KISII UNIVERSITY

SCHOOL OF MEDICINE
DEPARTMENT OF MEDICAL PHYSIOLOGY
PRACTICAL: TESTS FOR VISUAL FUNCTON
OBJECTIVES
1. To examine the fundus using an ophthalmoscope, describe what is seen in a normal physiological fundus and pathological fundus
2. To describe visual acuity; far and near distance vision; perform Snellen Chart test on subjects.
3. To describe astigmatism; perform astigmatism fan chart tests on subjects
4. Describe and determine physiological blind spot
5. Describe near point of vision; determine the near point and accommodation of subjects.
6. Describe field of vision, scotoma, vision perimetry; perform confrontational visual field exam.
7. Describe color vision receptors and mechanism; perform Ishihara chart test on subjects.

FIGURE 1: Anatomy of the eye

 Sclera: the white part of the eye, a tough covering with which the cornea forms the
external protective coat of the eye.
 Iris: regulates the amount of light that enters your eye by dilation and constriction.
 Pupil: the circular opening in the Centre of the iris through which light passes into the
lens of the eye.
 Cornea: the transparent circular part of the front of the eyeball. It refracts the light
entering the eye onto the lens, which then focuses it onto the retina.
 Lens: a transparent structure situated behind your pupil. It is enclosed in a thin
transparent capsule and helps to refract incoming light and focus it onto the retina.
 Choroid: the middle layer of the eye between the retina and the sclera. It nourishes the
eye and contains a pigment that absorbs excess light so preventing blurring of vision.
 Ciliary body: the part of the eye that connects the choroid to the iris.
 Retina: a light sensitive layer that lines the interior of the eye. It is composed of light sensitive cells known as rods and cones.
 Macula: a yellow pigmented spot on the retina at the back of the eye which surrounds the fovea.
 Fovea: forms a small indentation at the centre of the macula and is the area with the greatest concentration of cone cells and no rods cells. When the eye is
directed at an object, the part of the image that is focused on the fovea is the image most accurately registered by the brain. Point of great visual acuity. Age
related Macular degeneration is a disease in which sharp, central vision is gradually destroyed
 Optic disc: the visible (when the eye is examined) portion of the optic nerve, also found on the retina. The optic disc identifies the start of the optic nerve
where messages from cone and rod cells leave the eye via nerve fibres to the optic centre of the brain. This area is also know n as the 'blind spot’. Optic
nerve: leaves the eye at the optic disc and transfers all the visual information to the brain.
 Rod cells are one of the two types of light-sensitive cells in the retina of the eye; used when light levels are low, its stimulation leads to monochromic vision
(black and white) vision. Cone cells are the second type of light sensitive cells in the retina of the eye; they function best in bright light and are essential for
acute vision. It is thought that there are three types of cones, each sensitive to the wavelength of a different primary colour – red, green or blue. Other
colours are seen as combinations of these primary colours.

PHYSIOLOGY OF SIGHT
Light is reflected into the eyes by objects within the field of vision. The processes involved in producing a clear image are:
1. Refraction(bending) of light rays
2. Adjustment of the pupil size
3. Accommodation (adjustment of the lens) for near vision.

1) REFRACTION OF LIGHT RAYS

When light rays pass from a medium of one density to another, they are refracted. Light rays entering the eye need to be bent to focus them on
the retina. The image formed on the retina is usually upside down but the brain is adapted to perceive it upright. The refractory power of the lens is
adjusted based on the distance of the object to enable appropriate vision.
2) ADJUSTMENT OF THE PUPIL SIZE
Pupil size contributes to clear vision by controlling the amount of light entering the eye. In bright light the pupil constricts and in dim light the light
is dilated.
3) ACCOMMODATION OF THE EYE
In order to focus on near objects, i.e., within 6 meters, the eye must make the following adjustments:
I. Constriction of the pupils
II. Convergence (movement of the eyeballs)
III. Increase the refractive power of the lens
When looking at an object further than 6 m, the refractory power of the lens is decreased, the pupils dilate and convergence is no longer required

RHODOPSINS AND COLOR BLINDNESS

Rhodopsin: a family of light sensitive pigments, found in both rods and cones, which are broken down(bleached) when they absorb light hitting the
cell. Rods have only one rhodopsin, absorbing at a single wavelength hence rods give monochromatic vision. Cones have three different rhodopsin,
absorbing at three wavelengths and give rise to red, blue and green cones. Color perception depends on the combination of red, blue and green cones
stimulated.
COLOUR BLINDNESS is a common condition affecting men than women. Affected individuals see colors but do not differentiate between them
because the rhodopsin in one or more cone types is abnormal. The most common type is the red-green color blindness, which is transmitted by sex-
linked recessive gene; greens, oranges, pale reds and browns are all perceived as the same color and can only be distinguished by their intensity
Among humans and non- human primates, the visual system is the most dominant sensory system employed. The essential function of the
Visual system in to convert the light energy into neuronal (electrical impulses) and construct an image.
The eye is complex sensory structure and contrary to popular view the eye does not see. It has two functions

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 1. An optical function through which the rays of light from an object are focused on the retina.
2. Transduction of the light energy into neuronal impulses.
The “seeing” is done by areas of the brain given to analysis of the patterns of neuronal activity generated by the photoreceptors in the retina.
The main area is the visual cortex located in the occipital lobe of the brain. However, it should be noted that there are 32 brain areas involved in
visual processing
This practical introduces a set of tests to determine if the various functions of the visual system are functioning normally or not, if not then
where possible an aid (spectacles) can be given to the person to compensate for the malfunction. Unfortunately, currently, there are no cures for
defects in the visual system but through such things as gene therapy and understanding the normal development (especially the growth factors
involved) in the future it will be possible to provide a cure.
The tests for optical function include but are not limited to:
1. Fundus examination
2. Visual acuity
3. Astigmatism
4. Blind spot
5. Near point
6. Visual perimetry
7. Color vision

The conditions that affect the eye include but are not limited to:
a) Myopia: nearsightedness and shortsightedness, visual abnormality in which the resting eye focuses the image of a distant object at a point
in front of the retina, resulting in a blurred image. Corrected using concave lenses with negative focal lens
b) Hyperopia: farsightedness is a common vision condition in which you can see distant objects clearly, but objects nearby may be blurry.
The images are formed behind the retina. Corrected using convex lens with positive focal lens
c) Presbyopia: long-sightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age. Causes of
presbyopia include:
 The weakness of ciliary muscle in old age person.
 Loss of elasticity to change the focal length of a lens which causes a decrease in the flexibility of eye lens.
d) Amblyopia: a disorder of sight in which the brain fails to fully process input from one eye and over time favors the other time. Vision in
one or both eyes do not develop fully during childhood
e) Astigmatism: is a common and generally treatable imperfection in the curvature of the eye that causes blurred distance and near vision.

1. FUNDUS EXAMINATION USING AN OPTHALMOSCOPE

The fundus is examined to see if there is any physical defect or damage using an ophthalmoscope.
An ophthalmoscope is used to examine the fundus of the eye-the interior part of the eye opposite to the lens which includes the retina, optic disk,
macula and fovea and posterior pole. The arteries, arterioles and veins in the superficial layers of the retina near its vitreous surface can be examined.
This is one place in the body where arterioles are readily visible. Ophthalmoscopic examination is of great value in diagnosis and evaluation of
diabetes mellitus, hypertension, glaucoma and diseases that affect blood vessels. The retinal Vessels supply the ganglion and bipolar cells; the
receptor cells are nourished by capillary plexus in the choroid. When there is retinal detachment, there is damaging to the receptor cells. Glaucoma
can be due to increased Intraocular Pressure (IOP) among other causes; It is a degenerative disease in which there is loss of retinal ganglia cells.
Open-angle Glaucoma is caused by a decreased permeability through the trabeculae into the Schlemm which leads to increased IOP and maybe due
to genetic defects. Closed angle Glaucoma is caused by forward ballooning of iris so that it reaches the cornea and destroy the filtration angle thus
reducing the outflow of aqueous humor.
Glaucoma causes changes in the fundus appearance and seen in the ophthalmoscope.
NORMAL ABNORMAL
COLOR AND Pinkish with clearly sharp margins Pale of chalky white especially at the
MARGINS OF center or erythema with indistinct
OPTIC DISK margins
BLOOD VESSELS Relatively flat, straight or slightly Vessels are distorted at the margin due
gradually curved blood vessels because to lack of support tissues
they have intact support tissues around Tortuous blood vessels-no smooth
them appearance with abnormal growth.
BACKGROUND Normal color Hemorrhages, cotton wool spots, hard
APPEARANCE exudates and aneurysm-bulging on
vessels may be seen besides an
abnormal color.
APPEARANCE

Direct ophthalmoscope allows you to look into the back of the eye to look at the health of the retina, optic nerve, vasculature and vitreous humor.
This exam produces an upright image of approximately 15 times magnification

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 FIGURE 2: OPHTHALMOSCOPE

Requirement: Functional ophthalmoscope

PREPARATION:
1. Wash your hands.
2. Introduce yourself to the patient and explain what you
are going to do. An ophthalmoscope is a magnifying
tool. The examiner might get close to subject’s eye and
may hold the subject’s forehead to avoid bumping into
each other. Eye drops may be used to dilate the pupil
which may have some side effects to them.
3. Gain Patient’s consent and position the patient so that
the ophthalmoscope is held directly at the level of the patient’s eye. Enquire whether the subject is experiencing any pain before you proceed.

INSPECTION OF THE EXTERNAL EYE: This can provide a lot of valuable clinical information.
Ask the patient to look straight ahead and inspect both of the eyes assessing the following;
 Peri-orbital regions
 Eyelids
 Eyes (including pupils)
Note any abnormalities such as:
 Swelling
 Redness
 Discharge
 Prominence of the eyes
 Abnormal eyelid position: ptosis (droopy eyelids) can be a sign of Horner’s syndrome (often very subtle ptosis with miosis-excessive pupil
constriction) and oculomotor nerve palsy (can vary from partial to complete ptosis and usually with a ‘down and out’ eye position and an
enlarged pupil)
 Abnormal pupillary shape, size and/or asymmetry

Pathology which may be noted during general inspection

Examples of pathology you may note during general inspection of the eye include:
 Periorbital erythema and swelling: a feature of preseptal cellulitis (anterior to the orbital septum) or orbital cellulitis (posterior to the orbital
septum)
 Eyelids: lumps (benign or malignant), oedema, ptosis and entropion/ectropion
 Eyelashes: loss of eyelashes (can be associated with malignant lesions), trichiasis (eye lashes rubbing on the cornea) and blepharitis
collarettes
 Pupils: abnormal size, shape, colour and symmetry (see above)
 Conjunctival injection (redness): this can be diffuse, sectorial or limbal. Dilated inflamed blood vessels can be due to infection, allergy,
trauma and inflammation.
 Cornea: diffuse haziness in acute angle-closure glaucoma or a patch of white infiltrate due to a corneal ulcer. Staining of the cornea with
fluorescein suggests epithelial loss. A dendritic pattern is seen with herpes simplex infection.
 Anterior chamber: a fluid level may be noted in hyphaema (blood – red in colour) or a hypopyon (inflammatory cells – yellow in colour).
 Discharge: watery discharge is typically associated with allergic or viral conjunctivitis or reactive physiological production (e.g. corneal
abrasion/foreign body). Purulent discharge is more likely to be associated with bacterial conjunctivitis. Very sticky, stringy discharge can
suggest chlamydial conjunctivitis while blood staining can be seen with gonococcus.

INSPECTION USING AN OPTHALMOSCOPE

 It is essential to darken the room for the examination.
 Dilate the patient’s pupils using short-acting mydriatic eye drops such as tropicamide 1%. You will be unable to monitor pupil reactions
once dilating drops have been applied, furthermore assessing vision, colour vision, double vision and visual fields will be less accurate
once drops are instilled.
 Ask the patient to look straight ahead for the duration of the examination (asking the patient to fixate on a distant target such as a light
switch can cause confusion if you then obstruct the view of this target).
 Assess for fundal reflex. The term fundal reflex is preferred over red reflex as the colour of the healthy reflex varies depending on a
patient’s skin colour. In patient’s with lighter skin, the reflex typically appears orange-red in colour, whereas in those with darker skin, the
reflex can be yellow-white or even blue in colour.
Causes of an absent fundal reflex
1. Absence of the fundal reflex in adults is often due to cataracts in the patient’s lens blocking the light. Other causes include vitreous
haemorrhage and retinal detachment.
2. Absence of the fundal reflex in children can be due to congenital cataracts, retinal detachment, vitreous haemorrhage and retinoblastoma.
To set up the ophthalmoscope for assessing the fundal reflex adjust the diopter dial to correct for your refractive error so that you can see the patient
and their eye clearly from a distance:
 If you have normal visual acuity, you can set the diopter dial to 0.
 If you have a refractive error but are planning to wear glasses/contact lenses that correct this when using the ophthalmoscope, you can also
set it to 0.
 If you have a refractive error and are not going to wear your glasses/contact lenses you should adjust the diopter dial to match your
prescription (e.g. -2).

How to assess for the fundal reflex

 Look through the ophthalmoscope, shining the light towards the patient’s eye at a distance of approximately one arm’s length.
 Observe for a reddish/orange/white/yellow/blue reflection in each pupil, caused by light reflecting back from the vascularized retina.
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  Rotate the disc of the lenses to higher values until sharp focus is achieved.

To set up the ophthalmoscope for assessing the fundus, adjust the diopter dial so that it is the net result of yours and the patient’s refractive
error:
If you and the patient have normal visual acuity, set the dial to 0 (e.g. 0 + 0 = 0).
If you have a refractive error but are planning to wear glasses/contact lenses that correct this, assume you have a refractive error of 0 and
add the patient’s refractive error to this (e.g. 0 + -2 = -2).
If the patient has a refractive error and you have normal visual acuity set the dial to the net refractive error. An example of this would be
(your refractive error of 0) + (patient’s refractive error of -2) = a setting of -2.
If the patient has a refractive error and you have a refractive error set the dial to the net refractive error. An example of this would be (your
refractive error of +3) + (patient’s refractive error of -2) = a setting of +1.
If things appear out of focus during the assessment, simply adjust the diopter dial until things look sharper. The farsighted eye requires
more plus/green number lenses. The nearsighted eye requires more minus/red number lenses.

ASSESMENT OF THE FUNDUS

 If you are assessing the patient’s right eye, you should hold the ophthalmoscope in your right hand and vice versa. Place the hand not
holding the ophthalmoscope onto the patient’s forehead to prevent accidental collision between yours and the patient’s face.
 Approaching from a 10-15-degree angle slightly temporal to the patient, move closer whilst maintaining the fundal reflex.
 Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches point like
arrows towards the optic disc).
 Once you identify the optic disc assess its characteristics including the contour, color and the cup (“3Cs”):
 Contour: the borders of the optic disc should be clear and well defined. If the borders appear blurred it may suggest the presence of
optic disc swelling (papilledema) secondary to raised intracranial pressure.
 Color: a healthy optic disc should look like an orange-pink doughnut with a pale center. The orange-pink color represents well-
perfused neuro-retinal tissue. A pale optic disc suggests the presence of optic atrophy which can occur as a result of optic neuritis,
advanced glaucoma and ischemic vascular events.
 Cup: the cup is the pale center of the orange-pink doughnut mentioned previously. The pale color of the cup is due to the absence of
neuro-retinal tissue. The vertical size of the cup can be estimated in relation to the optic disc as a whole, known as the “cup-to-disc
ratio”. A cup-to-disc ratio of 0.3 (i.e. the cup occupies one-third of the height of the optic disc) is generally considered normal. An
increased cup-to-disc ratio suggests a reduced volume of healthy neuro-retinal tissue, which can occur in glaucoma.
 Examine the vascular appearance in the posterior pole.
 Finally, inspect the macula by asking the patient to briefly look directly into the light of the ophthalmoscope. The macula is found lateral
(temporal) to the optic nerve head and is yellow in colour. The central part of the macula, the “fovea” is about the same diameter as the
optic disc and appears darker than the rest of the macula due to the presence of an additional pigment.
 Repeat the examination on the other eye.

Types of macula pathology

 Hard exudates: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding leaking
microaneurysms. They are most commonly associated with diabetic retinopathy, grade 3 hypertensive retinopathy and retinal vein
occlusions.
 Drusen: yellow-white flecks scattered around the macular region representing remnants of dead retinal pigment epithelium. Most
commonly caused by age-related macular degeneration.
 Cherry-red spot: associated with central retinal artery occlusion which typically presents with sudden profound visual loss.

Types of retinal pathology

 Arteriolar narrowing: subtle, with generalised arteriolar narrowing with typical copper or silver wire appearance. Most commonly
associated with the early stages of hypertensive retinopathy.
 Arteriovenous nipping/nicking: areas of focal narrowing, and compression of venules at sites of arteriovenous crossing. The typical
appearance involves bulging of retinal veins on either side of the area where the retinal artery is crossing. Most commonly associated with
grade 2 hypertensive retinopathy.
 Dot and blot haemorrhages: arise from bleeding capillaries in the middle layers of the retina and may look like microaneurysms if small
enough. They are most commonly associated with diabetic retinopathy.
 Flame haemorrhages: larger haemorrhages with a flame-like appearance caused by rupture of pre-capillary arterioles or small veins in the
retinal nerve fibre layer. Most commonly associated with grade 3 hypertensive retinopathy, thrombocytopaenia, retinal vein occlusion and
trauma.
 Cotton wool spots: appear as small, fluffy, whitish superficial lesions and represent infarcts of the neuro-retinal layer. They are most
commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.
 Hard exudates: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding leaking
microaneurysms. They are most commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.
 Neovascularisation: formation of new blood vessels that appear as a net of small curly vessels, with or without associated haemorrhages.
They may be located on the optic disc or elsewhere on the retina. They are most commonly associated with advanced proliferative diabetic
retinopathy.
 Pan-retinal photocoagulation: the primary treatment for proliferative diabetic retinopathy. Clinically it is seen as clusters of pale burn
marks on the retina which have been created by the laser used in the treatment process.
 Branch retinal vein occlusion: blockage of one of the four retinal veins, each of which drains about a quarter of the retina. Typical signs
include flame haemorrhages, dot and blot haemorrhages, cotton wool spots, hard exudates, retinal oedema, and dilated tortuous veins.

ACTIVITY 1
OBSERVATIONS AND FINDINGS:

INVESTIGATION COMMENT
GENERAL INSPECTION

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KSU: DEPARTMENT OF MEDICAL PHYSIOLOGY- 2023
 FUNDUS REFLEX
OPTIC DISC: COLOR

MARGINS
RETINAL BLOOD
VESSELS
MACULA AND FOVEA
ANY PATHOLOGY
OBSERVED

2. VISUAL ACUITY
Visual acuity is the measure of the ability of the eye to distinguish shapes; contour and the details of objects at a given distance. It is defined in
terms of the shortest distance by which two lines can be separated and still perceived as two lines.
Clinically, visual acuity is often determined using charts of different printed font sizes placed at a distance away from the subject.
1. Snellen letter charts viewed at a distance of 20 ft (6 m). The individual being tested reads aloud the smallest line distinguishable. The
results are expressed as a fraction. The numerator of the fraction is 20, the distance at which the subject reads the chart. The denominator is
the greatest distance from the chart at which a normal individual can read the smallest line. Normal visual acuity is 20/20; a subject with
20/15 visual acuity has better than normal vision (not farsightedness); and one with 20/100 visual acuity has subnormal vision. The Snellen
charts are designed so that the height of the letters in the smallest line a normal individual can read at 20 ft subtends a visual angle of 5
minutes. Each of the lines is separated by 1 minute of arc. Thus, the minimum separable in a normal individual corresponds to a visual
angle of about 1 minute. Visual acuity is influenced by a large variety of factors, including optical factors (eg, the state of the image-
forming mechanisms of the eye), retinal factors (eg, the state of the cones), and stimulus factors (eg, illumination, brightness of the
stimulus, contrast between the stimulus and the background, length of time the subject is exposed to the stimulus) and drugs side effects
e.g. aspirin and tamoxifen used for breast cancer treatment.
Other charts that are used to determine visual acuity are The Tumbling E and Jaeger Chart.
2. The Tumbling E chart can detect nearsightedness in young children who don’t yet know all letters of the alphabet; also are useful to test
the distance visual acuity of children or adults who cannot communicate verbally due to a physical or mental disability, language barrier ,
failure to recognize alphabet letters or other reasons. The chart is placed 10 FEETS (3m) away from the subject. The direction where the
letter E faces is determined by the subject verbally or by show of finger. It is effective in determining astigmatism.
3. The Jaeger Card: While Snellen chart evaluates visual acuity (sharpness/clarity) of distant vision; Jaeger card evaluates visual acuity
(sharpness/clarity) of near vision. It is used to test and document near visual acuity at a normal reading distance. It consists of printer’s
fonts of varying sizes. Refractive errors and conditions that cause blurry reading vision include astigmatism, hyperopia (farsightedness)
and presbyopia. It is held 14 inches(35.6cm) away from the subject’s eye and their ability to read through the paragraphs is determined. A
result of 14/20 means that a person can read at 14 inches what someone with normal vision can read at 20 inches. The score is given from
the smallest font size as J1 to the largest font size based on the number of prints i.e., J1, J2, J3… The J1 paragraph on the chart is
considered the near vision equivalent to 20/20 vision in a Snellen Chart.
For the Snellen and Tumbling E charts one eye is tested at a time while covering the eye that is not being tested, pressure should not be applied to the
covered eye as it may interfere with normal vision. For the Jaeger Card test, both eyes are tested together, unless a big difference is noted on their
ability to see

ACTIVITY 2
METHOD

1) Working in pairs or groups; let the subject stand 6m/20 feet away from the Snellen chart.
2) While covering one eye, the subject reads aloud letters of each row beginning at the top
3) The smallest row that can be read accurately indicates the visual acuity in that specific eye; for example, if the subject read correctly the 70
feet row, then that person’s visual acuity is 20/70.
4) Repeat the steps and test for visual acuity in the other eye.
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 5) Determine whether there are people with myopic, hyperopic or ametropic vision from your groups.
NOTE: While reading the letters in the rows, a maximum of only 2 mistakes is allowed, when more mistakes are made, the previous raw that was
read accurately is considered as the score for the subject.

RESULTS:
SUBJECT VISUAL ACUITY SCORE
1
2
3

3. ASTIGMATISM
Astigmatism is a refractive error of the eye that causes the visual image in one plane to focus at a different distance from that of the plane
at right angles; most often results from too great a curvature of the cornea in one plane of the eye than the other. Because the curvature of the
astigmatic lens along one plane is less than the curvature along the other plane, light rays striking the peripheral portions of the lens in one plane are
not bent nearly as much as the rays striking the peripheral portions of the other plane . The light rays passing through an astigmatic lens do not all
come to a common focal point because the light rays passing through one plane focus far in front of those passing through the other plane. The
accommodative power of the eye cannot compensate for astigmatism because, during accommodation, the curvature of the eye lens changes
approximately equally in both planes; therefore, in astigmatism, each of the two planes requires a different degree of accommodation. Thus, without
the aid of glasses, a person with astigmatism never sees in sharp focus; the persons experience blurred distance and near vision. Correction of
Astigmatism is by use of cylindrical glasses.
Several methods exist for determining the axis of the abnormal cylindrical component of the lens system of an eye. One of these methods
is based on the use of parallel black bars. Some of these parallel bars are vertical, some are horizontal, and some are at various angles to the vertical
and horizontal axes. The commonly used astigmatism charts include Clock Dial Chart and Astigmatism Fan Chart and Astigmatism fan and
block chart. The other method is Jackson’s cross cylinder method used to refine the astigmatic refraction by fine-tuning the axis and strength of
astigmatism.
The fan and block test is used to determine the axis and magnitude of astigmatism. It determines the presence of any astigmatism and its
principal axes. Correction for astigmatism is by use of cylindrical lens. The astigmatism fan chart has line differences in 10,15- or 30-degrees
intervals. Some charts have correcting cylinder axis marked in chart written at top of each spoke of line and some charts just only represent the actual
representation of line orientation in degree. We can easily find out whether correcting the cylindrical axis is marked or the line orientation in degree.
If the 12 o’clock (vertical) line is marked as 180 or zero, it means the axis of correcting cylinder is written. If the 12 o’clock (vertical) line is marked
as 90, means it represents line orientation in degrees. In this case, correcting cylindrical lens axis will be 90 degrees perpendicular (if the axis is less
than 90 add 90 to it or if more than 90 then subtract 90)
The optics behind the astigmatism clock dial and fan chart ought to have been understood. A combination of methods including
determining of the visual acuity of a subject first, fogging of the eyes during test are used to determine the type of cylindrical lens a subject will use.
The goal is to determine when the patient is able to see the lines which are the blackest, sharpest and clearest and identify in terms of clock
position the meridian/lines which are least blurred

ASTIGMATISM FAN AND ASTIGMATISM CLOCK DIAL TEST

METHOD
1. Subjects stands 6 meters away from the astigmatic fan while wearing spectacles if they have a problem in their visual acuity.
2. Each eye is tested separately.
3. Subject notes if all bars are clear and in focus (blackest, sharpest and clearest); if any of the bars are not in focus, the degree is
noted. This means that the radius of curvature in that degree or meridian is different from the rest. Note the degree in your
data

OBSERVATIONS AND FINDINGS

SUBJECT DESCRIPTION OF NOTE THE UNCLEAR
THE VISION OF BARS BARS-DEGREE

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 1
2
3

4. BLIND SPOT
The small circular area at the back of the retina where the optic nerve enters the eyeball and which is devoid of rods and cones and is found
about 15 degrees lateral to the central point of vision and is not sensitive to light. Every eye has a blind spot. Blind spots may be small or large
and can be temporary or permanent and can either be physiological or pathological.
The physiological blond spot is can be determined with one eye covered; fix your gaze on the cross (the more nasally located of the two
marks), then move the figures (a paper with a cross and dot) towards and away from you until, at a certain distance, the spot disappears. At this
moment, the image of the spot is falling on the physiological blind spot.
When a blind spot is found in other areas in the visual field rather than the optic disc, they are called scotoma; they are frequently caused
by damage to the optic nerve resulting from glaucoma (too much fluid pressure in the eyeball), allergic reactions in the retina, or toxic
conditions such as lead poisoning or excessive use of tobacco.

Requirement: Paper with a cross and a dot 6-8 inches apart

FIGURE 7: Blind spot test paper

METHOD:
To find your right eye’s blind spot:
 Close your left eye.
 Use right eye to stare at the circle.
 Move closer to the screen, then farther away.
 Keep doing this until the plus sign disappears.
 When it disappears, you have found your right eye’s blind spot.
 Record the distance of the work-paper from the eye.
To find your left eye’s blind spot:
 Close your right eye.
 Use left eye to stare at the plus sign.
 Move closer, then farther away.
 When the circle disappears, you have found your left eye’s blind spot.
 Record the distance of the workpaper from the eye.

RECORD YOUR OBSERVATIONS

SUBJECT OBSERVATION DISTANCE OF WORKPAPER
FROM THE EYE
Your Right eye
Your Left eye

5. VISUAL FIELD -PERIMETRY

The field of vision is the visual area seen by an eye at a given instant when the eye is fixed at a single point. The area seen to the nasal side
is called the nasal field of vision, and the area seen to the lateral side is called the temporal field of vision. Because of the location of the eye ball in
the orbital cavity and the nose, the visual field of each eye has a boundary or a perimeter. The shape of the visual field is recorded to see if there is
any damage or lesion in the visual pathway. From the shape of the visual field one can determine the location along the visual pathway where the
damage has taken place. Note that damage to the retina produces “holes” in the visual field called scotomas while damage to the visual pathway
results in reduction of the perimeter of the visual filed.
To diagnose blindness in specific portions of the retina, one charts the field of vision for each eye by a process called perimetry. This
charting is performed by having the subject look with one eye toward a central spot directly in front of the eye; the other eye is closed. A small dot of
light or a small object is then moved back and forth in all areas of the field of vision, and the subject indicates when the spot of light or object can
and cannot be seen. Specialized equipment is used to determine the visual field defects e.g. the Humphrey Visual Field machine that are capable of
sensitive measurements that can detect small defects throughout the entire visual field.
Visual field can be determined using simple technique called Confrontational Visual Field Exam which is less sensitive but highly specific
test and it is used to assess the peripheral vision of the patient without the use of expensive specialized equipment. It is useful as there are a variety of
conditions that can affect the peripheral vision such as glaucoma, retinal detachment, stroke, vascular occlusions within the eye and certain brain
tumors.
The peripheral portions of the visual fields are mapped with an instrument called a perimeter, and the process is referred to as perimetry.
One eye is covered while the other is fixed on a central point. A small target is moved toward this central point along selected meridians, and, along
each, the location where the target first becomes visible is plotted in degrees of arc away from the central point. The central visual fields are mapped
with a tangent screen, a black felt screen across which a white target is moved. By noting the locations where the target disappears and reappears, the
blind spot and any objective scotomas (blind spots due to disease) can be outlined. The central parts of the visual fields of the two eyes coincide;
therefore, anything in this portion of the field is viewed with binocular vision. The impulses set up in the two retinas by light rays from an object are
fused at the cortical level into a single image (fusion). The points on the retina on which the image of an object must fall if it is to be seen binocularly

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as a single object are called corresponding points. If one eye is gently pushed out of the line while staring fixedly at an object in the center of the
visual field, double vision (diplopia) results; the image on the retina of the eye that is displaced no longer falls on the corresponding point.

HUMPHREY VISUAL FIELD MACHINE

METHOD 1: HOW TO PERFORM THE CONFRONTATIONAL VISUAL FIELD EXAM:
1. The subject removes the hat or anything the interfere with their peripheral vision.
2. The examiner sits opposite; 3-4 feet (about 1 meter) away from the subject in a manner that their eyes are at the same level.
3. To test for the right eye, the subject is asked to cover their left eye with their left hand and instructed to fix their gaze at the
examiner’s left eye throughout the test.
4. While the subject is focusing on the examiner’s left eye, the examiner closes their right eye and maintains fixation on the
patient’s open eye through the test. The examiner raises their hand to the inferior temporal edge of their peripheral vision
halfway between them and the patient; while holding up 1,2 or 5 fingers- this numbers are easily distinguishable by the
subject. The subject is asked to state how many fingers they are able to see.
5. Step 4 is repeated for testing all the four quadrants of the right and left eye: Inferior temporal, inferior nasal, superior
temporal, and superior nasal.

OBSERVATION AND FINDINGS

State whether or not the patient mentioned the correct number during the examination
QUADRANT RIGHT EYE LEFT EYE
Inferior temporal
Inferior nasal
Superior temporal
Superior nasal.

METHOD:
1. The subject sits or stands opposite to the examiner and both look into each other’s eyes
2. Without moving eyeballs, the examiner moves a finger to the sides and above; both should observe whether the finger disappears or not

NORMAL OBSERVATION
With both persons having normal visual perimeter, both should see the finger disappear.
ABNORMAL OBSERVATION
If the finger disappears for one person before the other, then this would indicate a defect of the visual filed in this case the person would now have
his or her visual perimeter mapped using visual perimeter apparatus to obtain the shape of the visual field

OBSERVATION AND FINDINGS

OBSERVATION
EXAMINER
SUBJECT

6. NEAR POINT DETERMINATION

The nearest point to the eye at which an object can be brought into clear focus by accommodation is called the near point of vision. It
is the minimum distance of the object from the eye, which can be seen distinctly without strain. The mechanism by which the eye can
focus on distant and near objects is called accommodation and involves changing the radius of curvature of the lens. Three processes
are involved for on to see an object near the eye; accommodation-is the increase in the curvature of the lens; convergence and
pupillary constriction.
The near point recedes throughout life, slowly at first and then rapidly with advancing age, from approximately 9 cm at age 10 to
approximately 83 cm at age 60. This recession is due principally to increasing hardness of the lens, with a resulting loss of
accommodation due to the steady decrease in the degree to which the curvature of the lens can be increased. By the time a normal
individual reaches age 40– 45, the loss of accommodation is usually sufficient to make reading and close work difficult. This
condition, which is known as presbyopia, can be corrected by wearing glasses with convex lenses. In adulthood, the normal near
point vision distance is about 25cm (10 inches)
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KSU: DEPARTMENT OF MEDICAL PHYSIOLOGY- 2023
The power of accommodation for a normal eye is calculated as

1 meter ( 100 cm )
ACCOMMODATIVE POWER (DIOPTERS)
Distance measured∈m(cm)
The Power of accommodation is 4 D (diopter), for a human of normal eyesight. A diopter is a unit measuring a lens's refractive power, in this case
the eye lens.
Requirement: Ruler, accommodative target (a paper with clear writing or picture; a pen etc)
PROCEDURE
1) Let the subject sit comfortably
2) Place a ruler at the bottom of the eye
3) The subject should focus on the target as the examiner moves it towards their eyes. The subject should read the writings on the target
without straining and notify the examiner by lifting their thumb when they see blurry writings or when using a pen when they see two
objects.
4) Upon receiving the notification from the subject, the examiner will measure the distance from the eye to the target and noted
5) Repeat the above steps while covering one eye; for both eyes; and compared the results obtained with results obtained when using both
eyes
6) Calculate the accommodative power of the subject.

RESULTS
SUBJECT NEAR POINT DISTANCE ACCOMMODATION
POWER(DIOPTERS)
1
2
3

7. COLOR VISION
The ability to perceive color is based on the presence of the erythrolabe (red sensitive or long-wave (723–647 nm); cyanolabe (blue-sensitive or short-
wave (492–417 nm) and chlorolabe (green-sensitive or middle-wave (575–492 nm) pigments cone photoreceptors. Red, blue and green are primary colors of light and
combination of these make all the colors seen.
Colors have three attributes; hue, intensity, and saturation (degree of freedom from dilution with white) For every color, there is a complementary color
that when properly mixed with it, produces a sensation of white. The sensation of white, any spectral color, and even extra-spectral color (e.g. purple) can be produced
by mixing various proportions of primary colors. Black is the sensation caused by absence of light. It is probably a positive sensation, because the blind eye does not
“see black”, it “sees nothing”. Finally, the color perceived depends on the color of other objects in the visual field.
The genes for human Rhodopsin are encoded on chromosome 3, the genes for blue-sensitive S cone pigment are encoded on chromosome 7, the red and
green cone pigments are encoded on q arm of the X chromosome. Color blindness is the inability to perceive colors or perceive certain colors weakly. This abnormality
is inherited as recessive and X-linked characteristic- appears in men when linked to the X-chromosome and in female when both X-chromosomes have the abnormal
gene.; colorblindness may be due to lesions of area V8 of the visual cortex-the region uniquely concerned with color vision in humans; the transient blue green color
weakness may occur as a side effect in individuals taking sildenafil(Viagra) for treatment of erectile dysfunction because the drug inhibits the retinal as well as penile
form of phosphodiesterase. The most common type of color blindness is the red-green color blindness in which the red-sensitive and green sensitive pigments is shifted
in its spectral sensitivity.
Color blindness test can be performed on a subject using three methods: The Ishihara charts, Edridge green lantern-an electrical apparatus with green, red
and blue lights and using the Holmgren’s wool where colored yarns are matched by the subject.
The Ishihara Charts are lithographic color plates available in book form. The plates are constructed that numbers and wavy lines made up of spots of
confusing colors, are printed against backgrounds of differently colored spots of identical size. Some color blind individuals are unable to distinguish certain colors,
whereas others have a color weakness.
 Protanopia-defects of the red cone system
 Deutranopia- defects of the green cone system
 Tritanopia- defects of the blue cone system (rare condition)
 Trichromats-individuals with normal color vision
 Dichromats- individuals with only two cone systems (common in men- protanopia or deutranopia)
 Monochromats- individuals with only one cone system

ISHIHARA PLATES SAMPLE

Requirements: ISHIHARA CHART
METHOD:
1. Use the Ishihara chart to determine if there is a
problem with color perception. The subject needs
adequate day light when reading the plates. Direct
sunlight and electricity may cause discrepancies in
color shades.
2. Ask subject to read the numbers and trace the wavy
lines in successive plates.
3. Use the accompanying booklet to determine what a
normal person would see and what a person with
particular defects would see.

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**The current passing score is 12 correct of 14 red/green test plates (not including the demonstration plate). Research has
shown that scores below twelve indicate color vision deficiency, and twelve or more correct indicate normal color vision, with
97% sensitivity and 100% specificity.

OBSERVATIONS AND FINDINGS

SUBJECTS OBSERVATION- PLATE NOT TYPE OF COLOR BLINDNESS
WELL READ DETECTED
1
2
3

ANSWER THE FOLLOWING QUESTIONS

1. What is an ophthalmoscope?
2. Is an ophthalmoscope important in diagnosis of eye conditions? Explain and give examples.
3. Describe what can be seen in a normal fundus.
4. What is visual acuity
5. Which tests are used to determine
 Distance vision
 Near reading distance
6. State the factors affecting visual acuity.
7. What is astigmatism
8. What causes astigmatism
9. How is astigmatism diagnosed
10. How is astigmatism corrected
11. Define physiological blind spot
12. What is a scotoma?
13. Describe near point of vision. What is the average near point of vision in adults?
14. What does accommodation of the eye involve?
15. Why does eye accommodation ability reduce with age?
16. Describe field of vision. How is the field of vision determined?
17. What is color blindness?
18. What causes color blindness?
19. Which tests can be used to determine whether a patient has color blindness or not?
20. Explain the practical importance of color blindness test.

1. VISUAL PERIMETRY

FIGURE 9: DIAGRAM OF THE VISUAL PATHWAY

ASSIGNMENT
In your data sheet; show the different visual fields defects you would expect for
lesions in the different parts of the visual pathway and name the defect for each
site (use a diagram)

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KSU: DEPARTMENT OF MEDICAL PHYSIOLOGY- 2023
COMPILED BY IRENE VUREMY
LABORATORY TECHNOLOGIST-MEDICAL PHYSIOLOGY

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KSU: DEPARTMENT OF MEDICAL PHYSIOLOGY- 2023