Download - Macular Examination, Jay Chhablani
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Evaluation of Macula
Dr Jay Kumar Chhablani
Smt. Kanuri Santhamma Retina &Vitreous Centre
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Anatomy of macula
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Evaluation of macula
History Examination Investigations
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History
Distortion of images Blurring of images Unable to identify faces Difficulty in color vision
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Examination
Binocular indirect ophthalmoscpy Slit-lamp biomicroscopy
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Slit lamp Biomicroscopy
Slit lamp-
Adjustable 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
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Slit lamp biomicroscopy
Principle-
Use of an accessory lens to image the fundus in aposition, where it can be reimaged by slit lamp
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Accessories-
Contact lenses:-Neutralizes corneal power
Noncontact lenses: use refractive power of cornea and high convex /
concave lens to image the fundus
Slit lamp biomicroscopy
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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 ofocular movements
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Lenses used
NON CONTACTMETHOD
Hruby lensAspheric lenses(+60, +78, +90D)
CONTACT METHODGoldman three mirror lensGoldman posterior lensMainster lensPanfundoscopicQuadrisphericVolk Super Quad
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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
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Non Contact Methods
Indirect fundus biomicroscopy-
High convex lenses (+60D, +78D, +90D) Image : Real, Inverted, High quality Magnify the pupil - wider fieldFundus scanning : Upto pre equatorial region with certain adjustments
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Volk TransEquator
132 Dynamic Fieldof View
0.7x Magnification 1.44 Laser Spot
Magnification Factor
13
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Volk SuperQuad 160
160 Field of View 0.5x Magnification 2.0x Laser Spot
Magnification Factor
14
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Mainster Lens
35 - 48 Dynamic Fieldof View
0.95 x Magnification 1.05 Laser Spot
Magnification Factor
15
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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
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Indirect fundus biomicroscopy
Increasing field of Exam-
Shifting patients gaze Changing beam width / magnification Moving Slit Lamp
Vertically / Horizontally Vertical tilt by 150
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LENS
FEATURE 60D 78D 90D
Magnification 1.18D 0.95D 0.75
Field of view 76 degrees 84 degrees 94 degrees
Focal length 19mm 15mm 12mmClear lens aperture 30mm 29mm 19mm
Indirect fundus biomicroscopy
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Contact Lens Methods
Needs coupling solution Topical anaesthesia cannot be used in immediate post op. period / infectionAdvantages:
Better stability Better quality of image (less interfaces) No need to retract the lids Can control ocular movements
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Contact Lens Methods
3 mirror lens (Goldmann)-
Clear central portion planoconcave (-64D)Views central 300 of an emmetropic eye
Radially arranged 3 mirrorssmall (590) - for Gonioscopy, region anterior to oramiddle (670)-pre-equatorial partlarge (730) -post. pole to equator
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Contact Lens Methods
3 mirror lens (Contd.)-
ImageCentral lens : Erect, virtualPeripheral mirrors : A-P inverted
: Not laterally reversed
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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
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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
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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
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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
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Contact lens methods
Mainster lens: Modifications-
View Magnification
(degrees) Standard 90 0.96x Ultrafield 140 0.53x Widefield 125 0.68x High mag. 75 1.25x
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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
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Investigations
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Visual acuity measurement Color visionContrast sensitivity
Amsler charts Visual discrimination tests (Two point
discrimination) Entoptic imagery tests
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Fundus fluorescein angiogram ICG angiogramOCT
Elecrophysiology
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Pinhole visual acuity Clinical interferometersGuyton-Minkowski Potential Acuity Meter(PAM)
Visual acuity measurement
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Blue field entoptoscopy
penlight ortransilluminator
To observe the flowof white blood cells in
the parafoveal
capillaries.
Blue light is absorbedby the red blood cells
but not the white
blood cells.
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Two-point discrimination
Two light sources of equal intensity About 25 inches (or 62 cm)No information is learned about macularpotential.
Fully mature cataracts or otherwise denseocular media.
Gross color perception
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Potential acuity
PAM Reducedsnellen chart
Laser inferometry
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Contrast sensitivity
Terry Acuity Pelli-Robson
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Amsler: Set-up
Pt holds grid 28cm-30cm Grid should be brightly illuminatedPt should be wearing best-corrected Rx fornear
10 degree of the visual field10 cm square
AMLSER GRID: Charts
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1: Standard grid (mostcommon)
black lines on whitebackground or white lines onblack background
central fixation spot
AMLSER GRID: Charts
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AMLSER GRID: Charts
2: chart 1 with diagonal lines" Use on pt w/
central scotoma fixation problems
" Help maintain fixation
pt fixate at intersection ofdiagonals lines
AMLSER GRID Ch t
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AMLSER GRID: Charts
3: Red grid on black background acts like a Red desaturation test
toxic amblyopic pts better for relative scotomas
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AMLSER GRID: Charts
4: Random dots Pt with paracentral
relative scotomas
can delineate defectsbetter due to no linedistortion
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AMLSER GRID: Charts
5: Parallel horizontallines
Sensitive tometamorphopsi
a b/c lines
adjusted to
defects
orientation
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AMLSER GRID: Charts
6: chart 5 w/additional horizontal
lines 1 degree
above & belowfixation
" Helpful for evaluation
complaints ofmetamorphopsia @
the reading level
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AMLSER GRID: Charts
7: breaks horizontalcentral area
3cm X 4cm square more sensitive to
subtle defects in the
fovea
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Color vision
Ishihara pseudo isochromatic charts FM 100 hue test D 15 test
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Farnsworth D-15 Color Vision Test
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Fransworth Munsell 100 hue test
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Photo Sttress Test
BCVA checked Pen torch / indirect about 3 cm away for abou
10 seconds
Photostress recovery time - to read any threeletters of the pre-test acuity line (15-30
seconds)
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Optical Coherence Tomogram(OCT)
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Central Serous Retinopathy
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Pigment Epithelial Detachment
M l h l
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Macular hole
T i
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Traction
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