Evaluation of Macula

Dr Jay Kumar Chhablani Smt. Kanuri Santhamma Retina & Vitreous Centre

Anatomy of macula

Evaluation of macula
History Examination Investigations

History
Distortion of images Blurring of images Unable to identify faces Difficulty in color vision

Examination
Binocular indirect ophthalmoscpy Slit-lamp biomicroscopy

Slit lamp Biomicroscopy

Slit lampAdjustable intense illumination Slit beam
adjustable width / length 3600 rotation, variable angle

Provides optical section Provides high magnification and stereopsis Surface contours of chorioretinal lesions better appreciated

Slit lamp biomicroscopy

Principle Use of an accessory lens to image the fundus in a position, where it can be reimaged by slit lamp

Slit lamp biomicroscopy

Accessories Contact lenses: - Neutralizes corneal power Noncontact lenses:
use refractive power of cornea and high convex / concave lens to image the fundus

Advantages
NONCONTACT METHOD Quicker Examine post op. and infected patients No coupling agent No topical anaesthesia CONTACT METHOD Better stability Better quality of image Some control of ocular movements

Lenses used
NON CONTACT METHOD Hruby lens Aspheric lenses (+60, +78, +90D) CONTACT METHOD Goldman three mirror lens Goldman posterior lens Mainster lens Panfundoscopic Quadrispheric Volk Super Quad

Non Contact Methods

Hruby lens Plano concave (-58.6 D) Mounted on slit lamp View: 300 vertical / 600 lateral Image : Erect / virtual / in pupillary plane Minification of pupil To view only post. pole

Non Contact Methods

Indirect fundus biomicroscopy High convex lenses (+60D, +78D, +90D) Image : Real, Inverted, High quality Magnify the pupil - wider field Fundus scanning : Upto pre equatorial region with certain adjustments

Volk TransEquator

132 Dynamic Field of View 0.7x Magnification 1.44 Laser Spot Magnification Factor
13

Volk SuperQuad 160

160 Field of View 0.5x Magnification 2.0x Laser Spot Magnification Factor

14

Mainster Lens
35 - 48 Dynamic Field of View 0.95 x Magnification 1.05 Laser Spot Magnification Factor

15

Indirect fundus biomicroscopy

Technique Narrow slit width / low intensity Lowest magnification Align illumination / visualization angle straight ahead Focus the cornea with beam passing through dilated pupil Hold the lens in front of pupil Pull the slit lamp back to get fundus image

Indirect fundus biomicroscopy

Increasing field of Exam Shifting patients gaze Changing beam width / magnification Moving Slit Lamp
Vertically / Horizontally Vertical tilt by 150

Indirect fundus biomicroscopy

LENS 78D 90D 0.95D 0.75 84 degrees 94 degrees 15mm 12mm 29mm 19mm

FEATURE 60D Magnification 1.18D Field of view 76 degrees Focal length 19mm Clear lens aperture 30mm

Contact Lens Methods

Needs coupling solution Topical anaesthesia cannot be used in immediate post op. period / infection Advantages: Better stability Better quality of image (less interfaces) No need to retract the lids Can control ocular movements

Contact Lens Methods

3 mirror lens (Goldmann) Clear central portion planoconcave (-64D) Views central 300 of an emmetropic eye Radially arranged 3 mirrors small (590) - for Gonioscopy, region anterior to ora middle (670)- pre-equatorial part large (730) - post. pole to equator

Contact Lens Methods

3 mirror lens (Contd.) Image Central lens : Erect, virtual Peripheral mirrors : A-P inverted : Not laterally reversed

Contact lens methods

3 mirror lens (Contd.) Technique
Position patients head on slit lamp Hold the lens in first 3 fingers Ring finger to retract lower lid Patient to look up Place the lens on cornea Patient to look straight ahead

Contact lens methods

3 mirror lens (Contd.) Slit lamp
Slit beam along the radial axis of mirror

Evaluate fundus by
Rotation of mirrors Readjusting the slit beam Redirecting the patients gaze

Contact lens methods

Panfundoscope lens (Rodenstock) Meniscus lens coupled with spherical lens (+81 D) Image :
Real, inverted Within the lens Minification (0.7X)

Wide angle view (upto equator) More useful for Laser photocoagulation

Contact lens methods

Mainster lens Meniscus lens with double aspheric lens Image
Inverted, real High lateral and axial magnification Excellent resolution

Image plane is very anterior - Difficult focusing Used for examination / Laser treatment

Contact lens methods

Mainster lens: ModificationsView (degrees) Standard Ultrafield Widefield High mag. 90 140 125 75 0.96x 0.53x 0.68x 1.25x Magnification

Care of Lenses
Sterilization : ETO gas (520 C) Cleaning:
Rinse in cold / tepid water Clean with dishwashing liquid Rinse and blot dry with lint free cloth

Disinfection:
2% Glutaraldehyde - (20 min.) Rinse in cool water dry 1:10 sol. of Na. hypochlorite (10 min) Rinse Dry

Never boil or Autoclave

Investigations

Visual acuity measurement Color vision Contrast sensitivity Amsler charts Visual discrimination tests (Two point discrimination) Entoptic imagery tests

Fundus fluorescein angiogram ICG angiogram OCT Elecrophysiology

Visual acuity measurement

Pinhole visual acuity Clinical interferometers Guyton-Minkowski Potential Acuity Meter (PAM)

Blue field entoptoscopy

penlight or transilluminator To observe the flow of white blood cells in the parafoveal capillaries. Blue light is absorbed by the red blood cells but not the white blood cells.

Two-point discrimination
Two light sources of equal intensity About 25 inches (or 62 cm) No information is learned about macular potential. Fully mature cataracts or otherwise dense ocular media. Gross color perception

Potential acuity
PAM Reduced snellen chart Laser inferometry

Contrast sensitivity
Terry Acuity Pelli-Robson

Amsler: Set-up
Pt holds grid 28cm-30cm Grid should be brightly illuminated Pt should be wearing best-corrected Rx for near 10 degree of the visual field 10 cm square

AMLSER GRID: Charts

1: Standard grid (most common)
black lines on white background or white lines on black background central fixation spot

AMLSER GRID: Charts

2: chart 1 with diagonal lines

"

Use on pt w/
central scotoma fixation problems

"

Help maintain fixation

pt fixate at intersection of diagonals lines

AMLSER GRID: Charts

3: Red grid on black background
acts like a Red desaturation test toxic amblyopic pts better for relative scotomas

AMLSER GRID: Charts

4: Random dots
Pt with paracentral relative scotomas can delineate defects better due to no line distortion

AMLSER GRID: Charts

5: Parallel horizontal lines

Sensitive to metamorphopsi a b/c lines adjusted to defects orientation

AMLSER GRID: Charts

6: chart 5 w/ additional horizontal lines 1 degree above & below xation
"

Helpful for evaluation complaints of metamorphopsia @ the reading level

AMLSER GRID: Charts

7: breaks horizontal central area
3cm X 4cm square more sensitive to subtle defects in the fovea

Color vision
Ishihara pseudo isochromatic charts FM 100 hue test D 15 test

Farnsworth D-15 Color Vision Test

Fransworth Munsell 100 hue test

Photo Sttress Test

BCVA checked Pen torch / indirect about 3 cm away for abou 10 seconds Photostress recovery time - to read any three letters of the pre-test acuity line (15-30 seconds)

Optical Coherence Tomogram (OCT)

Central Serous Retinopathy

Pigment Epithelial Detachment

Macular hole

Traction