the machine itself sets Tomography, OCT
the vertical and horizontal optic nerve head cup- In the spectral domain OCT, Cirrus OCT (Carl
ping ratio, the area of the optic nerve head cup- Zeiss Meditec, Dublin, California), the edge of
ping area, the area ratio of the optic nerve head, the optic nerve head is determined by the termi-
and the volume of the optic nerve head cupping. nation of Bruch’s membrane. The neuroretinal
Reproducibility is low, pupil dilation is neces- rim area of the optic nerve head is determined
sary, and it is difficult to obtain a good image if by measuring the amount of nerve tissue in the
the ocular medium has turbidity. optic nerve. This method differs from methods
used in HRT that determines the cupping edge Confocal Laser Scanning
After confocal laser scanning was first devel-
oped, Heidelberg retina tomograph (HRT,
Heidelberg Engineering, Heidelberg, Germany)
was commercialized. HRT 3 can be used to con-
struct a 3D image of the optic nerve using a 670
micron diode laser with 64 cross sections with
1/16 mm intervals (Fig. 13.2). The depth of each
of the 64 sections is 4 mm, and each section has
384 × 384 points, and each of the points has the
horizontal, vertical, and height values. When the
image is obtained, the examiner displays the
optic nerve head contour and sets the reference
plane 50 μm behind the contour and the retinal
surface (350–356°) on the papillomacular bun- Fig. 13.2  Heidelberg retina tomograph (HRT) 3
176 K.-H. Park

Quality: Very good (SD 13 µm) Follow-Up Report Quality: Good (SD 27 µm)
Focus: –2.00 dpt Focus: –3.00 dpt
Operator: --- OD OS Operator: ---
Disc Size: 2.41 mm2 (average) Disc Size: 1.68 mm2 (average)
Linear Cup/Disc Ratio [ ]
0.59 Asymmetry 0.92
–0.33 (+0.00)
p = 0.35 p = 0.006 p < 0.001

Cup Shape Measure [ ]

–0.16 Asymmetry 0.04
–0.20 (–0.07)
p = 0.47 p = 0.001 p < 0.001

Rim Area [mm2]
1.57 Asymmetry 0.25
1.32 (+0.00)
p = 0.25 p < 0.001 p < 0.001

Rim Volume [mm3]

0.43 Asymmetry 0.03
0.40 (–0.02)
p > 0.5 p = 0.01 p < 0.001

MRA: Within normal limits MRA: Outside normal limits

RNFL –0.2

0.0 0.0
Height Variation Contour [mm]
0.2 0.2
0.36 Asymmetry 0.17
0.4 0.4
0.19 (–0.12)
0.6 0.6
p > 0.5 p = 0.04 p = 0.01
0 45 90 135 180 225 270 315 360 0 45 90 135 180 225 270 315 360
RNFL Profile Mean RNFL Thickness [mm] RNFL Profile

0.27 Asymmetry 0.10

Within normal limits p > 0.05 0.17 (+0.05) Comments:

Borderline p < 0.05 p > 0.5 p = 0.004 p = 0.007

Outside normal limits p < 0.001
Inter-Eye Asymmetry 61%

Fig. 13.3  Confocal laser scanning for optic nerve head and retinal nerve fiber layer

relative to the plane, intersecting the plane at a C/D ratio is given as the square root of the cup-
fixed distance above the optic nerve head ping area ratio to the optic nerve head area, and
(Fig. 13.4). the vertical C/D ratio is the ratio of the cupping
The neural rim area (mm2) is a summary of the diameter to the optic nerve head diameter in the
dark gray neural rim range shown at the top of the vertical meridian. The cupping volume is a 3D
RNFL thickness map. The light gray range on the measurement defined as the volume between the
same map is the cupping area (mm2), and the plane generated by the cupping contour at the vit-
total area of the optic nerve head is the neural rim reous interface and the backside of the optic
area plus the cupping area (mm2). The average nerve head.
13  Optic Nerve Head and Retinal Nerve Fiber Exam 177

ONH and RNFL OU Analysis:Optic Disc Cube 200x200 OD OS

Optic nerve head parameters
RNFL thickness map OD OS RNFL thickness map
350 350 OD OS
Average RNFL thickness 69 µm 75 µm
RNFL symmetry 52% Average RNFL thickness 69 µm 75 µm
Rim area 1.14 mm2 1.05 mm
175 175 RNFL symmetry 52%
Disc area 1.45 mm2 1.38 mm

Rim area 1.14 mm2 1.05 mm2

Average C/D ratio 0.45 0.48
Vertical C/D ratio 0.45 0.51 Disc area 1.45 mm2 1.38 mm2
0 µm
Cup volume 0.048 mm2 0.097 mm2
0 µm
Average C/D ratio 0.45 0.48
RNFL deviation map RNFL deviation map
Vertical C/D ratio 0.45 0.51
Neuro-retinal rim thickness
µm OD OS Cup volume 0.048 mm2 0.097 mm2


Disc center (-0,15,0.06) mm RNFL thickness Disc center (0,15,0.06) mm
Extracted horizontal tomogram Extracted horizontal tomogram
µm OD OS



Extracted vertical tomogram TEMP SUP NAS INF TEMP Extracted vertical tomogram
80 Distribution of normals 94

S NA 95% 5% 1% S
58 T N 55 69 N T 65
RNFL circular tomogram 81 71 RNFL circular tomogram
83 74 83 77 79 126
65 62 88 79

55 50 RNFL 62 57
53 53 Hours 56 59
72 88 85 88 59 66

Fig. 13.4  Optic nerve head summary parameters

13.2 Evaluation of the Retinal while illuminating red or green light or photo-

Nerve Fiber Layer graphed with a fundus camera.

The main cause of visual field defect in glau-

13.2.2 Scanning Laser Polarimetry
coma is the loss of ganglion cells. The purpose
of examining the retinal nerve fiber layer is to
The GDx variable corneal compensator (GDx VCC,
diagnose early glaucoma and progression of
Carl Zeiss Meditec, Dublin, Calif.) indirectly mea-
glaucoma changes early (Fig.  13.5). In addi-
sures the thickness of the retinal nerve fiber layer by
tion to glaucoma, localized retinal nerve fiber
illuminating a 780 nm diode polarized laser onto the
layer defects can also be caused by optic nerve
retina and analyzing the double refraction of the
drusen, toxoplasma, retinochoroidal scars, and
retinal nerve fiber layer with a polarimeter.
cotton-­wool spots in ischemic retinal disease.

13.2.3 Optical Coherence

13.2.1 Retinal Nerve Fiber Layer Tomography, OCT
It is a noncontact, noninvasive method using near-
It is the easiest way to examine the retinal nerve infrared wavelengths of 830–843 nm. Although a
fiber layer. The retinal nerve fibers are observed high-resolution monolayer image can be obtained
three-dimensionally through a slit lamp micro- within 1  s, a pupil of about 5  mm or more is
scope using a contactless or noncontact lens required (see Chap. 18).
178 K.-H. Park

a b
Papillomacular bundle

Temporal retina Nasal retina

Horizontal raphe

Fig. 13.5  The retinal nerve fiber layer. (a) A schematic diagram of direction of retinal nerve fiber coming from the
optic nerve head. (b) Retinal nerve fiber layer defect

optic disc photographs for glaucoma: the European

Suggested Reading Optic Disc Assessment Trial. Ophthalmology.
Airaksinen PJ, Drance SM. Neuroretinal rim area and reti- Sakata LM, DeLeon-Ortega J, Sakata V, Girkin
nal nerve fiber layer in glaucoma. Arch Ophthalmol. CA.  Optical coherence tomography of the retina
1985;103(2):203–4. and optic nerve–a review. Clin Exp Ophthalmol.
Folio LS, Wollstein G, Schuman JS.  Optical coherence 2009;37(1):90–9.
tomography: future trends for imaging in glaucoma. Stone RA, G-s Y, Pearson DJ, Bansal M, Puri M,
Optom Vis Sci. 2012;89(5):E554. Miller E, Alexander J, Piltz-Seymour J, Nyberg W,
Hawkins S, Osborne A, Schofield S, Pournaras D, Maguire MG.  Utility of digital stereo images for
Chester J. Improving the accuracy of self-assessment optic disc evaluation. Invest Ophthalmol Vis Sci.
of practical clinical skills using video feedback–the 2010;51(11):5667–74.
importance of including benchmarks. Med Teach. Swindale NV, Stjepanovic G, Chin A, Mikelberg
2012;34(4):279–84. FS.  Automated analysis of normal and glaucoma-
Hoyt WF, Frisen L, Newman NM. Fundoscopy of nerve tous optic nerve head topography images. Invest
fiber layer defects in glaucoma. Invest Ophthalmol Vis Ophthalmol Vis Sci. 2000;41(7):1730–42.
Sci. 1973;12(11):814–29. Wollstein G, Garway-Heath DF, Hitchings
KongYXG, Coote MA, O'Neill EC, Gurria LU, Xie J, Garway- RA.  Identification of early glaucoma cases with the
Heath D, Medeiros FA, Crowston JG.  Glaucomatous scanning laser ophthalmoscope. Ophthalmology.
optic neuropathy evaluation project: a standardized inter- 1998;105(8):1557–63.
net system for assessing skills in optic disc examination. Yücel YH, Gupta N, Kalichman MW, Mizisin AP,
Clin Exp Ophthalmol. 2011;39(4):308–17. Hare W, de Souza Lima M, Zangwill L, Weinreb
Mwanza J-C, Budenz DL. New developments in optical RN.  Relationship of optic disc topography to optic
coherence tomography imaging for glaucoma. Curr nerve fiber number in glaucoma. Arch Ophthalmol.
Opin Ophthalmol. 2018;29(2):121–9. 1998;116(4):493–7.
Nicolela MT, Drance SM.  Various glaucomatous Zangwill LM, Chan K, Bowd C, Hao J, Lee T-W, Weinreb
optic nerve appearances: clinical correlations. RN, Sejnowski TJ, Goldbaum MH. Heidelberg retina
Ophthalmology. 1996;103(4):640–9. tomograph measurements of the optic disc and para-
Quigley HA, Addicks EM.  Quantitative studies of reti- papillary retina for detecting glaucoma analyzed by
nal nerve fiber layer defects. Arch Ophthalmol. machine learning classifiers. Invest Ophthalmol Vis
1982;100(5):807–14. Sci. 2004;45(9):3144–51.
Reus NJ, Lemij HG, Garway-Heath DF, Airaksinen PJ, Zupan M, Mikek K, Gruden S. Ophthalmoscopic evalu-
Anton A, Bron AM, Faschinger C, Holló G, Iester ation of the optic nerve head. Slovenian Med J.
M, Jonas JB.  Clinical assessment of stereoscopic 2002:71(2).
Visual Field Test
Ji-Woong Lee

The visual field examination is a method of mea- 14.1 S

 election of Visual Field Test
suring the sensitivity of test points and the range Method
of visual fields from the fixation point (Fig. 14.1).
The line connecting the test points that can recog- Screening test is used to check the presence or
nize the equivalent stimulus within the visual absence of abnormalities, while threshold test is
field is called an isopter, which indicates the limit used to precisely examine the degree of abnormal-
of the area within which a specific target can be ities. Usually the visual field test is performed after
seen. The visual field test is performed in patients a general ophthalmologic examination, so choose
with visual disturbance, glaucoma, diplopia, hys- a proper method to detect the abnormality of a sus-
teria, retinal detachment, central serous chorio- pected disease. Screening test can be done in a
retinopathy, retinal pigment degeneration, retinal short time, so it is useful for children or elderly
vein occlusion, papillary edema, and optic disc people who have difficulty in having threshold
disease. In addition, it is performed in patients examination. The Humphrey visual field analyzer,
with headache, epilepsy, brain tumor, head which is the most commonly used automated
trauma, and fracture. Since the optic nerve fibers perimeter, includes Central 40, Full field 120, and
have constant arrangement from the retina to the Central 76 and full threshold (30-2, 24-2), Fastpac,
cortex, lesions affecting the pathway of the nerve SITA strategy (30-2, 24-2). The Swedish
fibers cause a characteristic change in visual Interactive Testing Algorithm (SITA) strategy can
field. By examining these changes in visual field, be performed in a short period of time.
important information can be obtained for diag- The confrontation method does not need a
nosis, lesion location in visual pathway, and dis- device and can be performed for patients who can-
ease progression. not be seated or if their visual acuity is very poor.
In the early stage of disease, visual field test is The Goldman perimeter is useful for children or
a very useful method to detect and evaluate visual elderly people who cannot cooperate well because
loss due to glaucoma because glaucoma does not examiner can see the patient’s reactions during the
cause a decrease in visual acuity until very examination. It is also useful for the detection of
advanced stage. peripheral visual field defect and location of intra-
cranial disease, especially for evaluation of occipital
lesions. On the other hand, it is difficult to precisely
evaluate the central scotoma within 10 degree, and
it is necessary to have an experienced examiner.
J.-W. Lee, MD., PhD. (*)
Department of Ophthalmology, Pusan National The automated perimeter is effective because
University School of Medicine, Busan, South Korea it examines the sensitivity reduction near the cen-

© Springer Nature Singapore Pte Ltd. 2019 179

J.-S. Lee (ed.), Primary Eye Examination,
180 J.-W. Lee

50 – 60° repeated tests. The influence of age on visual

field is mainly observed in the peripheral visual
Fixation target Blind spot
field and upper field. In automated perimeter,
fixation loss is automatically recorded. Patient
cooperation is important for visual field exami-
60° 100 – 110°
nation, and the patient’s cooperation can be
assessed through false-positive rate, false-­
negative rate, and fixation loss. Reliability
should be considered when interpreting the
70 – 75°
results of visual field tests. The learning effect,
Fig. 14.1  Normal visual field. The normal range of fatigue, drug, concentration, tension, and anxi-
visual field is the widest at 100–110 degrees on temporal ety affect the test results, so the visual field
side, 70–75 degrees on the inferior side, 60 degrees on the examination room should be cool, dry, dust-
nasal side, and 50–60  degrees on the superior side.
free, backlit, and comfortable.
Normally, there is a blind spot, or physiological blind
spot, at about 15 degrees from the center of the macula to
the temporal side, which corresponds to an optic nerve
head that does not have photoreceptor layer
14.2.2 Ocular Factors
ter and detects the early stage of glaucoma. It
evaluates the change in visual field during the The patients need to have visual acuity good
follow-up and useful in finding out the visual enough to see the target used for visual field
field defect with respect to the vertical meridian. tests. Generally, Snellen visual acuity should
It is not affected by the examiner’s skill. However, be 0.3 or more for automated perimetry. Near
it is necessary to consider the reliability of test vision correction according to age is necessary
results for interpretation. for patients with presbyopia. If astigmatism is
Basically, it is efficient to examine the cen- less than 1.25 diopter, it should be corrected
tral visual field defect with the static visual field with spherical equivalent. If astigmatism is
test and the peripheral visual field defect with greater than 1.25 diopter, it should be cor-
the dynamic visual field test. Because central rected with cylindrical lens. The aphakic eyes
visual field defect occurs in the early stage of are corrected with a contact lens. A pupil size
optic tract disease, static visual field is useful of 3 mm or more is suitable. If the pupil size is
for the diagnosis. The lesion located ahead of smaller, the overall sensitivity decreases, so it
the optic chiasm also often causes a central sco- is recommended to record the pupil size. The
toma. Therefore, the examination of the central media opacity, such as corneal opacity, cata-
visual field is helpful for diagnosis. In a lesion ract, and vitreous opacity, also reduces the
of the central nervous system behind the optic sensitivity.
chiasm, the confrontation technique may be
simpler and more useful. In order to evaluate the
precise boundaries of the hemianopsia, the
14.2.3 Factors Related to Examination
dynamic visual field test may be useful.
Generally, the target has uniform brightness in
14.2 F
 actors Affecting Visual Field white, circular shape. The bigger the target, the
Test Results easier it is to be recognized. The background illu-
mination is usually 4–31.5 apostilb (asb), and the
14.2.1 Patient Factors visual field defect pattern may be different
depending on the background illumination. If the
As age increases, the visual field sensitivity target’s exposure time is too short, the sensitivity
decreases, and fluctuations become severe in may be reduced.
14  Visual Field Test 181

14.3 Manual Perimetry

14.3.1 Confrontation Test


Confrontation test can detect the approximate N

shape and range of visual field defect. The exam-
iner’s visual field should be normal. The patient LE RE
and the examiner sit 1  m away. Cover the eyes
that face each other. The right eye is examined Fig. 14.3  The results of confrontation test show supero-
temporal quadrantanopsia
first, but if there is a difference in visual acuity
between the two eyes, the better eye is examined
first. Make sure that the unexamined patient’s eye Use a white grid or a red line on a black back-
is completely covered. The examiner also closes ground with a grid of 5 mm (single-pitch) spac-
the eye opposite to the patient’s covered eye. ing and 20  ×  20 grid (Fig.  14.4a). Patient with
Have the patient look at the eyes or nose of the near vision correction closes the untested eyes.
examiner. Place the target (finger or light source) The patient is asked to answer if the whole grid is
at the middle in between the examiner and the complete with each line is parallel or it is bent
patient, move the target from the periphery to the while he or she is looking at the central point of
center, and examine the visual field of the patient the whole grid. Ask the following questions and
by comparing the position at which the target is have the patient record the results on a grid of
recognized by the examiner. It is convenient to black lines on a white background (Fig. 14.4b),
use an eye-drop bottle with a colored cap the name of the patient, the eyes examined, the
(Fig. 14.2). If abnormality is found, the defect is date, and whether the abnormality is indicated on
displayed on the 360-degree visual field figure the patient’s outcome sheet:
(Fig. 14.3).
• Do you see the point in the center?
• Looking at the center point, can you see the
14.3.2 Amsler Grid Test four corners of a large square?
• Is there a broken hole or spots in the middle of
Amsler grid test can detect the visual field defect the grid? If so, where?
from macular degeneration, central serous cho- • Are the entire horizontal and vertical lines
rioretinopathy, and optic nerve diseases such as parallel when you are looking at the center
retrobulbar optic neuritis for central 10–20 degree point? Is each grid a complete square?
macula. • Do you see anything other than faint or bent
• How many normal square grids can you see
from the center to the faint or bent line?

14.3.3 Goldmann Perimetry

Goldmann perimetry is useful for evaluating

overall visual field in patients with brain diseases,
advanced glaucoma, retinitis pigmentosa, and
visual disturbance of psychogenic origin particu-
larly when it is difficult to identify the visual field
Fig. 14.2  The technique of confrontation test. The exam-
iner has an eye-drop bottle with a red-colored cap in his defect pattern with the automated perimetry. The
left hand while he covers his right eye with the right hand Goldman perimeter consists of a hemisphere
182 J.-W. Lee

a b

Fig. 14.4 (a) Amsler grid. (b) Amsler grid result of patient shows the lesion area where several lines are bent Methods
Install the perimeter so that direct light does not
enter the hemisphere. Adjust the horizontal plane
turning the two handles on the sides. Check
whether the light source for inspection is set in
proper condition. Set the target brightness. Set the
target size to V and the target brightness to 4
(1000 asb), and place the recording sheet at a pre-
determined position. When the target moving
plate is fixed to the right 70-degree position on the
horizontal meridian, the target is projected on the
brightness measuring instrument, and the target
brightness is adjusted to be 1000 asb. Set the
background brightness. If you move the plate in
the brightness measuring instrument, the target is
projected onto the plate with the same reflectance
as the hemisphere. Set the target brightness to 1
(31.5 asb). Look through the telescope from the
opposite side and adjust the target and background
brightness uniform. Always adjust the target and
background brightness before every measurement
to make the inspection conditions constant.
Fig. 14.5  Goldman perimeter with dome and chin rest The refraction of the eyes should be corrected
for central 30-degree visual field test. Normal or
with a white background (Fig. 14.5). It is designed better eyes should be performed first. Make sure
to examine visual field under the constant mea- that the eye is completely covered by eye patch
surement condition by standardizing the back- that does not cross the nose. Raise the upper eye-
ground brightness and the size and intensity of lid with a bandage for the eyes with ptosis. Move
the target in several steps and test both the center the chin rest to the left during the right eye test
and peripheral fields. and move the chin rest to the right for the left eye
14  Visual Field Test 183

Fig. 14.6  The result of

Goldman perimeter of
the left eye

test. Allow the patient to be used to the perimetry target to the center of the blind spot after turning
for 2 minutes before starting the test. Behind the off the target and confirm that it is invisible by
hemisphere through the telescope, adjust the flashing the target. Move the target in four direc-
patient’s pupil position to the center with the tions up and down, left and right from the center,
adjusting screw, and observe the fixation status and eight directions in between. Then draw a line
frequently during the examination. The target connecting the points which the patient signals.
size ranges from 0 to V (0, 1/16 mm2; I, 1/4 mm2; Normally, each isopter is drawn at almost the
II, 1 mm2; III, 4 mm2; IV, 16 mm2; V, 64 mm2). same interval. If there is scotoma, the range of the
The stimulus intensity ranges from 1 to 4 scotoma is quantitatively measured by changing
(increased by 5  dB) and a to e (increased by the brightness or size of ​​the target. If there is no
1 dB). The test generally starts from I-4-e, I-3-e, scotoma, change the brightness of the target, and
I-2-e, and I-1-e. If the isopter is narrow, check measure the isopter in the middle area (Fig. 14.6).
with larger targets (II–V). Refractive correction for examination distance
Start examination while moving the target from (33 cm) should be done. If patients have myopic
the periphery of the meridian to the center at a rate glasses, they may use it. Use the corrective lens
of about 5  degrees/sec, and examine the central after performing the refractive correction if the
field at a rate of 2–3 degrees/sec. The meridian is visual field is narrower than the normal range of
measured at an interval of 30–45 degrees. When each isopter or if the target is not visible. Always
measuring the next isopter, check the meridian that monitor the patient’s attention during the exami-
has not been inspected before. The V-4 target does nation. Some patients do not blink because they
not need to be measured very precisely, just move focus too much on the test, but in this case,
the target at a 45-degree interval. When the patient fatigue or dryness of the cornea may reduce the
looks at the target and signals, record the target accuracy of the test.
with a pencil, and connect the points as smoothly
as possible to draw an isopter. When moving the Characteristic Visual Field
target from the center to the periphery, be sure to Findings and Examination
turn off the target before moving. Method
The blind spot is located at about 15 degrees From the shape of the visual field defect, it is pos-
on the temporal side and 3 degrees on the inferior sible to speculate where the brain lesion is pres-
side of the horizontal meridian. Move the I-4 ent. Ring scotoma is characteristic visual field
184 J.-W. Lee

defect of retinitis pigmentosa. First, measure projection manner. The projection method can
from the periphery with the V-4 target, and then change the color of the target, and early detection
measure with the I-4 target. If a ring scotoma is of glaucoma has been attempted using short-­
suspected, the V-4 target is statically illuminated wavelength automated perimetry (SWAP) which
between V-4 and I-4. If there is no abnormality project a blue target on a yellow background.
with the V-4 target, you may use II-4 or III-4 tar- Humphrey projects stimulus for 0.2 second and
get. In the early stage, scattered isolated scoto- Octopus projects stimulus for 0.1  second. The
mas may be found in some cases. interval between projections of stimulus can be
Glaucoma is characterized by paracentral sco- adjusted according to the reaction of the patient.
toma, Bjerrum scotoma, and nasal step. In more The size of the stimulus is the same as the Goldman
than 90% of cases, the scotoma is located within perimeter size III (4  mm2), and the brightness is
the central 30 degree. adjusted according to the strategy. The distance
Central scotoma is found in cases with optic from the eye to the stimulus is about 30–51  cm
neuritis and macular holes. First, measure from depending on the perimetry. Patient fixation can be
the periphery with the V-4 target, identify each monitored directly by the examiners or monitoring
isopter, and then move the target from the center of pupil position and eye blinking using a video
toward the periphery to check the size of sco- camera and stimulation of the blind spot.
toma. If the decline in sensitivity at the center is Several statistical programs have been devel-
not severe, the I-4 target can be used because the oped to analyze the visual field change. The most
scotoma may not be detected with the V-4 target. commonly used ones are Humphrey’s STATPAC
and Octopus’s Delta program. These statistical
programs incorporate statistical data on the nor-
14.4 Automated Perimetry mal visual field sensitivity of the patient’s age
group, assessing the significance on the visual
The automated perimetry is a visual field system field abnormalities from the patient’s visual field
that automatically illuminates the target and sensitivity and assessing progression compared
records the response of the patient to the target with previous examinations. These statistical
illuminated. It is possible to quantitatively mea- programs provide an accurate interpretation of
sure the photosensitivity of the area by changing visual field changes, but the judgment by experi-
the brightness of the target at a predetermined enced ophthalmologist is essential in the applica-
check point so that it is possible to detect a small tion in clinical practice.
scotoma more sensitively than the manual perim-
etry and standardize the inspection conditions
equally so that the objective visual field can be
judged. Because of installed age-­matched sensi-
tivity, the accuracy and reproducibility of the test
results were excellent, and it became the standard
of glaucoma visual field test. Typical automated
perimetries include Octopus® and Humphrey®
(Fig. 14.7).
The backlight is generally fixed depending on
the device. Octopus uses a brightness of 4 asb,
and Humphrey uses brightness of 31.5 asb, same
as the Goldman perimetry. Depending on the
equipment that illuminates the target, the type of
perimetry can be divided into one with a projec-
tion method or a semiconductor method.
Humphrey and Octopus project their targets in a Fig. 14.7  Humphrey perimeter
14  Visual Field Test 185

14.4.1 Testing Strategies stimulus decreases by 4 dB until it cannot be rec-

ognized. The brightness is then increased by 2 dB
Suprathreshold static perimetry is a measurement (4-2 algorithm). It is checked once more by 2 dB
method that gives a stimulus slightly higher than (4-2-2 algorithm). Repeating three times takes
the normal threshold to the corresponding retina longer but more accurate than repeating only two
to detect the presence or absence of the reaction. times. At present, the general visual field test sys-
The test time is short and is used as a screening tem uses the 4-2 algorithm. Thus, the time
test, but it is not suitable for finding the depth or required to examine the central visual field
shape of a scotoma. To compensate for aforemen- 30  degrees is about 15–20  minutes, which
tioned drawbacks, a threshold-related strategy requires considerable patient fatigue. Several
that projects 4–6 dB brighter stimulus than the algorithms have been developed to shorten the
threshold of the patient’s previous examination to examination duration.
can be used to determine the progression of Fastpac measures threshold only once per test
visual field defect. ‘Three Zone’ option of the location with changing the stimulus intensity by
multiple level test (Humphrey) distinguishes the 3  dB.  The examination duration is shortened to
absolute scotoma from the relative scotoma by about 70%, but it is affected by the patient’s mis-
stimulation of a field defect with maximum inten- takes, and the fluctuation of the threshold value is
sity that did not respond to suprathreshold stimu- large. The error between the tests was reported to
lus. Octopus program 03 or 07, ‘Quantify be similar to that of the full threshold. The SITA
Defects’ options measure the sensitivity of a field strategy, reduced the test time to half of the full
defect that does not recognize the suprathreshold threshold with visual field modeling and infor-
stimulus. mation index, control of the examination time
Threshold static perimetry is the standard depending on the patient response time, and
method to detect the threshold of each test loca- recalculation of the measured thresholds. Test
tion of patient’s visual field with first projecting results were reported to be similar to that of full
suprathreshold stimulus and then increasing or threshold.
decreasing the stimulus intensity gradually. A
commonly used program is to measure the
thresholds of 70–80 test points in the central 14.4.2 Methods
24  degree and 30  degree with a 6-degree-­apart
grid test (Octopus program 32, Humphrey central Turn on the power and select the type of visual
24-2 and 30-2). For patients with central visual field test. Enter patient information such as iden-
field abnormality, the central 10-2 examination tification number, name, date of birth, correction
with 2-degree-apart grid is recommended lens, and other eye conditions (diagnosis, pupil
(Table 14.1). size, visual acuity, intraocular pressure, cup-to-
The basic algorithm is a full threshold. The disc ratio). The pupil should be located at the
first stimulus gives a brighter light than the center of the corrective lens, and a contact lens is
expected threshold of the patient. If the patient more preferred for patients with ±6 diopter or
recognizes the stimulus, the brightness of the more. After covering one eye not to be inspected,

Table 14.1  Typical threshold testing program for Humphrey perimeter

Program Purpose Location Number of test points Density
Central 30-2 Within 30 degree Central grid 76 6 degree
Central 24-2 Within 24 degree Central grid 54 6 degree
Central 10-2 Within 10 degree Central grid 68 2 degree
Macula Macula Central grid 16 2 degree
Peripheral 60-4 30–60 degree Peripheral grid 60 12 degree
186 J.-W. Lee

have the patient to get accustomed to the bright- fatigue. If the false-negative rate is more than
ness of the visual field machine for about 3 min- 33%, a warning sign is displayed.
utes before the examination. Have the patient In Octopus, 10% of the total stimuli given are
look at the bright light of fixation target in the catch-trials, and the number of catch-trials with
center, and press the response button when the wrong answer is given as a reliability factor and
stimulus projected to the hemisphere is flashing. expressed in %. If the reliability factor is 10%, it
The examiners monitor through the screen is assumed that 10% of the answers in the other
whether patient’s gaze is directed at the fixation tests are not answered correctly, and care must be
target. If the patient feels tired during the test and taken when the reliability factor value is more
is unable to focus on the test, the test can be tem- than 10%. The wrong answer should not be more
porarily discontinued with the response button than 15%. The threshold values are measured
pressed. After the test is completed, save the test twice at the predetermined 10 points to evaluate
result and examine the fellow eye and print the the consistency of the response. Short-term fluc-
result if necessary. tuation is used to calculate corrected pattern stan-
dard deviations and increases in visual field
defect. The SITA algorithm does not calculate
14.4.3 Interpretation of Reliability short-term fluctuation.
Normal subject may also have visual field
To determine the threshold of one test location, defects at initial examination. Most patients with
usually five stimuli are needed. If there is a visual glaucomatous visual field defects should be
field defect, the number of stimuli increases. In par- trained for visual field testing until reliable visual
ticular, if the patient’s response is inconsistent, the field results are obtained. The learning effect is
number of stimuli and the test time will increase. minimal at the central visual field, while periph-
Reliability is low when more than 550 stimuli are eral visual field is more likely affected by learn-
projected or when the test takes more than 18 min- ing effect. It is unlikely that a visual field appears
utes. On the other hand, the patient’s fatigue may normal due to the learning effect. Therefore, if
increase and the sensitivity of the visual field may other reliability indices are reliable and the visual
decrease. In extreme cases, the visual field may field test result is completely normal, the test
show the cloverleaf shape because of the difference result is reliable. In the case of three or more of
in sensitivity between the test area in the late stage the following factors in the visual field test, the
of the test and the test area in the early stage of the reliability is low:
test. If the patients press the response button even
when the stimulus is projected to physiological • Total questions ≥400
scotoma, it is considered as fixation loss (Heijl- • Fixation loss ≥20%
Krakau technique). A warning sign is displayed if • False-positive responses ≥33%
the fixation loss rate is over 20%. • False-negative responses ≥33%
When the patients press the response button • Short-term fluctuation ≥4.0 dB
even when stimulus is not projected or the stimu-
lus under threshold is projected, it is considered
as false-positive error. If the patients keep press- 14.4.4 Interpretation of the Results
ing the button, they are probably “trigger-happy” of Automated Perimetry
patients. If false-positives are above 33%, a warn-
ing sign is displayed. When the patients do not Numeric Results
press the button when the greater stimulus is pro- and Grayscale
jected to the area where the threshold was already There are two largest images on the printout next
measured, it is considered as false-negative error. to the reliability indices. The image with actual
It can be scored high regardless of reliability in threshold values at each test location has numeric
patients with advanced glaucoma because of results expressed in dB scale. The grayscale plot
14  Visual Field Test 187

is extrapolated from the corresponding sensitiv- of the same age group? The higher the hill
ity of numeric results. The higher threshold value of vision, the more uneven and irregular
or the brighter the gray scale is, the higher the the patient’s visual field. If there is a local
sensitivity is and the vice versa. field defect such as glaucoma, PSD
If there is media opacity like cataracts or a becomes significantly higher. PSD and LV
small pupil, the overall sensitivity is reduced. are the values adjusted with short-term
Local sensitivity deterioration is more important fluctuation value. PSD and CPSD are not
than overall sensitivity deterioration. Identify the used by SITA algorithm.
glaucomatous visual field changes, such as the
paracentral scotoma, the arcuate scotoma, and Total Deviation
nasal step. and Comparison Table
Continuous visual field defect in multiple test The difference between the age-matched normal
points is more significant than a severe sensitivity value and the actual threshold value of patient at
deterioration in one point. A sensitivity reduction each location is calculated, and probability sym-
of 5–6  dB at three continuous points, 8–9  dB bols indicating the significance of abnormality
reduction at two continuous points, and reduction are provided. The negative value of total devia-
of sensitivity more than 10 dB at one point in two tion of Humphrey perimetry and the positive
or more consecutive visual field tests are consid- value of Octopus comparison table mean that the
ered as local visual field sensitivity loss in sensitivity of the test location is lower than that of
patients with early glaucoma. the age-matched normal group. Global Indices Pattern Deviation

1. Mean deviation (MD, Humphrey) and mean When glaucoma and cataract coexist, the visual
defect (MD, Octopus) field sensitivity can decrease diffusely (general-
• MD is an averaged value of overall differ- ized depression) due to the effect of cataracts,
ence between the expected threshold value which makes differentiating visual field loss
of the same age group with normal visual caused by lens opacity from that caused by glau-
field and the actual threshold value of the coma challenging. In pattern deviation plot, the
patient. The Humphrey perimetry provides local field defect (localized loss) becomes more
mean deviation value. The more negative apparent by excluding the diffuse deterioration of
mean deviation value means the lower the visual field sensitivity. Pattern deviation is
visual field sensitivities. The Octopus also helpful for excluding sensitivity loss due to a
perimetry provides the mean defect value. pupil contraction. A probability symbols are also
The positive mean defect value means displayed.
visual field sensitivity loss.
2. Shor-term fluctuation (SF) Glaucoma Hemifield
• Shor-term fluctuation means intra-test vari- Test (GHT)
ability. It is calculated with examining ten GHT is a strategy provided by the Humphrey
predefined test locations for two times and perimetry STATPAC 2 to detect localized loss.
is less than 2 dB in 90% of group with nor- It detects early glaucomatous changes by com-
mal visual field. SF is not used by SITA paring the threshold values in corresponding
algorithm. mirror image areas of the superior and inferior
3. Pattern standard deviation (PSD, Humphrey), hemifield.
corrected pattern standard deviation (CPSD,
Humphrey), loss variance (LV, Octopus), and Examples (Figs. 14.8 and 14.9)
corrected loss variance (CLV, Octopus) 1. Patient data and testing strategy
• How similar is the shape of the visual field At the top of the single field printout, the
of the patient to that of normal visual field patient’s name and date of birth are recorded.
188 J.-W. Lee

Fig. 14.8  A printout of visual field test shows patient data and test program, reliability index, numeric scale and gray
scale, total deviation, pattern deviation, glaucoma hemifield test, and global indices

Beneath it, the patient’s pupil size, visual acu- is less than 3 mm, the overall sensitivity of the
ity, test date, and test program are shown. This visual field may decrease. If the corrected
patient underwent a Central 30-2 and SITA- visual acuity is less than 0.3, the reliability
standard test program. If the size of the pupil may decrease.
14  Visual Field Test 189

Fig. 14.9  A printout of visual field test shows visual field index (VFI) and guided progression analysis

2. Reliability this patient shows 10% (2/20) of fixation

Fixation loss, false-positive rate, false-­ loss, 3% of false-positive rate, 6% of false-
negative rate, and test time are shown as the negative rate, and the test time less than
reliability indices of the test. The printout of 9 minutes.
190 J.-W. Lee

3. Numeric scale and gray scale the glaucoma hemifield test and global indices
This patient shows a typical arcuate scotoma (MD, PSD) on the printout. The VFI based on
in the upper visual field. pattern deviation analysis is reported to be less
4. Total deviation affected by cataract than MD. The VFI is pre-
In this patient, the decrease in sensitivity is sented in %, where 0% indicates blindness and
noted as negative value of dB in the arcuate 100% represents normal visual field. A linear
scotoma and is also displayed in the probabil- regression analysis of VFI can be displayed if
ity plot below. more than five visual field tests are performed
5. Pattern deviation for at least 3 years.
In this patient, the upper visual field defect is 8. Guided progression analysis (GPA)
shown similar to the result of total deviation. GPA helps detect the visual field progression,
6. GHT which is available in SITA standard, SITA
The results of GHT (the comparison of thresh- Fast, and full threshold modes of Humphrey
old value of the corresponding five mirror perimetry.
zones for lower and upper hemifield) are com- Triangle symbol display
prised of the following five findings. This
• Small open triangle: when it was signifi-
patient has “outside normal limits” message
cantly worse at any point (p < 0.05)
because the sensitivity in the upper visual
• Half-filled triangle: when it was signifi-
field was significantly reduced compared to
cantly worse on two consecutive tests
the lower visual field.
• Filled triangle: when it was significantly
• Outside normal limits: The pair difference
worse on three consecutive tests
is greater than that found in 1% of the nor-
GPA alert
mal population in one or more areas.
• Possible progression: significant deteriora-
• Borderline: The pair difference is that
tion at three or more points on two consecu-
found in less than 3% of the normal popu-
tive tests
lation, but the criteria for outside limits are
• Likely progression: significant deteriora-
not met.
tion at three or more points on three con-
• General depression of sensitivity or abnor-
secutive tests
mally high sensitivity: General depression
of sensitivity means even the highest value
is lower than 0.5% the normal control 14.4.5 Frequency Doubling
group value. Abnormally high sensitivity Technology Perimetry
means the highest 15% of the values are (Fig. 14.10)
greater than 99.5% normal population
value. There are two types of retinal ganglion cells: P
• Within normal limits: If the above criteria cell and M cell. P cell constitutes the majority of
are not reached, this message is displayed. retinal ganglion projecting to the parvocellular
• Global indices in this patient: MD was layer of lateral geniculate nucleus. The conduc-
−12.92  dB, showing a large difference in tion velocity is slow because the axon diameter of
mean threshold value compared to the nor- these cells is relatively small. P cells respond to
mal control of the same age group. PSD stimulus with high spatial frequency and low
was measured as high as 14.86 dB, indicat- temporal frequency. Another cell is called M cell.
ing that there is a local field defect. SF and M cells account for about 15% of human retinal
CPSD are not shown because the SITA- ganglion cells projecting to the magnocellular
standard testing strategy was performed in layer of lateral geniculate nucleus. The conduc-
this patient. tion velocity is fast because the axon diameter of
7. Visual field index (VFI) the cells is relatively large. These cells respond to
VFI was developed by Boel Bengtsson and stimulus with low spatial frequency (large target)
Anders Heijl in 2008. It is displayed in between and high time frequency (moving target) and are
14  Visual Field Test 191

examination of 17 points mentioned above. It

takes 4–5 minutes to test one eye with C-20 and
5–6 minutes with N-30. The results of the thresh-
old test are printed with basic information such as
name, test time, actual value of the contrast sen-
sitivity in dB, and the analysis result compared
with the age-matched normal contrast sensitivity
of the FDT perimetry data base.
The contrast sensitivity of each test point is
compared with the contrast sensitivity of the age-­
matched normal subjects in the FDT.  The total
deviation and pattern deviation same as the
Humphrey visual field were calculated. They are
divided into four significance levels: the signifi-
cance level < 5%, < 2%, < 1%, and < 0.5%. In the
Fig. 14.10  Frequency doubling technology perimetry
FDT perimetry, there are several parameters such
as MD and PSD corresponding to the global indi-
mainly involved in motion processing and high-­ ces of the Humphrey perimetry, and it is possible
frequency flicker information. to comprehensively evaluate the test results using
When a flicker stimulus is applied at a high statistical techniques.
time frequency of 15 Hz or more with a low spa-
tial frequency grating pattern of 1 cycle/degree or
less, it looks like a grating pattern of double fre- 14.4.6 Interpretation of Visual Field
quency rather than gray. This is an induced opti- Test in Clinical Practice
cal illusion of flickering called frequency
doubling illusion. M cells are involved in this Hemianopsia is defined as a defect in half of the
phenomenon. FDT is useful for early detection visual field, and quadrantanopsia is defined as a
and screening of glaucoma. FDT, which selec- defect in one fourth of the visual field. It is called
tively stimulate M cell, can detect glaucomatous temporal, nasal, or vertical according to the loca-
visual field defect earlier than white-on-white tion of the defect and is divided into homony-
perimetry because M cell may be more suscepti- mous and heteronymous according to the spatial
ble to glaucomatous damage. relationship of the two eyes.
Screening tests are performed with
0.25  cycle/degree grating pattern with 25  Hz Depression
flicker stimulus to induce frequency doubling The depression indicates the decrease in thresh-
illusion. The test time is short (about 1 minute old sensitivity compared with normal expected
for one eye) because it is performed with supra- value. It can be divided into general depression
threshold stimulation. The C-20 screening test and local depression.
examines a total of 17 test locations within cen-
tral 20  degrees: the test points consist of four Contraction
rectangular-shaped targets of 10  degrees in The isopter moves toward the center due to a
diameter for each quadrant and one target with a decrease in sensitivity of the peripheral visual
radius of 5  degrees in the center. The N-30 field. The sensitivity decreases in the periphery
screening test has two more points with a diam- while the sensitivity is normal near the fixation.
eter of 10 degrees at nasal side.
C-20 and N-30 threshold tests randomly select Scotoma
1 test point from 17 test points and show the tar- 1. Absolute scotoma is a visual field defect that
get and change the contrast sensitivity step by persists even when the highest stimulus is
step. The two added points are measured after the used, while relative scotoma disappears when
192 J.-W. Lee

tested with brighter stimulus. The central is the visual field defect that extends from cen-
visual field defect is named as the central sco- ter to the blind spot (Fig. 14.11).
toma, and adjacent scotoma is named as the 2. An arcuate scotoma is a visual field defect
paracentral scotoma. The cecocentral scotoma that occurs in area about 10–20  degrees

Fig. 14.11  Superior paracentral scotoma in the right eye

14  Visual Field Test 193

upward or downward from the fixation.

4. Central scotoma or central blind spot is
Seidel scotoma is the arcuate scotoma that is observed in dominant optic atrophy and optic
connected to a blind spot. The ring-shaped neuritis (Fig. 14.14). Because the nerve fibers
visual field defect with superior and inferior of the temporal retina intersect at the optic chi-
arcuate scotoma is called a ring scotoma asm, the lesion before the optic chiasm does
(Fig. 14.12). The arcuate scotoma appears in not follow the vertical meridian, and the visual
glaucomatous optic neuropathy but may also field damage due to the lesions at the optic chi-
occur due to retinal disease, optic disc asm and lesions posterior to optic chiasm fol-
lesions, anterior optic nerve lesions, and low the vertical meridian (Fig. 14.15).
lesions on the posterior part of the optic
pathway. Examples of Incorrect Test
3. When the upper and lower arcuate scotoma Results
meet at the temporal raphe, the difference in The visual field test results can be influenced by
the size of the two scotomas can lead to a the edges of the corrective lens, fatigue, ptosis,
stepped field defect called the nasal step learning effect, and trigger-happy phenomenon
(Fig. 14.13.). (Figs. 14.16, 14.17, 14.18, and 14.19).
194 J.-W. Lee

Fig. 14.12 (a) Superior arcuate scotoma of the left eye. (b) Ring scotoma of the left eye
14  Visual Field Test 195

Fig. 14.12 (continued)
196 J.-W. Lee

Fig. 14.13  Nasal step in the right eye

14  Visual Field Test 197

Fig. 14.14  A 21-year-old female patient with central scotoma in both eyes. She had a history of familial history and an
OPA1 mutation and was diagnosed as autosomal dominant optic atrophy
198 J.-W. Lee

Fig. 14.14 (continued)
14  Visual Field Test 199

Fig. 14.15  Asymmetric bitemporal visual field defects in a 44-year-old male patient who reported a sudden drop in
visual acuity in his left eye a month ago. A pituitary gland adenoma was found in the pituitary MRI scan
200 J.-W. Lee

Fig. 14.15 (continued)
14  Visual Field Test 201

Fig. 14.16  Example of incorrect test result due to corrective lens rim
202 J.-W. Lee

Fig. 14.17  Clover leaf appearance due to increased false-negative rate related to patient fatigue
14  Visual Field Test 203

Fig. 14.18  Upper visual field defect (a) due to ptosis is not found in visual field examination (b) after ptosis
204 J.-W. Lee

Fig. 14.18 (continued)
14  Visual Field Test 205

Fig. 14.19  Learning effect of visual field test. Since the had severe damage in the initial visual field test, but the
automated visual field test has a learning effect, the initial visual field improved remarkably as the patient became
visual field tests may not be reliable. Patients in this case accustomed to the test environment
206 J.-W. Lee

Fig. 14.19 (continued)
14  Visual Field Test 207

Suggested Reading Caprioli J.  Should we use short-wavelength automated

perimetry to test glaucoma patients? Am J Ophthalmol.
Alencar LM, Medeiros FA. The role of standard automated
Heijl A, Leske MC, Bengtsson B, Bengtsson B, Hussein
perimetry and newer functional methods for glau-
M, Early Manifest Glaucoma Trial Group. Measuring
coma diagnosis and follow-up. Indian J Ophthalmol.
visual field progression in the Early Manifest Glaucoma
Trial. Acta Ophthalmol Scand. 2003;81(3):286–93.
Anderson DR, Patella VM.  Automated static perimetry.
Lee J-W, Morales E, Yu F, et al. Effect of cataract extrac-
St. Louis: Mosby; 1999.
tion on the visual field decay rate in patients with glau-
Arnalich-Montiel F, Casas-Llera P, Muñoz-Negrete FJ,
coma. JAMA Ophthalmol. 2014;132(11):1296–302.
Rebolleda G.  Performance of glaucoma progression
Leeprechanon N, Giaconi JA, Manassakorn A, Hoffman
analysis software in a glaucoma population. Graefes
D, Caprioli J.  Frequency doubling perimetry and
Arch Clin Exp Ophthalmol Albrecht Von Graefes Arch
short-wavelength automated perimetry to detect early
Für Klin Exp Ophthalmol. 2009;247(3):391–7.
glaucoma. Ophthalmology. 2007;114(5):931–7.
Bengtsson B, Heijl A. A visual field index for calculation
Leske MC, Heijl A, Hyman L, Bengtsson B.  Early
of glaucoma rate of progression. Am J Ophthalmol.
Manifest Glaucoma Trial: design and baseline data.
Ophthalmology. 1999;106(11):2144–53.
Fundus Examination
Han-Jo Kwon and Sung-Who Park

The fundus exam views the eye’s interior through The rays of the light bulb built in the ophthal-
the pupil, which is a small hole. moscope are reflected on the patient’s retina
If necessary, the pupil is examined after it is through the pupil, and the reflected light returns
dilated with 0.5–1% tropicamide or 2.5–10% to the eye of the examiner through the pupil
phenylephrine. Because pupil dilatation may (Fig. 15.2a).
cause angle closure glaucoma, it should be
performed after checking the anterior chamber
depth. 15.1.1 Methods
The fundus examination can be performed
through fundus photography or by means of Setting the Ophthalmoscope
direct ophthalmoscope, indirect ophthalmoscope, (Fig. 15.2b)
and slit lamp. • The white color is used for the illumination
• Choose the narrow illumination light in the
15.1 Direct Ophthalmoscopy not dilated pupil.
• Choose the wide illumination light in the
The direct ophthalmoscope is compact and dilated pupil.
doesn’t weight much, making it portable and easy • Place the lens power scale at 0 diopter. Check
to operate. It has an upright image with a magnifi- the being in the focus with 0 diopter scale.
cation of 15. It is suitable for observing the poste-
rior pole including optic discs, retinal vessels, and Process
macula. The direct ophthalmoscope, however, • Dim the light.
does not allow stereopsis, and it is difficult to • The examiner sits opposite the patient or
observe things if the lens or the vitreous bodies stands next to the patient.
are opaque. The observation range is narrow, • Open both eyes of examiner and the patient.
ranging from 8° to 10° (Fig. 15.1). • Place the hand that is not holding the ophthal-
moscope on the patient’s head, and pull the
eyelid with thumb, when the eyelid fissure is
H.-J. Kwon, MD. (*) too narrow to be examined.
Department of Ophthalmology, Pusan National • Have the patient look at an object 3–5 m away
University Hospital, Busan, South Korea
and slightly higher than the eye level.
S.-W. Park, MD., PhD • When examining the patient’s right eye, hold
Department of Ophthalmology, Pusan National
University School of Medicine, Busan, South Korea the ophthalmoscope with your right hand, and

© Springer Nature Singapore Pte Ltd. 2019 209

J.-S. Lee (ed.), Primary Eye Examination,
210 H.-J. Kwon and S.-W. Park

Viewing window

Lens wheel Mirror

Lens power scale

adjustment button
Light adjustment Aperture
collar adjustment wheel

Power base
and handle

Light adjustment

Power base
and handle

Fig. 15.1  Direct ophthalmoscope

Patient Examiner

Aperture Description How to use

Large aperture When viewed through a large pupil

Small aperture When viewed through a small pupil

Detect changes in the retinal nerve fiber layer or

Red-free filter
observe microaneurysm and vascular abnormalities

Slit beam Detecting the contour of the retina

Small retinal lesion, measuring vessel diameter

(in 0.2 mm increments)

Fig. 15.2 (a) Principle of the direct ophthalmoscope, (b) Parameters of the direct ophthalmoscope
15  Fundus Examination 211

Fig. 15.3  How to hold the direct ophthalmoscope

look with your right eye. When examining the

Fig. 15.4  Indirect ophthalmoscope, scleral depressor and
patient’s left eye, hold the ophthalmoscope convex lenses
with your left hand, and look with your left
eye (Fig. 15.3).
• As an examiner, place your index finger on the medium. It is the best way to exam the fundus
front of the lens so that you can adjust the with a scleral depressor, so that it is commonly
diopter of the lens diaphragm during the exam- used in examination of retinopathy of prematu-
ination, and hold the ophthalmoscope with the rity and in scleral buckling surgery. Using a
rest of your fingers. Fix the head of the oph- scleral depressor, you can examine the anterior
thalmoscope to your eyebrow, and bring your portion of the equatorial retina, the ora serrata,
eye as close as you can to the observation hole. and even the pars plana. The indirect image can
• Check the red fundus reflex by putting a light be confusing as it is reverse and upside down, and
on the patient’s pupil about 30 cm away from one needs practice in order to use the indirect
the patient. ophthalmoscope well. It has a rather low magni-
• As you continue to approach the red eye fication of two to five, which limits the obser-
reflex, you will see the reflection of the cornea vance of microscopic changes to the retina
surface. The reflection disappears, and fundus (Fig. 15.4).
will appear when you are 7–8 mm away from
the cornea. The closer the distance, the wider
the field of view becomes. 15.2.1 Methods
• When the patient is looking straight, you can
see the patient’s optic disc if you look into the Principle and Process
eye about 15° to the ear. If you can’t find optic The rays from the ophthalmoscope converge at
disc, follow thicker vessel to find it. a point on the pupil after passing a convex lens
• Focus on the retinal vessels by turning the lens placed in front of the patient’s eye, which then
power scale. ray get in the inside of the eye. The rays
• The green number on the lens power scale reflected from the fundus pass through the same
indicates the plus diopter, and the red number convex lens, and examiner can observe reverse
indicates the minus diopter. images at 30–50  cm apart from the observer
(Fig. 15.5).
Put the ophthalmoscope on your head, and fix
15.2 Indirect Ophthalmoscopy it by turning the vertical and horizontal fixing
screws after putting the ocular lens as close to
The indirect ophthalmoscope has a wide and ste- your eye as possible. It is better not to wear eye-
reoscopic view. It can provide relatively clear glasses to shorten the distance between your eyes
view even with some degree of opacity in the eye and ocular lens, because it provides wider view.
212 H.-J. Kwon and S.-W. Park

Fig. 15.5  Principles of

the indirect Retinal image plane

Convex lens Examiner


You can insert the lens to correct your refractive close to the patient’s foot and looking up from
error into the ocular lens of the ophthalmoscope. there or by making the patient look up. Observe
Place your thumb 40 cm apart from your eyes. the temporal, inferior, and nasal fundus in the
Adjusting the pupil diameter, make your thumb same way. It is better for you to observe the
the center of each view when you close the other patient from various directions and angles by
eye. And then check your binocular vision. moving yourself around than moving the
Make direction of the illumination ray come patient’s eyes, because you can make a continu-
into the upper half of your view. An excessively ous observation that way.
bright light might cause phototoxicity. Make sure Observe the ora serrata and the peripheral ret-
you select the appropriate brightness, and avoid ina using a scleral depressor.
long examination on fovea. The pupil is tilted when you observe the
Dilate the pupil. peripheral retina, which makes the field of vision
Examination is possible when the patient is in narrow. You should adjust your head and body
bed or sitting. However it is better that patients lie position in order to get a stereoscopic view. You
down when the examination takes long or when cannot get a stereoscopic vision if one of your
scleral depressor is used (Fig. 15.6). visual axes is located within the pupil.
Check the red pupil reflex without convex lens
at the distance of about 30–50 cm. Choosing and Using the Lens
If you are right-handed, hold the convex lens Make sure that the convex side of both lenses
using your left thumb and index finger, and put faces toward the examiner.
your ring and little finger on the patient’s eye You can use a lens of +14–+40 diopters. The
socket or his/her forehead. Your left middle finger most commonly used one is a +20 diopter lens.
could pull the upper or lower eyelid. You can pull The higher the power of lenses, the closer the
the other eyelid or press the sclera with your right distance between the examiner and the patient
hand. and the distance between the lens and the patient’s
Move the lens slowly toward the patient’s eye eye. The distance between the lens and the
from a distance of about 15  cm in front of the patient’s eye is 100 cm divided by the lens power.
patient’s cornea, and find a spot where the fundus In other words, a +20 diopter lens should be
is clearly visible. You can also find the spot by placed about 5 cm in front of the patient’s eyes,
moving the lens gradually away from 1.5–2 cm in 14 diopters 7 cm, and 30 diopters 3.3 cm.
front of the patient’s eyes. The magnification is inversely proportional
to the power of convex lenses. It is obtained by
Observation Procedure dividing the refractive index (about 60 diopters)
Stand on the right side of the patient and exam- of the patient’s eye by the power of the convex
ine the right eye. Observe the optic disc first lens. In other words, the magnification using a
and then the macula. Then observe the area 20-diopter lens is 60/20 = 3 times, 4 times for a
nearby along the blood vessel. When you 14-diopter lens and 2 times for a 30-diopter
observe the superior fundus, do so by moving lens.
15  Fundus Examination 213

Fig. 15.6  Indirect ophthalmoscopy. (a) Indirect ophthal- is raised, and the examiner is bent and examined in a low-
moscope. (b) The doctor is standing and checking around gaze position. Record the fundus findings on a chart
the patient’s head. The patient is laid down, and the chair placed upside down on the patient

Lenses with low magnification such as the Let the patient lie down straight after dilating
+30 diopter lens have a wide field of vision, but the pupil to the maximum. Put the eye under
the fundus appears dark and small. Lenses with anesthesia in appropriate methods such as topical
high magnification such as the +14 diopter lens anesthesia.
have a bright fundus and a high magnification but There are various types of sclera depressors:
a narrow field of vision. some put pressure on the eyelid, while others put
A lens with a low magnification such as a +30 pressure on the conjunctiva.
diopter lens is recommended in cases with small The end of the depressor, the pupil of the
pupil or opacity on its medium. patient, the convex lens, and the axis of
Using yellow filter lens, which reduces short-­ illumination light must be aligned for the optimal
wavelength light that is easily scattered, is helpful observation.
in case of opacity on its medium. Because the superior, inferior, and temporal
sides are easy to press, but the nasal side has no H  ighlights in Using a Scleral eyelid, the examiner finally anesthetizes the eye
Compressor (Fig. 15.7) and compresses on the conjunctiva.
Scleral depression is performed to examine areas
between the equatorial portion of the fundus
(14 mm from limbus) and the ora serrata (8 mm 15.3 Slit Lamp Ophthalmoscopy
from limbus). When the scleral is depressed, the
retina can be observed from various angles, The slit lamp ophthalmoscopy allows us to exam-
allowing the retinal ridge, tear, and traction to be ine the vitreous body and the retina in stereo-
observed more clearly. scopic vision. It had been mainly used for an
214 H.-J. Kwon and S.-W. Park

a b c

d e

f g

Fig. 15.7  Indirect ophthalmoscopy using a scleral depressor. (a) Examination posture. (b) Superior side. (c) Inferior
side. (d) Temporal side. (e) Nasal side. (f) Above the eyelid. (g) Pressure on conjunctiva

in-depth examination of a lesion found through Adjust the magnification of the slit lamp to
indirect or direct ophthalmoscopy, but it has 10–16 times. Note, however, that increasing the
recently become a common examination method magnification does not mean an increased
for the retina and vitreous. resolution.
Set the illumination device to almost match
with the visual axis of the microscope while
15.3.1 Methods putting the focus on the center of the corneal sur-
face with a slit width of 4 mm.
The slit lamp alone can only let you observe one Choose the brightness of the light within the
third of the anterior of the vitreous body, so an range that the patient can easily tolerate.
auxiliary lens is needed for you to observe the Hold a convex lens of +60–+90 diopters with
fundus. The concave lens neutralizes the your thumb and forefinger, and place it 4–12 mm
refractive power of approximately +60 diopter of in front of the patient’s cornea. The distance
eyes to allow for the direct observation of the between the lens and the patient’s cornea is
fundus. The concave lens is contact lens. shorter if the lens’ power is higher. Put your hand
The convex lens also can be used to exam the on the head immobilizer or on the patient’s cheek
fundus. Some are contact lens, and the others are to support and your elbow on the stand, and open
noncontact. You can observe the fundus indi- the patient’s eyelids with your middle and ring
rectly by placing a convex lens (contact or non- fingers. Check that the patient’s pupil is at the
contact lens). center of the lens.
Keep the slit light at the center of the convex Noncontact Lens lens and cornea. Hold the handle of the slit lamp
Make the examination room as dark as possible with the other hand, and pull it toward you and
and dilate the pupil sufficiently. away from the patient’s eyes to identify red
Place the patient on a slit lamp. reflexes and retina.
15  Fundus Examination 215

If the light reflection is severe, tilt the convex When examining the right eye of a patient, hold
lens a little to reduce the light reflection. the lens with the left hand; when examining the
It is advisable to have a routine of fundus left eye of the patient, hold the lens with the right
examination. In general, you should check the hand. This will allow you to fix your elbow with
optic disc first, and then check the peripheral area the elbow support, and you can take a stable
and the macula. Observe the patients’ fundus posture. When air bubbles enter into the lens, you
while making him/her look away or look at your can make them disappear by letting the patient
finger. move the eyes a little or by tilting or rotating the
When observing the vitreous body, change the lens if the bubbles are small. If the air bubbles are
direction of the illumination light such that the large, refit the lens.
angle between the illumination light and the Hold the lens with your thumb and your index
microscope is approximately 10–15°, and focus finger, and fix it with a light pressure so that it
on the vitreous body by pulling the noncontact does not fall out during the observation. Support
lens slightly toward the examiner. Making the the lower part of the lens with your middle or
patient move the eyeballs around may help as it ring finger, and fix your little finger on the
creates movement of the vitreous body (Fig. 15.8). patient’s eye socket. If there are light reflections,
tilt the lens slightly. The axis of the illumination Contact Lens system and observation system of the slit lamp
Perform topical anesthesia. Make the patient sit should be 5–10°. Set the slit lamp light to the
comfortably in front of the slit lamp and fix his/ brightest and narrow the width. Adjust the height
her head and jaw. Place one or two drops of the of the slit lamp light so that the rays can enter the
1–2% methyl cellulose solution on the concave pupil, and lower the magnification to 10–16
side of the contact lens without letting the air in. times. Move the adjustment knob up and down
Let the patient open the eyes wide and look and back and forth to focus on posterior pole of
upward. Open the eyelids with the thumb and the the fundus.
index finger of your other hand. Place the lower Start the observation while changing the mag-
part of the lens in the lower fornix conjunctiva nification and the direction of the slit lamp light.
under the cornea and the lower part of the cornea, If necessary, you can give it the vertical tilt by
and put the lens close to the cornea. When you let rotating the direction of the slit lamp light axis by
the patient slowly look straight, then the lens will 90° so that the light beam can be projected up
be attached to the front of the cornea (Fig. 15.10). from below. Wrinkling eyelid or pressing the

a b c

Fig. 15.8  Contact lens insertion method. (a) After the the lower surface of the eyeball. (c) The patient looks at
patient has seen the upper side, the lens is inserted into the the front, and then the lens is in full contact with the
inferior conjunctival fornix. (b) Contacting a lens to half eyeball
216 H.-J. Kwon and S.-W. Park

a b c d

e f g h

Fig. 15.9  Types of auxiliary lenses Volk noncontact lens: (f) SupraQuad 160 lens for observing the periphery retina.
(a) Super Pupil XL lens. (b) Super Field NC lens. (c) Fundus peripheral examination lens with scleral depres-
Digital Wide Field lens. (d) 78 diopter Volk contact lens. sor: (g) Kyoto Contact lens (suitable for Asians with nar-
(e) Area Centralis lens for observation of posterior pole. row palpebral fissures). (h) Haag-Streit lens

sclera near the lens edge disconnects the contact

between the lens and the cornea.

15.3.2 Characteristics and Tips

of Lens Noncontact Lens

If the patient’s palpebral fissure is narrow, lift the
upper eyelid up with the middle finger holding
the lens, and fix the lens at the same time
(Figs. 15.9 and 15.10). Fig. 15.10  Widening of the palpebral fissure
A +54 to +130 diopter lens, high-refraction
convex, has aspheric on both sides, so there is no
front side difference. A focal length of +90 diop- observe eyes with small pupil diameters or opac-
ter lenses is about 6 mm from the cornea and that ity on the medium. It consists of a central lens
of +60 diopter lenses is about +12 mm. The +90 (−58 to −60 diopters) and three reflectors around
diopter is widely used, because it shows wide the lens, 59° (goniscopic), 67° (peripheral), and
vision and is easy to use even when the pupil is 73° (equatorial).
small or when media opacity was existed. About 30° of the posterior pole of the retina is
A  +  60-diopter lens provides higher resolution observed through the central lens, and the periph-
and narrower vision than +90 diopter, making it eral and anterior chamber angles are observed
advantageous for macular observation. through the reflector. Observe the peripheral ret-
ina and anterior chamber angle as you rotate the Contact Lens lens 360°. The central lens provides a direct
image with the field of vision of 30°, and it is
Goldman Three-Mirror Lens used to observe the macula of the papilla. When
A Goldman three-mirror lens is a concave lens, you observe the peripheral retina with three
providing direct and narrow view. It is difficult to reflectors, set the long axis of slit light to be per-
15  Fundus Examination 217

67° a

b b
d c


Fig. 15.11  Range of observation of slit lamp fundus (b) From the equator to the ora serrata and pars plana. (c)
examination using Goldmann three-mirror lens. (a) 30° to the equator. (d) Observation of 30° range including
Structure of Goldmann three-mirror lens. (a) From macula. (b) Range of fundus visible by each lens. (c)
peripheral retina to pars plana and anterior chamber angle. Goldmann three-mirror lens

pendicular to the reflector for easier observation Tilting the lens or changing the patient’s line
(Fig. 15.11). of sight makes the range of vision wider. To see
Use a vertical slit light when observing at 12 more of the peripheral side with the reflector,
or 6  h periphery retina, and it does not matter provide as much mydriasis as possible, and let
whether the illumination light is shed from the the patient face the opposite side of the reflector.
left or the right side (Fig.  15.12a). When the A lens with a scleral depressor should be used
reflector is located at 6 o’clock, periphery retina to observe the ora serrata and the pars plana.
at 12  h was observed with the image upside
down. When you are observing the inferior retina High-Refraction Convex Lens
with the reflector sitting obliquely on the upper The fundus is observed as indirect image with
part of the horizon, let the light come in from the upside down. Peripheral fundus can be observed
same side as the reflector and from the meridian even in pseudophakia, media opaque, or small
direction with the light providing an elevation as pupil. There are various lenses ranging from 60°
it shines up from below (Fig.15.12b, c). When for posterior pole to 165° for ultra-wide-field
you are observing the inferior retina with the view. The higher the power of refraction pro-
reflector sitting obliquely on the upper part of the vides, the wider the field of vision. However, its
horizon, let the light come in from the opposite image is darker and lower magnificated.
side to the reflector and from the meridian direc- It is easy to observe using a slit light without
tion with the light providing an elevation angle an angle. And you can move the slit light slightly
(Fig. 15.12d, e). Increase the angle of elevation as to the left and right in order to obtain a stereo-
the reflector is closer to the horizontal. At 3 and 9 scopic effect. It is possible to observe the periph-
o’clock (i.e., in the horizontal direction), the ery if you tilt the lens toward the opposite side
maximum angle of elevation is given horizontally from your vision. The magnification of the image
with the vertical slit light providing illumination, is the power of the eye (about 60 diopters) divided
and the angle between the slit light and the micro- by the power of the convex lens. That is, a
scope is 0 or coaxial (Fig. 15.12f). 60-diopter lens has a magnification of 1×, but a
218 H.-J. Kwon and S.-W. Park

Three mirror


a b c

d e f

Fig. 15.12  Direction of illumination of the slit lamp fun- from the same side of the reflector. (d, e) The reflector is
dus examination with Goldmann three-mirror lens. (a) located on the inferotemporal and inferonasal sides:
Reflector at 12 o’clock, 6 o’clock position: Both sides can reflects the light from the opposite side of the reflector. (f)
be illuminated. (b, c) The reflector is located on the Reflector at 3 o’clock, 9 o’clock position: illuminates
superotemporal and superonasal sides: reflects the light coaxially and give maximum angle of elevation

90-diopter lens has a magnification of fitting the lens to the eye. It is difficult to examine
60/90  =  2/3×. [The resolution of the image patients with poor cooperation under bright light.
obtained by a lens with high refractive power Using a contact lens (convex lens, concave
does not increase even if you increase the lens) is advantageous in that although the process
magnification of the slit lamp microscope.] of fitting the lens to the eye itself is cumbersome,
Volk’s SuperQuad 160 lens and Ocular’s Mainster the eye movement and the blinking of the eye can
PRP 165 lens are some of the ultra-wide angle be restricted after the fitting.
lenses, and they are useful when you perform Using a contact concave lens (a Goldman three-
panretinal photocoagulation or when you are mirror lens), it is difficult to observe the periphery
looking for a retinal break. The low-magnification in case of insufficient mydriasis or opacity on the
lens has higher resolution and narrower visual medium. You can be confused with the direction
field and is appropriate for focal laser treatment during observing the periphery because the image
on the posterior pole. However its visual field is is turned upside down. An advantage is using a
wider than that of Goldman three-mirror lens contact concave lens that the anterior chamber
(concave lens). angle can be checked simultaneously.
The contact convex lens has various magnifi-
cation types, and you can select the appropriate
15.3.3 Choosing the Lens one as needed. It is commonly used in photoco-
agulation. The contact concave lenses has narrow
The noncontact convex lens is the most conve- visual field, so it is restricted using in panretinal
nient because it does not require the process of photocoagulation.
15  Fundus Examination 219

15.3.4 How to Examine the Vitreous 15.4.1 Camera Type

Fundus cameras consist of an intricate micro- Observing the Anterior scope and a flash-enabled camera.
One-Third of the Vitreous The optical design of fundus cameras is based
Body on the principle of monocular indirect
The anterior part of the vitreous body is well ophthalmoscopy. A fundus camera provides an
observed without any ancillary equipment. Pupil upright, magnified view of the fundus. A typical
dilatation is needed to observe fine change. camera views 30–50° of retinal area, with a
Changing the illumination angle by 15–20° or magnification of 2.5×. The optics of a fundus
moving the focus of the slit lamp might be helpful camera is similar to those of an indirect
to observe the anterior part of the vitreous body. ophthalmoscope in that the observation and
The wrinkle-rich membrane looks like a curtain. illumination systems follow dissimilar paths.
It moves together when the eyeball moves. When the button is pressed to take a picture, the
retina is illuminated by flash, and reflected light Observing the Posterior are captured onto film, a digital charge-coupled
Two-Thirds of the Vitreous device (CCD), or complementary metal-oxide
Body semiconductor (CMOS).
Put the focus on the retinal surface first and then
move the focus to vitreous.
Changing the illumination angle might be 15.4.2 Scanning Laser
helpful to observe the vitreous body. Ophthalmoscopy Type
Observe vitreous movement while eyeball is
moving. Scanning laser ophthalmoscopy (SLO) is a
method of examination of the eye using the Interpretation of Vitreous technique of confocal laser scanning microscopy.
Change A small point laser beam is scanned in the fun-
Young people appear to have a homogeneous gel-­ dus, and images are formed by the reflected light,
like structure of the vitreous, but it becomes lique- which is observed with CCD.  Because it uses
fied as they age. The liquefied parts appear very low light intensity, it can obtain clear images
optically void. In case of high myopia or vitreo- with little glare. High degree of spatial sensitivity
retinal degenerative diseases, thickened gelatinous can be obtained. Since the single-­ wavelength
vitreous membranes are often seen. If posterior light is used, a real color image can’t be obtained
vitreous detachment occurs, the anterior vitreous by SLO. Ultra-wide-field retinal imaging devices
gel is enriched and often shows ring-­shaped Weiss of Optos used two wavelengths (red laser 635 nm
ring in front of the optic disc. Vitreous opacity can and green laser 532 nm) and can produce digital
be caused by various factors such as degeneration, pseudo-color images.
inflammation, or hemorrhage, and it requires accu-
rate diagnosis. If vascular or fibrous tissue prolif- Optos
eration is observed in the vitreous body, note the You can shoot without enlarging the pupil, but if
area and the degree of adhesion to the retina. you enlarge the pupil, you can shoot a wider
range 200° more clearly. Because it utilizes laser
light, relatively clear images can be obtained
15.4 Fundus Photography even in cases of cataract or media opacity, but it
is affected by the patient’s movement or lid laxity.
Fundus photography involves capturing a photo- Because the color image is digitally recombined
graph of fundus. Fundus photography can be from two wavelengths, it differs from the color
classified to camera type and scanning laser oph- seen in actual fundus examination. Although it
thalmoscopy according to the light source. shows a wide range view of 200°, the resolution
220 H.-J. Kwon and S.-W. Park

Fig. 15.13  Optos ultra-wide-angle scanning laser ophthalmoscope. (a) Machine appearance. (b) Fundus photography
of normal eye

is less than that of a digital camera with a range

of 30–50°. Image distortion occurs in periphery 15.6 Fundus Autofluorescence
because the spherical eyeball is shown as a plane
(Figs. 15.13 and 15.14; Table 15.1). A fluorophore is a material that can re-emit light
upon light excitation. Fundus autofluorescence is
an imaging technique that maps the distribution
15.5 Red-Free Photography of fluorophore in the fundus. Lipofuscin granules
accumulating in the retinal pigment epithelium
The longer the wavelength of the light, the less are the main fluorescent material. Collagen and
scattering occurs, and it can reach to deep areas elastin component in the choroidal blood vessels
of tissue (Fig. 15.15). On the other hand, short-­ act as minor fluorophores.
wavelength light is reflected on the superficial The scanning laser ophthalmoscope (SLO)
area. Camera type (fundus photography) uses uses a light source of 488 nm in wavelength and
white light as light source which consists of vari- detects autofluorescence by using an emission fil-
ous wavelengths. Red-free photography takes a ter of 500–700  nm. It takes several images and
fundus photo with short-wavelength light only. amplifies the autofluorescence to produce an
Its photos mostly have the information of the image. The camera, on the other hand, uses a
superficial area of the retina. It is useful for light source of 580 nm filter as excite light and an
observing retinal vessels, hemorrhage, reticular emission filter of 695 nm.
drusen, exudate, pigmentation of retinal pigment Fundus autofluorescence can be obtained by
epithelium, retinal edema, macular frontal mem- using near-infrared rays. The light of 805-nm
brane, and nerve fiber layer defect on retinal sur- wavelength was used as the stimulating light. The
face layer (Fig.  15.16a). Green filter on white autofluorescence excited by near-infrared is
light source makes short wavelengths of around known to be mainly related with melanin pigment
500 nm. of the choroid.
15  Fundus Examination 221

Fig. 15.14 Laser
Forehead rest
ophthalmoscope (HRA)

Body Objective lens

Up and down
adjustment knob Chin rest
Focus adjustment knob

System control input device



a b

c d

Fig. 15.15  Pictures taken with the same epiretinal mem- raphy. (c) Red light fundus photography. (d) Red-­free fun-
brane. (a–c) Camera-type fundus photography. (a) Blue dus photography. (HRA2 shot with laser scanning
light fundus photography. (b) Green light fundus photog- ophthalmoscope)
222 H.-J. Kwon and S.-W. Park

Table 15.1  Comparing fundus photography 15.7 Normal Findings in Fundus

Digital camera SLO (Optos) The fundus is divided into four quadrants by the
Light source White light Laser (532um horizontal and vertical meridians with the fovea
and 633um)
as the center of the eye, and they are called
View 30–50° 200°
Image High resolution Low superotemporal, superonasal, inferotemporal,
Color resolution and inferonasal quadrants. The anterior end of
Pseudo color the retina is the ora serrata, and the circumference
Challenging Media Eyeball connecting the neck of the vortex vein is called
condition opacity(cornea, lens, movement
the equator. The area surrounded by the superior
or vitreous) Lid laxity
Photophobia and inferior vascular arcade, including the macula
and the optic nerve, is called the posterior pole.
The area from the vascular arcade to the umbilical
15.6.1 Reading vein along the umbilical artery is called the mid-­
periphery. The area from the vortex vein to the Normal Autofluorescence ora serrata is called the periphery. Peripheral
Taken images depend on excite source, emission fundus can be divided into equatorial parts and
filters, and used devices (camera or SLO). ora serrata parts (Fig. 15.17).

SLO (488 nm-Light Source with 500–

700 nm Emission Filter) 15.7.1 Posterior Pole
The macular pigment of xanthophyll causes the
macula to appear dark, and the large retinal ves- Optic disc is an oval shape with a diameter of
sels and optic nerve head also have low 1.8 ± 0.3 mm horizontally and 1.9 ± 0.3 mm ver-
fluorescence. tically. Optic disc diameter (about 1.5  mm) can
be used to measure the size and position of fundal
Near-Infrared SLO lesions. Disc margins are usually sharp, but the
Because the density of choroidal pigment is high nasal side can be a little unclear. A choroidal pig-
in macula and long wavelength less affected by ment or a vascular network can be sometimes
Xanthophyll was used, macula appears bright. observed in the form of a blur light gray half-
The retinal vasculature and optic disc appear as a moon near the corner of the temporal disc, and
low fluorescence just as it did in the short-­ this is called conus. It is common for myopic
wavelength fundus autofluorescence. eyes. A white ring around the optic disc and a
black ring around it can be seen, which is called Hyperfluorescence the scleral ring and the choroidal ring,
Hyperfluorescence is observed when lipofuscin respectively.
accumulates excessively. It is often seen in The color of the optic disc is pink. It is called
genetic illnesses such as Stargardt’s disease and “physiologic disc cupping” because the center of
Best disease. It can also be observed in central the optic disc is depressed with a somewhat
serous retinopathy as the illness progresses. lighter hue than the circumference. When this
Drusen make also hyperfluorescence (Fig. 15.16). cupping is deep, the lamina cribrosa passing
through the optic nerve appears as gray spots. Low Fluorescence The cup/disc ratio, which is the ratio of the
Low fluorescence can be seen in fluorescence horizontal diameter of the disc cupping to the
blocking lesions such as hard protein or subreti- horizontal diameter of the disc, is 0.4 for normal
nal hemorrhage present on the retinal pigment people. In the case of glaucoma, however, the
epithelium or retinal pigment epithelium atrophy diameter of the cupping increases, and the cup/
and defect. disc ratio increases. The vein on the optic disc
15  Fundus Examination 223

a b c

Fig. 15.16  Autofluorescence. (a) Drusen. (b) Best disease (hyperfluorescence). (c) Dry age-related macular degenera-
tion (hypofluorescence)

Fig. 15.17 Anatomical
location of normal

Macula Optic disc


can pulsate occasionally, but pulsation on the the run and the thickness change easily when
artery is abnormal (Fig. 15.18). there is an abnormality in blood circulation.
The central artery and the central vein of the Arteries and veins often cross, and arteries usu-
retina come from the optic disc head and are ally pass through the upper part of the veins. The
divided into four stalks which are called supero- junctions of arteries and veins should be carefully
temporal, superonasal, inferotemporal, and monitored in case of hypertension and athero-
inferonasal arteries and veins. In healthy eyes, sclerosis. The cilioretinal artery sometimes
the vessel walls are transparent, and what is seen moves out from the choroidal vessels and is
using the ophthalmoscope is the blood flow in the located near the macula at the edge of the tempo-
blood vessels. Arteries are slightly thinner than ral disc regardless of the retinal artery.
veins, and the ratio of arterial diameter to vein The macula is located two disc diameters
diameter is 2:3 or 3:4. The arteries are bright red, away from the temporal edge of the optic disc
and veins are dark red. They all have light reflexes head, and it is the center of posterior pole.
(light streaks) at their centers, but the arteries Macular reflection can be observed with about
have clearer and thicker reflexes. In case of ath- 2  mm diameter in center of posterior pole, the
erosclerosis, this reflex is increased. The nasal inside of which is called a macula. Macula has
artery runs relatively straight, but temporal arter- rich xanthophyll so it looks dark brown. The cen-
ies are distributed in the arcuate shape above and ter of macula is avascular area of 500 μm diame-
below the macula. Arteries and veins run in simi- ter. Macula has a central depression with diameter
lar ways, but veins often exhibit tortuosity, and 350 um which is called fovea. Fovea consists of
224 H.-J. Kwon and S.-W. Park

Tapering Concealment Banking Deflection Humping

Fig. 15.18  Crossing phenomenon of retinal vessels

only cone cell. Macular and foveal reflexes are sclera. The line connecting this vortex vein
more distinctive in young age and become less becomes the equator.
distinctive as aging. Lattice degeneration, cystoid degeneration,
retinal tear and dialysis, pars plana cyst, and reti-
nal detachment are common in peripheral retina.
15.7.2 Peripheral Retina

The equator is the longest circumference of the 15.8 Fundus Drawings

eyeball and is located midway between the cor-
neal apex and the fovea. Since the equator is not Sketching fundus findings is helpful not only for
an anatomical structure, its position is recorded record but also for determining the overall fundus
with respect to other structures. The equator is status, understanding the disease course, and
13 mm away from the corneal limbus and is twice deciding the treatment policy.
distant from where the rectus muscle is attached. In general, the retinal fundus recorder has
Ophthalmologically, the equator is located four three concentric circles. The center corresponds
disc diameters away from ora serrata and just in to the fovea, the inner circle is the equator, the
front of ampulla of vortex vein. The peripheral middle circle is ora serrata, and the outer circle is
retina has one-third of the total area of the retina. the posterior edge of the ciliary process. Twelve
Long ciliary nerve is a flat, light yellow meridians are marked radially with time hours
straight line whose diameter is 1/3 of the disc like a clock (Fig. 15.19).
diameter, and it passes through the ora serrata The recording process of fundus is as
horizontally from the equatorial region. Long follows.
ciliary arteries appear red with medium size of First, draw optic disc.
retinal vessel and have no branches. Draw vessel from disc to the periphery in
Short ciliary nerves are light yellow and are four quadrants. The blood vessels are one of the
seen above and below the vortex veins. They are major indices indicating the position of the reti-
slightly curved, irregular in diameter, and some- nal lesion, so make sure you draw them
times branched. accurately.
It is called a vortex vein when the choroidal Draw the vortex veins. Those are also indica-
veins gather to form a vortex and pass into the tors of the equator.
15  Fundus Examination 225

OD, OS XII Record the observed fundus findings with

Name: XI I colored pencils accurately and in detail using
the standard symbols and standard color codes
X II on the fundus chart (Fig. 15.20, Table 15.2).
The commonly used color codes are modi-
fied slightly in each hospital. The basic principle
is that the red color is used to note optic discs,
retinal artery, retinal hemorrhage, the blue color
to note retinal detachment and retinal vein, the
green color to note media opacity such as cor-
VIII IV neal opacity or vitreous opacity, the yellow
color to note acute or active changed lesions, the
VII V brown color to note choroid findings, and the
VI black color to note cicatrix and old changes.
Attached retina in the eyes with retinal detach-
ment can be colored with red, but it is com-
monly left uncolored. These color codes would
be recommended, but some modification of
color code would not matter if they do not differ
Horizontal Vertical
cross section cross section
within same hospital (Table 15.3).

Fig. 15.19  Fundus chart

Fig. 15.20  Color code XII


11 12

6 14

19 9
8 18 5 4

2 1
3 20


226 H.-J. Kwon and S.-W. Park

Table 15.2  Characteristics of various fundus examinations

Direct Indirect
ophthalmoscope ophthalmoscope Slit lamp microscope Slit lamp microscope
Contact/ Noncontact Noncontact Contact lens Noncontact lens
Range of Posterior of the Up to peripheral Up to ora serrata using Posterior of the equator
observation equator retina scleral depressor
Convenience Good Less comfortable Uncomfortable Less comfortable
Resolution Low Low High High
Field of view Narrow 10° Wide 45° Wide Wide
Medium Strong Weak Little weak Middle
opacity effect
Stereopsis No Yes Yes Yes
The skill of the Not needed Somewhat needed Needed Needed
Observational Direct Indirect Indirect (Goldmann Indirect (Hruby: direct)
image three-mirror lens: direct
and mirror image)
Purpose of use Observation of Observation of the Used for Standard inspection
macular vascular wide range of retina photocoagulation with stereoscopic, wide
changes and optic Stereoscopic Poor dilatation of pupil field of view and
disc observation of can be used magnification
peripheral retina by conversion

Table 15.3  Color code (with description of Fig. 15.20)

Color Fundus findings
Blue Retinal vein (2), detached retina (4), retinoschisis (16), ora serrata with detached surroundings (12),
cystoid degeneration, retinal fold, white-without-pressure, retinal tuft (20)
Blue lattice in blue circumference: lattice degeneration on detached retina (11)
Red Not detached retina (3), preretinal and intraretinal hemorrhage (18), microaneurysm, retinal artery
vortex vein (21), hole of retinoschisis. chorioretinal atrophy, hemangioma, anastomosis vessel,
not detached fovea (Represented by +), optic disc
Red in blue circumference: retinal tear (9), retinal hole (10), thin retina in the detached retina (13),
ora dialysis (23)
Green Medium opacity (e.g., lens opacity (14), corneal and vitreous opacity (15), vitreous hemorrhage
(fresh bleeding is marked in red and surrounded by green lines, 22), posterior hyaloid membrane,
epiretinal membrane, foreign body in the vitreous
Black Retinal and choroidal pigmentation (6), fibrous proliferation tissue, cotton wool spot, laser
photocoagulation and cryopexy (19),
ora serrata with not detached surroundings (7), exudate (represented by x), conus, occlusive retinal
artery and vein, borderline of chorioretinal atrophy, cotton wool spot (represented by C)
Black lattice in black circumference: lattice degeneration on not detached retina (8)
Brown Choroidal pigment under the detached retina, choroidal detachment, subretinal detachment (it can be
expressed in red),
suprachoroidal hemorrhage, boundary of scleral buckling (24, under the detached retina), choroidal
Yellow Chorioretinal hard exudate (17), macular edema (5), active chorioretinitis,
recently treated laser photocoagulation and cryopexy lesion, drusen, retinal vascular sheath, long
ciliary nerve
Orange Elevated neovascularization
Purple Flat neovascularization
15  Fundus Examination 227

Suggested Reading Paton D, Hyman BN, Justice J Jr. Introduction to ophthal-

moscopy. Kalamazoo: Upjohn Co.; 1976.
Phillips CI. Dilate the pupil and see the fundus. Br Med J.
Eifrig DE.  A system for examining the ocular fundus.
North Carolina Med J. 1983;44:631–3.
Schmitz-Valckenberg S, Holz FG, Bird AC, Spaide
Feeney-Burns L, Berman ER, Rothmann H. Lipofuscin of
RF.  Fundus autofluorescence imaging: review and
human retinal pigment epithelium. Am J Ophthalmol.
perspectives. Retina. 2008;28(3):385–409.
Nover A. The ocular fundus: methods of examination and
typical findings. Blodi FC, Trans. 4th ed. Philadelphia:
Lea and Febiger; 1981.
Fluorescein and Indocyanine
Green Angiography 16
Ik-Soo Byon

16.1 Fluorescein Angiography, FA 485–600  nm. When fluorescein is injected into

the blood vessels and blue flash is illuminated
The purpose of FA is to evaluate the abnormali- using a blue excitation filter in front of the flash,
ties of the following retinal structures: fluorescein molecules that reach the blood ves-
sels and tissues in the eye generate green-yellow
• Retinal vessels: morphologic abnormalities fluorescence. The reflected blue light is shielded
(dilation, tortuosity, stenosis, anastomosis, by the green filter and only the green-yellow fluo-
aneurysm, etc.), perfusion, circulation, retinal rescence is passed through (Fig. 16.1).
neovascularization, and hyperpermeability of Eight percent of fluorescein dye is bound to
the retinal vessel due to functional abnormalities albumin in the blood, and the remaining 20%​​
• Retinal pigment epithelium: morphological diffuses freely in the bloodstream, emitting flu-
changes such as pigmentation, atrophy and orescence and leaking into extravascular tissues.
tear, and hyperpermeability due to blood reti- The leakage of fluorescein is not observed in the
nal barrier impairment normal retinal tissue because of the blood reti-
• Choroidal vessels: loss of choriocapillaris, nal barriers of the retinal vascular endothelial
choroidal circulation abnormalities, and cho- cells. And the fluorescence from the choroid is
roidal neovascularization blocked by the retinal pigment epithelium. The
retinal vessels can be clearly observed in the
FA is essential for the detection of vascular healthy eye.
filling defect, non-perfusion area, and choroidal
neovascularization. These FA findings can help
the physician to diagnose and treat the intraocular 16.1.1 Method
Fluorescein used as a contrast agent Dilate the patient’s pupil in the dark room, then
absorbs  blue light energy with a wavelength of sit in a comfortable position in front of the device
465–490  nm in the dissolved state and emits (Fig. 16.2), and focus on the fundus.
green-­yellow fluorescence with a wavelength of Take a fundus photograph and red-free fundus
photograph by inserting a green filter.
Insert a barrier filter under blue light and take
one or two images.
Run the timer while quickly injecting 5 ml of
I.-S. Byon, MD., PhD. (*)
Department of Ophthalmology, Pusan National 10% fluorescein into the anterior vein of the ante-
University School of Medicine, Busan, South Korea cubital vein.

© Springer Nature Singapore Pte Ltd. 2019 229

J.-S. Lee (ed.), Primary Eye Examination,
230 I.-S. Byon

Fig. 16.1  Principle of Excitation filter

fluorescein angiography
Excitation light(blue)

barrier filter

Fig. 16.2 Angiography
device Headrest with
fixation light

Filter lever
Focus knob

Camera base with

Touch panel joystick

Sensitivity knob

The choroidal fluorescence appears at approx- At this time, the moving width is preferably about
imately 7–8  s after the injection, and photos of 1  mm. To emphasize the stereoscopic effect,
the retinal arteriovenous phase are continuously increase the movement width. Do not change the
taken for 20 s at intervals of 1 s. height of the camera. Take two photos in succes-
After retinal venous phase, you can take sion. There is a camera that can take stereopho-
images at 3, 5, 10, and 30 min or as many hours tography simultaneously.
as you need, depending on the purpose. The pho- In children or patients who cannot be photo-
tos of the peripheral retina are taken by moving graphed with a fundus camera, a direct ophthal-
the eyeball or by moving the fundus camera. It is moscope, an ophthalmoscope, or a slit lamp
good to take the photos of another eye. microscope is considered using a blue filter.
To evaluate the retinal circulation, continuous
photographing should be performed. In order to
examine the state of blood vessels, photographs 16.1.2 Normal Fluorescein
should be taken when the contrast reaches the max- Angiogram
imum. The photographs should be taken more than
several minutes after the intravenous injection. Choroidal Phase
Stereophotography may be taken to differenti- It appears in 8–10 s after injection of fluorescein
ate the location of lesions within the retinal tis- into the anterior cubital vein. The choroidal artery
sue. Patients with macular disease are especially and choroidal capillaries begin to appear just
advised to take the stereophotography. For the before the central retinal artery showed fluores-
stereophotography, move the optical axis slightly cence. Irregular fluorescence from the posterior
to the right from the center of the pupil with a pole appeared as a map and spread widely to the
general fundus camera and then move the adjust- periphery, gradually distributing diffuse, granular
ment knob slightly to the left to take another one. background fluorescence. Because of abundant
16  Fluorescein and Indocyanine Green Angiography 231

xanthophylls, melanin and lipofuscin pigments, period of fluorescein filling between the retinal
the tall retinal pigment epithelium blocking the artery and the retinal vein in the same area of vas-
choroidal fluorescence, and physiological avas- cular arcade. It is within 11 s in the healthy eyes.
cular zone of macula, the central area of macula
can be dark at this phase. Recirculation Phase
The fluorescein flush begins to gradually decrease Retinal Arterial Phase from the retinal and choroidal circulation.
Imaging of the central retinal artery begins at However, the recirculation of fluorescence in low
9–12  s after injection of fluorescein and 1–2  s concentration starts at 25–30 s after injection. In
after choroidal fluorescence. The time from the 3–5 min, its flush diminishes with time. In 10 min,
initiation of intravenous injection to the fluorescein almost disappears from the vessels.
appearance of fluorescence in the central retinal
vein is referred to as arm-to-retina circulation Late Phase
time, usually 10–15 s (Fig. 16.3a). At 30–60 min after injection, the retinal and cho-
roidal vasculature begins to empty of fluorescein. R  etinal Capillary Phase, The background fluorescein remained faint due to
Arteriovenous Phase stain in the choroid, Bruch’s membrane, sclera,
At 12–14  s after the injection, capillaries are and optic disk. If the blood retinal barrier is dam-
visualized in succession on the arteries, and the aged, the fluorescein leak results in the staining of
capillary network of the macula is well visible. abnormal vessels or the pooling in the tissue space. Retinal Venous Phase

It appears 20–30 s after the injection. Fluorescence 16.1.3 Abnormal Fluorescein
enters the large vein from the retinal capillary, and Angiogram
the fluorescence intensity of the vein becomes
stronger than that of the artery. Fluorescein enters Depending on the degree of fluorescence,
the retinal veins from the postcapillary venules it  is  classified to hyperfluorescence and
along their walls. The blood flow is faster in the hypofluorescence.
center of vessel than on the sides of it, showing
laminar flow, which is called the early venous Hyperfluorescence
phase (Fig. 16.3b). The entire vein is then filled There are four causes of bright fluorescence in
with fluorescein, which is called the late venous excess of what would be expected on a normal
phase (Fig.  16.3c). The perifoveal capillary net- angiogram (Fig.  16.4). If hyperfluorescence is
work is best visualized in the peak venous phase detected, physicians should judge where the ori-
of the angiogram. Arteriovenous transit time is the gin of fluorescence is.

a b c

Fig. 16.3  Fluorescein angiography. (a) Arterial phase. (b) Early venous phase. (c) Late venous phase
232 I.-S. Byon

Preinjection Optic disc drusen, astrocytic hamartomas
hyperfluorescence Pseudofluorescence
Myelinated nerve fiber layer, whitish lesion with high reflection such as sclera

Transmitted RPE atrophy

fluorescence Hard drusen, retinal degeneration, myopia, age–related macular degeneration,
macular hole, mmotion retinae, angioid streak

Intraretina Cystoid macular edema

Diabetic retinopathy, retinal vein occlusion, retinal artery
macroaneurysm,uveitis,retinal capillary telangiectasia

Pooling Subretina Serous retinal detachment

Central serous chorioretinopathy, Vogt–Koyanagi–
Harada, choroidal circulation insufficiency, commotio retinae,
choroidal neoplasm

Sub-RPE RPE detachment

Age–related macular degeneration, central serous

Retinal vessel, edema
Tissue stain
Soft drusen, scar tissue, age–related macular degeneration,
retina artery macroaneuryms,retinal vein occlusion, uveitis, sclera, lamina cribrosa

Epiretinal membrane, tortuous arteriole

Aneurysm Retinal arteriole

Retina Retinal microaneurysm
Diabetic retinopathy, retinal vein occlusion,
hypertensive retinopathy, vascular disorder

Diabetic retinopathy, retinal vein occlusion, Eales’ disease,
Behcet’s disease, retinopathy of prematurity

Anastomosis Artery–vein anastomosis

Congenital cavernous angioma,
retinal capillary hemangioma

Artery anastomosis
Retinal artery occlusion

Abnormal vessel
Vein anastomosis
Retinal vein occlusion

Retina–choroid anastomosis
Age-related macular degeneration,
post-photocoagulation, trauma

Coat’s disease, juxtafoveal telangiectasia, angioid streak,
choroidal rupture, myopia etc.

Subretina Age–related macular degeneration, central serous
chorioretinopathy, angioid streak, choroidal reputre, myopia, etc
Vessel in scar tissue


Intraocular Hemangioms, retinoblastoma

Hemangioma, malignant, melanoma, metastalic neoplasm

Fig. 16.4  Classification of hyperfluorescence in fluorescein angiography

16  Fluorescein and Indocyanine Green Angiography 233

1. Preinjection Fluorescence the sclera and choroid, Bruch’s membrane, optic

Autofluorescence is the fluorescence of the disk, and retinal vessels, whereas it is pathologi-
tissue itself, which shows weak fluorescence cally seen in diseases including retinal vasculitis
before injection and is typically seen in the optic in Behcet disease and sarcoidosis, drusen, glial
disk drusen. What is caused by poor combination tissue of scar, and the pigment epithelium.
of excitation filter and barrier filter is called
pseudofluorescence. Hypofluorescence
Hypofluorescence is an abnormal reduction of
2. Transmitted Fluorescence (Pigment Epithelial fluorescence and appears dark on angiogram.
Window Defect) There are two causes (Fig. 16.5).
The transmitted fluorescence of the retinal
pigment epithelium appears at the early phase. 1. Blocked Fluorescence
The main causes are the atrophy of retinal pig- Hemorrhage, exudates, pigment, edema, etc.
ment epithelium and decrease of pigment gran- located in front of the retinal or choroidal vessels
ules. The fluorescence of the choriocapillaries blocked fluorescence and show hypofluorescence
appears to be visible. The transmitted fluores- on angiogram.
cence appears simultaneously at the early choroi-
dal phase and increases in intensity as the increase 2. Vascular Filling Defect
of choroidal fluorescence. The shape and size are Fluorescein is not present in blood vessels
not changed even at the late phase of angiogram. due to retinal or choroidal vascular occlusion,
It fades and disappears as the choroidal empty of and hypofluorescence is observed from the early
dye at the end of angiogram. phase of angiogram. Strictly speaking, hypoflu-
orescence due to a circulatory delay seen at the
3. Abnormal Vessels early phase of angiogram is called as the filling
When the abnormal vessels of the retina, cho- delay, whereas the complete absence of fluores-
roid, and optic disk such as neovascularization, cence from the early to the late phase of angio-
telangiectasis, and hemangiomas are filled with gram is called the vascular filling defect.
fluorescein, they show hyperfluorescence at the Because the conditions are different between
early phase of angiogram. filling delay and filling defect, it is better to dif-
ferentiate them.
4. Leakage Compared with ophthalmologic examination
The fluorescence leaks out of the blood or fundus photography, the vascular filling
­vessels due to breakdown of the blood retinal defect can be differentiated from the blocked
barrier or leaks from the choroid to the retina fluorescence. If materials are observed in
due to abnormalities of the retinal pigment fundus and correspond to hypofluorescence
epithelium. area, hypofluorescence is caused by blocked
If the fluorescein welled into an anatomical fluorescence.
space such as tissue or cellular gap, it is called
“pooling.” It is observed in central serosal chorio-
retinopathy, retinal pigment epithelial detach- 16.1.4 Side Effects
ment, Vogt-Koyanagi-Harada syndrome, etc. and Contraindications
Cystoid macular edema that accumulates in the
retina of diabetic retinopathy and retinal vein Nausea, vomiting, and dizziness may appear
occlusion is caused by leakage from the abnormal within a few minutes after the injection due to a
retinal capillaries at late phase of angiogram. side effect of fluorescence, and skin rash may
“Staining” refers to leakage of fluorescein into occur due to hypersensitivity reaction. Emergency
tissue. It is physiologically seen in glial tissues of equipment should be available at all times, since
234 I.-S. Byon


Optic disc drusen, astrocytic hamartoma

Blocked fluorescence
Myelinated nerve fiber layer, whitish lesion with high reflection such as sclera


Exudate, myelinated nerve fiber layer

Retina vessel

Retinal artery occlusion, retinal vein occlusion

Choroidal capillary occlusion

Internal carotid artery occluison, Takayasu disease, ophthalmic artery occluison

Retinal capillary occlusion

Filling defect Diabetic retinopathy, retinal vein occlusion, Eales’ disease, Behcet’s disease
retinopathy of prematurity

Posterior ciliary artery occlusion, Vogt–Koyanagi–Harada, acute posterior
multifocal placoid pigment epitheliopathy, hypertensive retinopathy

Choroidal atrophy
Degenerative myopia, macular degeneration, RPE degeneration,
post-photocoagulation, uveitis

Hypofluorescence in optic disc

Optic pit, ischemic optic neuropathy, melanoma

Fig. 16.5  Classification of hypofluorescence in fluorescein angiography

shocks can occur rarely. Contraindications include choroidal lesions in detail. ICG absorbs near-­
pregnancy, previous hypersensitivity reactions to infrared rays (maximum absorption at 790  nm)
fluorescein, side effects experienced by other and emits at approximately 835 nm. These char-
drugs, etc. In such cases, you should consult your acteristics of ICG can allow penetration of the
doctor about the benefit and risk of angiogram. retinal pigment epithelium. Therefore, it is
adapted to the discovery of choroidal lesions that
are difficult to detect in FA.
16.2 Indocyanine Green
Angiography (ICGA) • To find the lesions under preretinal/subretinal
Fluorescein-based angiography is very useful for • To find the subretinal pigment epithelium
evaluation of the retina. However, rapid leak lesions
through the choriocapillary and low penetration • To find the choroidal circulation disorder
through the retinal pigment epithelium are the
limitation in studying the vascular structure and Especially, ICGA is useful in detecting and
lesions of the choroid. However, indocyanine monitoring the location, activity, and response to
green angiography (ICGA) can demonstrate the anti-vascular endothelial growth factor or photo-
16  Fluorescein and Indocyanine Green Angiography 235

dynamic therapy in diseases that cause choroidal Start photographing before fluorescent light
neovascularization such as wet age-­related macu- appears after injection to obtain the earliest vessel
lar degeneration. Polypoidal choroidal vasculopa- filling image. Since the pigment enters quickly,
thy can be typically diagnosed in ICGA. take 8–10  s from the start of fluorescence and
The basic principle is similar to fluorescein shoot continuously at 1 s intervals for 30 s while
angiography, but ICG exhibits different properties adjusting the appropriate amount of light at high
in two ways. First, ICG absorbs 790  nm wave- speed. After that, it is necessary to shoot for
length in the near-infrared region and emits 835 nm 30 min every 5 min, such as 1 min, 3 min, 5 min,
wavelength fluorescence, which can pass through 10 min, and 15 min. In the late phase, the flash
the retinal pigment epithelium. Second, minimal intensity increases, and the gain and focus of the
leakage of ICG through choriocapillaries can allow video camera are adjusted to obtain as high-­
us to observe the detailed choroidal lesions because quality images as possible.
98% ICG is bound to proteins in the vessels. Re-injection of ICG: Since fluorescence
However, ICG has a low fluorescence intensity of becomes very weak after 30 min, the initial phase
about 4% of fluorescein, and its wavelength is in can be rephotographed by ICG reinjection. If ini-
the infrared region. It is difficult to obtain a good tial imaging fails or an initial phase of the oppo-
image using a general recording system. A video/ site eye is needed, a clear initial phase can be
digital fundus camera or scanning laser ophthalmo- obtained by reinjecting half of the normal amount
scopes are used to obtain ICGA. The fundus cam- of ICG to identify the vascular vessels.
era type has good temporal and spatial resolution,
which can show the vascular leakage well. Whereas
the scanning laser ophthalmoscope type can obtain 16.2.2 Normal Indocyanine Green
images with high contrast and sharpness and mini- Angiography
mal scatter light, this can help demonstrate the vas-
cular structure well. Most of the posterior ciliary arteries enter the
eyeballs near the macula and are distributed in
the choroid and radiate to the equator. The cho-
16.2.1 Method roidal artery begins filling 0.5–1.0 s earlier than
the central retinal artery.
The basic method is the same as FA. Although it is difficult to summarize the nor-
Before dye injection, perform color fundus mal ICGA findings because the vascular struc-
photography and red-free fundus photography. ture of the normal choroid has a three-­dimensional
When the blue, green, and red filters of the fundus structure with many variations, comparable to
are photographed separately, the lengths of the human fingerprint, three phases can be described
wavelengths reaching each wavelength are as follows.
different, so that the form of each layer of the
fundus can be separated and photographed. The Early Phase
blue light (400–500  nm) shows the internal Up to 5  min after injection can be classified as
limiting membrane, the nerve fiber layer, and the early phase. The fluorescein filling of choroidal
retinal folding well. The green light ­(500–600 nm) artery originating from short posterior ciliary
shows the retinal vessels and hemorrhages, dru- arteries (Fig. 16.6a) starts to appear in parafoveal
sen, and exudates. Choroidal vessels are well lesion before the filling of the retinal artery lesion
observed in red light (600–700 nm). Put both the about 10  s after ICG injection. The choroidal
excitation filter and the barrier filter in place, and artery is flexed and meandering, running radially
take a picture to check for autofluorescence and from the fovea to the periphery, and the choriocap-
pseudofluorescence. illaries are filled with fluorescein simultaneously.
Dissolve 25–50 mg ICG in 1–2 mL of distilled It is difficult to identify the individual chorio­
water, inject intravenously, and then immediately capillaries because faint fluorescence appears
inject 5 mL of saline. between the arterioles. At this time, ­several types
236 I.-S. Byon

of watershed zones can be seen as hypofluores- Mid-phase

cence lesions between the regions of the choroidal From 5 to 15 min after injection, it can be classi-
artery, which are physiological filling delay. The fied as mid-phase. During this period, the fluores-
vertical watershed zone can be seen around optic cence of the vessels gradually decreased over time.
disk, which is the filling delay area of the dye. It is difficult to confirm the outline of choroidal
After the choroidal artery begins to be visualized, vessels. Ground-glass-like fluorescence resulted
the choriocapillary layer is rapidly visualized. And from staining of the choroidal tissue, Bruch’s
then the drainage vein starts to be seen. Many membrane, and retinal pigment epithelium due to
veins appear for 2–4  s and drain into the vortex normal leakage from the choriocapillaries. If there
veins in the equator of each four quadrants. Vortex is abnormal vessel, fluorescence gradually
veins are sometimes in the posterior pole. Because becomes stronger at mid-­phase (Fig. 16.6d).
the choroid is thick and overlapped with the upper
and lower vessels, the strongest intensity of fluo- Late Phase
rescence is observed in the choroidal arteriove- Fifteen minutes after the injection is in late phase.
nous phase (Fig. 16.6b). It is impossible to observe The diffuse choroidal fluorescence appears as fairly
the choriocapillary layer with a capillary network. uniform background fluorescence. In the back-
Approximately 10  s after the first appearance of ground fluorescence, the retinal and choroidal ves-
fluorescence, the fluorescence of the choroidal sels look like hypofluorescence shadows as well as
artery almost disappears, and only the choroidal the optic disk. It is easy to detect abnormal hyper-
veins (Fig. 16.6c) are observed. or hypofluorescence at late phase (Fig. 16.6e).

a b c

d e

Fig. 16.6  Indocyanine green angiography. (a) Choroidal tral serous choroidopathy. (e) Late leakage in choroidal
artery phase. (b) Choroidal arteriovenous phase. (c) neovascularization
Choroidal venous phase. (d) Leakage at mid-phase in cen-
16  Fluorescein and Indocyanine Green Angiography 237

16.2.3 Abnormal Indocyanine Green veins at the posterior pole and the circle of Zinn-­
Angiography Haller can be seen. Harada disease shows fewer
choroidal vessels and indistinct vascular outline
ICGA shows insufficient resolution of complex in ICGA. Choroidal hemangioma is characterized
choroidal vasculature with a three-dimensional by a thick speculative hemangioma in the choroi-
structure. There is also an instrumental differ- dal arterial phase and a severe fluorescein leakage
ence in ICGA finding. Abovementioned features in the late phase. Abnormal vessels inside tumor
are the limitations for interpretation of the ICGA may be seen in malignant choroidal melanoma.
results. In general, the same approach as the FA ICGA is an effective method to detect ruptured
is applied to distinguish between hyperfluores- retinal artery macroaneurysm under the thick
cence and hypofluorescence, compared to the hemorrhage. Leakage from retinal abnormal ves-
surrounding region. Hyperfluorescence is classi- sels and retinal neovascularization is uncommon.
fied to pseudofluorescence, transmitted fluores- Pooling is in retinal pigment epithelial detach-
cence, abnormal vessel, and leakage (Fig. 16.7). ment and retinal detachment. Retinal pigment
Hypofluorescence blocked fluorescence and epithelial detachment varies widely from hyper-
vascular filling defect (Fig. 16.8). Even with the fluorescence to hypofluorescence.
same lesion, there can be many exceptions, since Tissue staining is physiologically and
hypofluorescence can be initially hyperfluores- pathologically staining of tissues including the
cence and vice versa depending on the time. blood vessel wall, pigment epithelium, Bruch’s
membrane, and choroid. Tissue staining of the Hyperfluorescence vascular wall is observed in uveitis, hyperten-
In ICGA, pseudofluorescence is seen in the sive choroidopathy, and preeclampsia. Central
boundary of retinal pigment epithelial detachment serous chorioretinopathy shows tissue staining
and dehemoglobinized hemorrhage. ICG with due to choroidal extravasation at mid phase.
high permeability is blocked by about 10% of
fluorescence. Fluorescence transmission of about Hypofluorescence
10% is increased in the area of retinal pigment Although near-infrared rays are used, faint choroi-
epithelial atrophy. Transmitted fluorescence is dal fluorescence at late phase can be blocked by the
observed in degenerative myopia with the retinal pigment epithelium. There are various find-
posterior staphyloma and thinning of the retinal ings in a blocked fluorescence due to hemorrhage.
pigment epithelium, choroid, and sclera. Thick vitreous hemorrhage and subretinal hemor-
At the early phase, abnormalities of the retinal rhage block background fluorescence. Scanty hem-
and choroidal vessels can be detected. ICGA has orrhage shows hypofluorescence only in the late
an important value in case that a latent choroidal phase. In retinal hemorrhage, blocked fluorescence
neovascularization in FA appears as a distinct does not appear. Serous retinal detachment, retinal
choroidal neovascularization in ICGA. Although pigment epithelial detachment, hard exudate, and
hyperfluorescence in late phase is an important soft drusen may also cause blocked fluorescence in
diagnostic clue, the early phase of laser scanning late phase. Thick choroidal tumors have a great
ophthalmoscopy demonstrates the choroidal effect of blocked fluorescence, which is helpful in
neovascularization, abnormal branching vascular determining tumor size and location.
networks and polyps of polypoidal choroidal Mild choroidal vascular occlusion is charac-
vasculopathy, retinal vascular anastomosis, and terized by localized hypofluorescence at the
neovascularization of the retinal angiomatous early phase and then slowly filled with fluores-
proliferation and feeder vessels. cein with time. However, hypofluorescence (fill-
Enlarged choroidal vessels are seen in central ing defect) continues until late phase in severe
serous chorioretinopathy. In high myopia, vortex vascular occlusion, accompanied with tissue
238 I.-S. Byon

Depigmented subretinal hemorrhage, fibrous tissue,

RPE atrophy
High myopia, age–related macular degeneration, retinal abnormality
RPE tear

Intraretina Cystoid macular edema

Diabetic retinopathy, retinal vein
occlusion, age–related macular degeneration

Subretina Serous RD
Central serous chorioretinopathy,
Pooling Vogt–Koyanagi–Harada disease

Hyperfluorescence SubRPE RPE detachment

Age–related macular degeneration,
central serous chorioretinopathy

Intrachoroid Leakage
Central serous chorioretiopathy

Retinal vessel
Retinal vein occlusion, retinal arery ameurysm,uveitis, internal carotid
artery occlusion, diabetic retinopathy

Tissue stain Choroidal vessel

Optic disc

Abnormal RPE, Bruch’s membrane, bard drusen, fibrin


Retinal arteriole aneurysm

Retinal microaneurysm
Diabetic reinopathy, retinal vein
occlusion, hypertensive
retinopathy, vascular disorder

Retinal carvernous humangioma,
Intraocular retinal capillary hemangioma
Intratumor vessel

Abnormal vessel Retina, RAP


Telangiectasia, tortuosity
Central serous chorioretinopathy

Age – related macular degeneration, idiopathic choroidal
neovascularization, angioid streak
Polypoidal choroidal neovacularization

Tumor vessel
Choroidal cavernous hemangioma, melanoma,
choroidal osteoma, retinoblastoma

Fig. 16.7  Classification of hyperfluorescence in indocyanine green angiography

16  Fluorescein and Indocyanine Green Angiography 239


Blocked fluorescence
Melanin, lutein, lipofucin


Exudate, myelinated nerve fiber layer, scar tissue, inflammation

cell infiltrate, tumor tissue, subretinal fluid, RPE detachment, soft drusen

Retinal vessel

Diabetic retinopathy, retinal vein occlusion, retinal

artery occlusion, Eale’s disease

Choroidal vessel
Vogt–Koyanagi– Harada disease, acute posterior placoid pigment
epitheliopathy, serpiginous choroiditis, malignant hypertension


Filling defect, delay Internal carotid artery occlusion, Takayasu disease

Choroidal atrophy

RPE degeneration, panretinal atrophy after photcoagulation,

macular disorder, choroidal rupture

Fig. 16.8  Classification of hypofluorescence in indocyanine green angiography

staining of choroidal vessels or leakage to the phase. Laser photocoagulation-induced chorio-

subretinal space. Harada disease, hypertensive retinal atrophy also shows a hypofluorescence.
choroidopathy, and preeclampsia show a filling
delay due to choroidal circulation disorder.
Harada disease is characterized by diffuse fill- 16.2.4 Side Effects
ing defect due to inflammatory cell infiltration and Contraindications
at the early stage and hypofluorescent dots con-
sistent with the location of the capillary lobule After intravenous injection, most ICG binds rap-
in the late phase. The serpiginous choroiditis idly to plasma proteins and is removed from the
and acute posterior multifocal placoid pigment liver and excreted into the bile. There are fewer
epitheliopathy show hypofluorescence in side effects and more safety than fluorescein.
affected lesions and the filling defect in chorio- However, emergency equipment should be avail-
capillaris and arterioles. able at all times because a few severe hypersensi-
If choriocapillaries are atrophied in macular tivity reactions have been reported. Patients with a
degeneration and retinal pigment degeneration, history of severe hypersensitivity reactions or liver
hypofluorescence remains from early to late disease should be avoided.
240 I.-S. Byon

16.3 Fluorescein Angiography However, since the SLO model uses direct
with Laser Scanning infrared laser light, it can stimulate the ICG
Ophthalmoscope efficiently and minimize the diffuse light. Using
the same focal point, record only fluorescence in
Real-time photographic equipment using exist- the focal plane, parallel to the time axis.
ing funduscopic cameras requires very bright
illumination in order to obtain a good image.
Therefore, it is difficult for the retina to withstand 16.3.1 Method
the amount of continuous illumination to obtain a
continuous image, and it is difficult to obtain a Infrared photograms and fluorescein angiogra-
good image if the pupil dilation is insufficient. phy show autofluorescence on an angiographic
FA and ICGA were developed using scanning screen, followed by ICG fluorescein angiography
laser ophthalmoscope (SLO) to overcome these and intravenous injection of ICG. The choroidal
disadvantages. The advantage of SLO is that the vessels should be photographed because the
intensity of illumination is low, so you can contrast changes rapidly from the onset of the
observe video with continuous shooting. choroidal vessels to 1 min after onset. When the
A model using a fundus camera can obtain 1 choroidal vessels begin to be visualized,
to 2 images per second, but an SLO can obtain recording of the choroidal artery should be
20–30 images per second. In addition, the clearly recorded because continuously taking
patient’s glare is small, the burden is small, the photograph is impossible up to 1 min after intra-
amount of the fluorescein can be reduced to about venous dye injection. Then, record at 3  min,
1/2, simultaneous imaging is possible while 5 min, 10 min, and 15 min and record the station-
simultaneously injecting fluorescein and ICG, ary image every 5 min for up to 30 min.
and the initial image is good. The disadvantages Upon completion of the initial imaging of ICG
are that the equipment is expensive and the field angiography, fluorescein is intravenously
of view is narrower than 40° compared with injected, and fluorescein angiography is per-
conventional real-time eye-gaze cameras, which formed. The imaging device is photographed at
are visible up to 60°. However, even with SLO the contrast medium introducer and then taken at
cameras, it is possible to shoot up to 60° with a 1  min, 3  min, 5  min, 8  min, and 10  min.
wide-angle lens. Currently available SLOs are Fluorescein angiography and ICG angiography
Heidelberg’s Heidelberg Retina Angiograph 2 are simultaneously taken at the same time. When
(HRA2) and Nidek’s F-10. the fluorescence is injected, a contrast image
Fluorescein angiography in the SLO model appears on the monitor. To make this image
stimulates fluorescein by 488  nm blue argon clearer, adjust the contrast and intensity of the
laser. The barrier filter passes fluorescence of a operation touch panel. Two fluorescence angio-
green-yellow wavelength around 500  nm grams can be taken at the same time after intrave-
generated by stimulation and simply shields the nous injection of both fluorescein and ICG from
reflected blue wavelength. ICG fluorescein the beginning.
angiograms stimulate ICG by scanning the In the fundus camera type, the contrast is weak
fundus with 790 nm diode laser light and isolate due to the reflected light and the scattered light.
the stimulus light and fluorescence with a 810 nm However, since the SLO type is mainly used for
cutoff filter. In the fundus camera model, the direct light, a very sharp and high-­ resolution
flash of the light is shed through the filter to the image with better contrast can be obtained than
fundus through the infrared ray, and diffuse light the image captured by the fundus camera. In ICG
is also casted. In addition to fluorescence parallel angiography using SLO, choroidal neovascular-
to the axis, scattered fluorescence is also taken. ization is clearly depicted. The feeding vessel to
16  Fluorescein and Indocyanine Green Angiography 241

a b

Fig. 16.9  Fluorescein angiography using scanning laser ophthalmoscope. (a) Indocyanine green angiography of pol-
ypoidal choroidal vasculopathy. (b) Fluorescein angiography of retinal angiomatous proliferation

choroidal neovascularization, the nodule of pol- Table 16.1  Instrumental difference between digital fun-
ypoidal choroidal vasculopathy, abnormal vascu- dus camera and scanning laser ophthalmoscope
lar plexus, and anastomosis in retinal angiomatous Scanning laser
proliferation are clearly depicted in the early Fundus camera ophthalmoscope
Light source White light Laser monochromic
phase (Fig. 16.9). However, it is difficult to deter-
(wavelength) light (785–790 nm)
mine the fluorescence leakage of fluorescein. In Filter Excitation No excitation filter
addition, late phase is unclear because of the weak filter Barrier filter
fluorescence of ICG in the choroid and the size of (640–780 nm) (805 nm)
the image file is large. Barrier filter
(820–900 nm)
On the other hand, it i