Dark Room Instruments

DR S Walia
MGMMC Indore
 Direct Ophthalmoscopy

• First given by Herman von Helmholtz,

• The light of the hand held self illuminated ophthalmoscope is
directed to patient’s pupil while observing it through the
fenestration in the ophthalmoscope.
• The examiner approaches the patient’s eye to a distance
within anterior principal focus i.e. about 15 mm, where a
virtual erect image of the fundus is seen formed behind
patient’s eye.
• magnifies the image about 15 times.
 Direct Ophthalmoscopy

Advantages Disadvantages

1. No stereopsis.
1. Easy to use and portable. 2. The illumination is low
2. Greater magnification therefore if media are hazy the
enables fine details to be visibility is poor.
examined. 3. Cannot be used for operative
procedures because of close
3. Patient can be examined proximity with the patient and
in any position. inability to sterilize the
4. Erect image does not ophthalmoscope.
cause any difficulty in 4. Field of view is small and the
retinal periphery cannot be
orientation. seen
Direct Ophthalmoscopy
 Direct Ophthalmoscopy

Selection of Viewing Lenses

– Turn the diopter disc counterclockwise for convex lenses- Green
– Turn the clockwise for concave lenses, which are printed in Red
Selection of Aperture Type
– There are five apertures.
– Large Spot : used for checking the fundus through dilated pupil
– Small Spot: used for general undilated fundus examination
– Slit: aids in depth perception -edema , staphyloma
– Central Net: Fixation
– Red-free Filter: used to examine blood vessels and bleeding in the r
– Cobalt blue light : Fluorescein staining
Direct Ophthalmoscopy
 Distant Direct Ophthalmoscopy
• Used to get a preliminary idea about the status of the ocular media and fundus
• Done routinely before doing a direct ophthalmoscopy
• Performed in a semi dark room , ophthalmoscope should be kept at a distance
of 20-25 cm from the patient’s eye
• Normally a red reflex is seen at the pupillary area
1 Opacities in the ocular media are seen as dark spots in the red glow at the
pupillar area . The plane of the opacities can be assessed by asking the patient to
move the eye from side to side while the examiner is observing the pupillary
glow (based on parallax principle)
– opacities in front of the pupil move in the direction of eye movement
– opacities in the pupillary plane do not move
– opacities behind the pupillary plane move opposite the direction of eye
movement
2 To differentiate between a mole on the iris and a hole in the iris
in oblique illumination, both appear dark
in distant direct ophtalmoscopy
mole – appears dark
 DDO

3. Keratoconus – ring shadow corresponding to the base of the

cone because of total internal reflection of light occuring at
base of cone
4. Cataract – type of cataract --- cuneiform , nuclear , polar
5. Subluxation of lens – dark crescent against fundal glow
6. Lens coloboma- notch
7. Vitreous hemorrhage – no red glow
8. Gray reflex – fundus coloboma, posterior staphyloma , retinal
detachment
 Indirect Ophthalmoscopy

Direct Ophthalmoscopy Indirect ophthalmoscopy

15 times 5 times when a +13D
3 times with +20D
Central retina only Peripheral retina
(by using a scleral depressor )
Virtual & erect image Real & inverted image
No stereopsis better stereopsis
Hazy Media- (seen with difficulty) Seen better
 Pin Hole
A black disc with 1 mm diameter fenestration in the center.

Increases Depth of focus by reducing the size of blur circle on retina

Light rays pass unrefracted through nodal point of eye hence effect of
spherical aberrations negated
 Pin Hole
Uses:
1. Diagnosis of refractive error -
if the vision improves to (nearly) normal then it denotes that the diminution is caused
by refractive error otherwise an organic cause may be present.
In cases with central media opacity and macular pathology the vision may deteriorate
with the pin-hole
2. Confirmation of the refractive correction is done by placing a pin-hole in front of
the corrective lenses, if the vision improves further it means the correction applied is
imperfect and needs improvement.
• 3. “Rule of 2” : Two illuminated points of 2 mm diameter size and 2 inches apart
are placed 2 feet away from the patient’s eye. The patient is then asked to indicate
whether he can perceive the two points separately.
• Due to scattering of light the minimum distance required for resolution increases
with increase in media opacity
• Sinclar et al adopted the following criteria and considered the response favourable
if the sepaation was-
<12.5 cms for VA equal to HM / PL ,<7.5 cms for VA CF to 6/60, <5 cms for VA better
than 6/60
As a low vision aid - patients with irregular cornea whose refractive error cannot
be
corrected by glasses, can be benefited by using opaque discs with multiple pin-
holes
which provide refractive correction whichever direction the
patient gazes.
 Staenopic Slit
This is an opaque black disc with a 1 mm thick 25 mm length slit running across the
center.
Uses:
1. Astigmatism - It is placed in front of the patient’s eye and slowly rotated by
180° . If the vision of the patient is significantly better in a particular position
than others then astigmatism is present. The staenopic slit has the same effect as
the pin-hole but only in one meridian which is at right angle to the slit itself.
( THORINGTON PRINCIPLE )
2. Confirmation of the power and axis of the cylinder can be made by placing the
staenopic slit in front of the cylinder along its axis. If the vision of the patient
improves further then the power of the cylinder is imperfect. Then the axis of
the slit is varied about the axis of the cylinder and if the vision improves then the
axis of the cylinder is required to be changed accordingly.
3. Emsley Fincham’s test is done using the staenopic slit to differentiate the colored
haloes caused by cataract (lenticular) from that caused by glaucoma
(corneal).Staenopic slit is moved across patient’s eye while the patient looks at a
bright point source of light which gives rise to halo.
cataract ----halos breaks into a fan the blades of which seem to move
glaucoma remains unchanged or just becomes a little faint.
 Staenopic Slit
• 4. Determination of meridian of optical iridectomy- A patient
who has a small central corneal or lens opacity may benefit
from optical iridectomy. Vision is first recorded with the
normal pupil then the pupil is dilated and staenopic slit is
placed in front of the eye and rotated; the axis where vision
improves markedly, is chosen for optical iridectomy. Although
empirically the optical iridectomy is done inferonasally in
patients whose occupation involves near work, and
temporally for out-door workers.
• 5.macular hole pathology
 MADDOX ROD
• a set of high power micro cylinders placed close and parallel to each other.
• converts a point source of light in to a line image at right angle to its axis.
Therefore, a point source of light seen through Maddox rod with the axis placed
horizontally, appears to be a vertical line.

• Principle – Breaks fusion

• Uses:
1. Latent squint can be diagnosed by placing Maddox rod in front of one eye and
asking the patient to look at a bulb in the center of Maddox cross mounted on a
wall. Patient sees bulb with the bare eye and a vertical line with the other eye.
– If the eyes are aligned the bulb is seen in the center of the line.
– Whereas if there is a latent squint the bulb is seen away from the line or eccentric on the
line.
• In esophoria the line is seen on the same side as the eye with Maddox rod (uncrossed diplopia) and
• in exophoria on the opposite (crossed diplopia).
– The amount of deviation can be measured by neutralizing the misalignment by putting prism
in front of the Maddox rod or by reading the scale mark corresponding to the line as seen on
the Maddox cross.
 MADDOX ROD
2. Macular function test is performed by placing Maddox rod in front of
the eye with opaque media and shining a bright torch on it. With
normal macula the patient sees a smooth, continuous and unbroken
straight line. If the macular function is deranged patient sees an
irregular or broken line.
3. Double Maddox rod test is done for the diagnosis of cyclotropia or
torsional squint. Two Maddox rods, one red and the other white, are
placed in front of the two eyes with the axes vertically. A 4D base-down
prism is placed in front of one of the rods to displace one of the lines
upwards. A patient without any cyclotropia will see two parallel lines
one above the other. Patient with cyclotropia will see one horizontal
line and one tilted line. He is then instructed to rotate the Maddox rod
corresponding to the tilted line such that the two lines become parallel
to each-other. The axis of this rod gives the degree of cyclo-deviation.
Trial frame

This is aluminium frame designed to permit

insertion of various lens to
correct refractive error

Reduced aperture trial frame

Light weight
Adjustable ( vertical and horizontal )
Comfortable nose resting

3-4 slots

Last – high powered lenses ( near addition), occluder

3rd – spherical
2nd – cylinder
first – accessories- prism , stenopic slit , pinhole
 • Full aperture

Half eye frame

• Transposition

• Transposing a glasses prescription is simply converting the

prescription from minus cylinder notation to plus cylinder
notation. The optical properties of the prescription remain the
same.
• Procedure

1) Algebraically add the cylinder power to the sphere power

to arrive at the new sphere power.
2) Change the sign of the cylinder power.
3) Add or subtract 90 from the axis
• Vertex Distance

• The distance from the back surface of the glasses lens to the
front surface of the eye (the vertex distance) can affect the
effective power of the lens, especially in higher powered
prescriptions
• The Distometer The distometer is a device used to
measure the vertex distance
 Red Green Glasses
• Diplopia Charting
• W4DT
• Malingerring (FRIEND TEST)
• TNO test
 Convex Lens
• converges the rays of light (or decreases divergence).

• Identification is done by holding the lens close to eye and moving it side ways while looking at a distant target. The target
seems to move in the opposite direction. Then the lens is rotated while still viewing a distant target, there is no distortion
of the image in a spherical lens (as opposed to a cylindrical lens).
IMAGE DEPENDS ON POSITION OF OBJECT
REAL INVERTED IMAGE
• Uses:

– Hypermetropia
–
– Presbyopia
–
– Aphakia
–
– Accommodative esotropia
–
– Indirect ophthalmoscopy
–
– Corneal loupe
–
– As part of (almost all) optical instruments , MICROSCOPES
– FOR LIO (20 d)
– ABRAHAMS IRIDOTOMY AND CAPSULOTOMY LENS
– PRP AND FOCAL GRID LENS
– lva
 Concave lens
• Concave or minus lens diverges the rays of light (or decreases convergence).

• Identification - the target seems to move in the same direction and there is
no distortion on rotating the lens.
Virtual erect image
• Uses:

– Myopia

– Hruby lens (-57.8 D) , which is a high power concave lens, is used for
visualizing the fundus on the slit-lamp examination.
– Central lens of Goldmann 3 mirror
– Kriger lens (-92D) for focal and grid laser
 Cylinder
• A cylinder is a lens which has refractive power only in one meridian but not at
right angle to it.
• It should be noted that the power of cylinder acts at right angle to it. So if power
is required vertically the cylinder axis is placed horizontally and vice versa.

• Identification is made by placing the lens close to eye and looking at a distant
target. On moving it horizontally or vertically target will move only with one
movement, and on rotation the image shows distortion.
– In convex cylinder the image seems to move in opposite direction and
– in concave cylinder it moves in the same direction.

• Use: Cylinders are used to correct astigmatism.

• Jackson cross cylinder
 PRIESTLEY-SMITH RETINOSCOPE
plane and a concave mirror

Plane mirror
– it is actually a very slightly concave mirror with a focal length of 1.5 m.
– a fenestration (hole) in the center……central hole is 2.5 mm on the mirrored side and tapers
out to 4 mm on the polished side.
– Preliminary examination at a distance of 1 m
– Uses Retinoscopy ,DDO

Concave mirror
– Focal length 25 cm.
– Central hole with same features as above.
– In past the central hole used to contain a +2 D convex lens to relax the accommodation of
the observer. Although the convex lens is no longer placed in the hole yet the
manufacturers continue to print +2 at the back of concave mirror.
– Looking into it the viewer’s own eye appears magnified (method of identification).

– Uses:

• Retinoscopy in patients with hazy media, high refractive error where the glow is faint
 Retinoscopy (Skiascopy)
• Objective method ofdetermining refraction of eye
• At 1 m
• Dilated pupil –
• Same direction- hypermetropic, emmetropic or myopia less
than 1 D
• Opposite – myopia more than 1 D
• No movement – myopia of 1 D
 Cycloplegics for retinoscopy
• Atropine 1 % - 0-5 yrs- amt to be reduced 1 D
• Cyclopentolate1% or homatropine - 5-8 yrs- 0.50D
• Tropicamide 0.5% - 0.25 to 0.50D
• Phenylepherine 5- 10% --- mydriatic
 Occluder
• Used to Cover either eye during
– Refraction
– Amblyopia therapy
– Binocular Diplopia management
– Uncover test
– Eccentric fixation
 Placido disc
• Placido disc is a device made of concentric rings drawn on a
device of white rings on a black background.The first
refracting surface of the cornea ( more accurately , the tear
film –air interface and not the epithelium) also acts as convex
mirror and reflects back light in a pattern dependent of the
corneal pattern
• Qualitative keratoscopy
• Place high convex les in center of disc
 Uses of cornealtopography
• Refractive surgery: To screen candidates for normal corneal shape, patterns and ruling out suspicious
or keratoconic patterns . Post operatively , topography can help to assess the dioptric change created
at corneal level ( thus the effective change in the cornea) , ruling out decentred or incomplete
ablation , post excimer ectasia or other changes.
• 2) Keratoconus : Early screening of keratoconus suspects is one of the most useful roles of
topography. Early keratoconus and suspects look normal on slit lamp examination ,and the central
keratometry (3 mm) gives only a limited assessment. Therefore topography has become the gold
standard in screening keratoconus suspects. In cases with established keratoconus, the role of
topography is paramount for monitoring progression and doing a timely collagen cross linking , and
in contact lens fitting.
• 3) Post surgery astigmatism : Post cataract surgery and post keratoplasty corneal astigmatism can be
studied with the topographer and selective suture removal or other interventions can be planned.
• 4) Surgical planning in cases with astigmatism : Limbal relaxing incisions and other methods of
topography guided incision placement are used by surgeons to reduce post operative astigmatism.
• 5) Effect of corneal and ocular surface disorders: Disorders such as pterygium , limbal dermoid ,
localised corneal scars can cause a change in the corneal topography and thus the monitoring is very
useful.
• 6) Other uses : Contact lens fitting , incision placement and intrastromal ring placement in
keratoconus , monitoring of ocular vs corneal wavefront.
 RAF rule ( royal air force )
• This instrument is used for determining the objective and
subjective convergence points, examining the accommodation
and determining the dominant eye.
• 50 cm long rule with a slider holding a rotating four-sided
cube
 Maddox wing
• The Maddox wing is an instrument by which the amount of heterophoria for near
(at a distance of 33 cm) can be measured. It is based on the principle of
dissociation of fusion by dissimilar objects.
• It has two slit holes in the eyepiece. The fields that are exposed to each eye are
separated by a diaphragm in such a way that they glide tangentially into each
other.
• The right eye sees a white arrow pointing vertically upward and a red arrow
pointing horizontally to the left.
• The left eye sees a horizontal row of figures in white and a vertical row in red.
These are calibrated in diopters of deviation.
• The arrow pointing to the horizontal row of figures and the arrow pointing to the
vertical row are both at zero in the absence of a squint or in the presence of
squint with a harmonious abnormal retinal correspondence.
• The Maddox wing should be held pointing 15 degrees inferiorly, as for reading.
• It is important to do the test with and without correction for refractive errors.
prism
THANKYOU